The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases

STUDY DESIGN: Review article.OBJECTIVES: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.METHODS: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.RESULTS: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.CONCLUSIONS: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

Effect of nonoperative periodontal treatment on changes of schneiderian membrane thickness of maxillary sinus in the chronic periodontitis patients using cone-beam CT / 中华口腔医学杂志

Objective@#To analysis the effect of nonoperative periodontal treatment on morphological changes of the schneiderian membrane of maxillary sinus in the chronic periodontitis patients by using oro-maxillaofacial cone-beam CT (CBCT) in order to provide the foundation in the diagnosis and treatment of maxillary sinusitis caused by chronic periodontitis.@*Methods@#Totally 30 chronic periodontitis patients with schneiderian membrane thickening [(40.0±5.6) years old (ranged 26-55 years old), 18 males and 12 females] were randomly recruited in Department of Periodontics, School of Stomatology, China Medical University from June 2014 to December 2016. All patients were scanned by CBCT. The probing depth (PD), clinical attachment loss (CAL), plaque index (PLI) and bleeding index (BI) of the maxillary first and second premolars and molars were recorded. All patients received systematic nonoperative periodontal treatment. After six months, patients were reviewed, periodontal indexes and CBCT scanning were recorded. The thickness of the schneiderian membrane of maxillary sinus were analyzed by the software of CBCT. The changes of clinical parameters, parameter dimensional values of membrane thickness before and after treatment were statistically compared by t test.@*Results@#In 30 chronic periodontitis patients, there was no statistically significant difference in the dimension and length of the maxillary sinus mucosa between the right and the left (P>0.05). The dimension of the mucosal thickening was positively correlated with PD and CAL values, and the correlation was statistically significant (P<0.05). Totally 58 maxillary sinus showed mucosal thickening. There were 20 mild thickening cases, and the dimension of mucosal thickening 6 months after treatment [(1.1±0.6) mm] was significantly lower than that before treatment [(2.5±0.7) mm] (P<0.05). There were 30 moderate thickening cases and the dimension of mucosal thickening 6 months after treatment [(2.3±0.6) mm] was significantly lower than that before treatment [(5.8±0.5) mm] (P<0.01). There were 8 severe thickening cases and the dimension of mucosal thickening 6 months after treatment [(4.2±0.4) mm] was also significantly lower than that before treatment [(11.2±1.8) mm] (P<0.01). The periodontal indexes of patients with mild, moderate and severe mucosal thickening in maxillary sinus showed statistically significant difference after treatment compared with before treatment (P<0.05).@*Conclusions@#Nonoperative periodontal treatment has a positive therapeutic significance for improving the schneiderian membrane thickening of maxillary sinus.

Antibiotic therapy for appendicitis treatment

Appendicitis is the most common diagnosis of acute abdominal pain that may require surgical treatment, and 8.6% for men and 6.9% for women are at risk for this illness over the course of their lives. During the past century, appendectomy was the standard treatment for acute appendicitis. However, laparoscopic appendectomy has been used as the first-line treatment choice for appendicitis since the introduction of laparoscopic surgery. In cases of perforation or abscess, interval appendectomy and percutaneous drainage are recommended. Treatment strategies have become more diverse. In recent years, in some European countries, non-surgical treatment has been used for simple appendicitis without complications, and nonoperative treatment of appendicitis has become increasingly common in adults and children. In this article, nonoperative treatment of appendicitis is introduced, and guidelines for the selection of antibiotics according to appendicitis classification are summarized.

Nonsurgical Treatment of a Distal Radius Fracture: When & How?

Distal radius fractures are a common upper extremity fracture and a considerable number of patients have a stable fracture. In the treatment of distal radius fractures, there is considerable disagreement regarding the need for a strict anatomical restoration with operation in elderly patients. Therefore, nonsurgical treatment is a still important treatment option in distal radius fractures. The radiological parameters of before or after manual reduction are important for deciding whether to perform operation or not. The radiological parameters include dorsal angulation of the articular surface, radial shortening, extent of dorsal comminution, intra-articular displacement, concomitant ulnar metaphyseal fracture, shear fracture, and fracture-dislocation of the distal radio-ulnar joint. In addition, clinical situations of patients, including age, activity level, underline disease, and recovery level, which the patients wish should be considered, comprehensively. For the duration of a splint or cast, three to four weeks are recommended in impacted or minimally displaced fractures and five to six weeks in displaced fractures. After reduction of the displaced fractures, patients should undergo a radiologicical examination every week to check the redisplacement or deformity of the fracture site until two or three weeks post trauma. Arm elevation is important for controlling fracture site swelling and finger exercises, including metacarpophalangeal joint motion, are needed to prevent hand stiffness. Active range of motion exercise of the wrist should be initiated immediately after removing the splint or cast.

Progress in treatment of acromioclavicular joint dislocation of Rockwood type Ⅲ / 中华创伤骨科杂志

Dislocation of the acromioclavicular joint is a common injury seen by surgeons.Although many orthopaedic surgeons hold that injuries of Rockwood types Ⅰ and Ⅱ are usually treated nonoperatively and injuries of types Ⅳ to Ⅵ surgically,there is no consensus with regard to the treatment of type]Ⅲ injuries.There are mainly 2 disputes in the management of AC joint dislocations of Rockwood type Ⅲ concerning operative versus nonoperative treatments and different operative techniques.In this paper,we will outline the current progress in the management of acromioclavicular joint dislocation of Rockwood type Ⅲ.

Risk Factors for Failure of Nonoperative Treatment for Unilateral Cervical Facet Fractures

STUDY DESIGN: Retrospective clinical study. PURPOSE: The purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management. OVERVIEW OF LITERATURE: According to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management. METHODS: A retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively. RESULTS: Seventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis. CONCLUSIONS: Patients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.

Nonoperative versus operative treatment of patients with degenerative spondylolisthesis / Tratamento conservador versus cirúrgico de pacientes com espondilolistese degenerativa / Tratamiento conservador contra quirúrgico de pacientes con espondilolistesis degenerativa

ABSTRACT Objective: To evaluate clinical and functional results of patients with lumbar degenerative spondylolisthesis treated with operatively or nonoperatively. Methods: Patients with degenerative spondylolisthesis treated either nonoperatively or operatively from 2004 to 2014 were selected from databases and a cross-sectional evaluation was performed. Outcome measures included back and leg visual analogue scales (VAS), Fischgrund criteria, Short Form-36 (SF-36) function score, and the modified Oswestry Disability Index (ODI). Results: 43 patients were evaluated: 20 with nonoperative treatment and 23 with operative treatment. Baseline characteristics were similar without significant differences between groups. Mean follow-up time was 43 months (range 10 - 72) for the nonoperative group and 36 months (range 6-80) for the operative group. Significant statistical difference in favor of operative group were found in back VAS (mean 4 versus 8, p = 0.000), leg VAS (mean 3 versus 6, p = 0.0015), SF-36 function score (mean 77 versus 35, p = 0.000), and ODI (mean 17 versus 46, p = 0.000). On the basis of the Fischgrund criteria, only 10 % of patients reported excellent or good health post nonoperative treatment versus 83% for those treated operatively (p = 0.000). Conclusion: In this cross-sectional study, we observed that symptomatic patients with degenerative spondylolisthesis who underwent operative treatment have superior clinical and functional scores compared to those that underwent nonoperative treatment.

RESUMO Objetivo: Avaliar os resultados clínicos e funcionais dos pacientes com espondilolistese degenerativa lombar tratados de maneira conservadora ou cirúrgica. Métodos: Foram selecionados pacientes com espondilolistese degenerativa tratados conservadoramente ou submetidos à cirurgia, durante 2004-2014, à partir da coleta de dados que possibilitou a realização da avaliação transversal. As medidas de avaliação da dor lombar e das pernas foram escalas analógicas visuais (VAS), critérios Fischgrund, Short Form-36 (SF-36) pontuação funcional, e o Índice de Incapacidade Oswestry modificado (ODI). Resultados: 43 pacientes foram avaliados: 20 do tratamento conservador e 23 do tratamento cirúrgico. As características de base foram similares, sem diferenças significativas entre os grupos. O tempo médio de acompanhamento foi de 43 meses (intervalo 10-72) para o grupo não-cirúrgico e 36 meses (intervalo 6-80) para o grupo cirúrgico. Diferenças estatísticas significativas em favor do grupo cirúrgico foram encontrados no VAS lombar (média de 4 versus 8, p = 0,000), VAS pernas (média 3 contra 6, p = 0,0015), SF-36 pontuação funcional (média 77 versus 35, p = 0,000), e ODI (média 17 versus 46, p = 0,000). Com base nos critérios Fischgrund, apenas 10% dos pacientes relataram excelente ou boa saúde de após o tratamento conservador contra 83% para aqueles tratados no cirúrgico (p = 0,000). Conclusão: Neste estudo transversal, observou-se que os pacientes sintomáticos com espondilolistese degenerativa que se submeteram ao tratamento cirúrgico têm escores clínicos e funcionais superiores em comparação àqueles que foram submetidos a tratamento conservador.

RESUMEN Objetivo: Evaluar los resultados clínicos y funcionales de los pacientes con espondilolistesis degenerativa lumbar tratados quirúrgicamente o sin cirugía. Métodos: Se realizó una evaluación transversal de los pacientes con espondilolistesis degenerativa, registrados en la base de datos, tratados conservador o quirúrgicamente desde 2004 hasta 2014. Las medidas de desenlace incluyeron: Escala Visual Análoga (EVA) de dolor lumbar y las piernas, criterios de Fischgrund, Short Form-36 (SF-36) e Índice de Discapacidad Oswestry modificado (IDO). Resultados: Se evaluaron 43 pacientes: 20 con tratamiento no quirúrgico y 23 con tratamiento quirúrgico. Las características de base fueron similares, sin diferencias significativas entre los grupos. El tiempo medio de seguimiento fue de 43 meses (rango 10-72) para el grupo no quirúrgico y 36 meses (rango 6-80) para el grupo quirúrgico. Diferencias estadísticamente significativas a favor del grupo quirúrgico fueron encontrados en EVA lumbar (media 4 contra 8, p=0,000), EVA pierna (media 3 contra 6, p=0,0015), SF-36 función (media 77 contra 35, p=0,000), e IDO (media 17 contra 46, p=0,000). Con respecto a los criterios de Fischgrund, sólo el 10% de los pacientes del grupo que recibió tratamiento no quirúrgico informo excelente o buen estado de salud en comparación con 83% de los que recibieron manejo quirúrgico (p = 0,000) Conclusión: En este estudio de corte transversal, se observó que los pacientes sintomáticos con espondilolistesis degenerativa que se sometieron a tratamiento quirúrgico tienen puntuaciones clínicas y funcionales superiores en comparación con los que se sometieron a tratamiento no quirúrgico.

Operative versus nonoperative treatment for displaced midshaft clavicle fractures: a meta-analysis based on current evidence

Literature searches of the Cochrane Library, PubMed, EMBASE, Web of Science, LILACS, China National Knowledge Infrastructure, and Wanfang Data databases were performed from 1966 to September 2014. Only randomized and quasi-randomized controlled clinical trials comparing operative and nonoperative treatments for displaced midshaft clavicle fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Thirteen studies were considered in the meta-analysis. Constant scores and the Disabilities of the Arm, Shoulder and Hand scores were improved in the operative fixation group at a follow up of one year or more. The nonunion and symptomatic malunion rates were significantly lower in the operative group. Additionally, the nonoperative group had a higher likelihood of neurological symptoms compared with the operative group. A significantly higher risk of complications was found in patients treated conservatively than in those who underwent operative fixation. However, when patients with nonunion and symptomatic malunion were excluded from the analysis, no significant differences in the complication rate were found. We concluded that based on the current clinical reports, operative treatment is superior to nonoperative treatment in the management of displaced midshaft clavicle fractures. However, we do not support the routine use of primary operative fixation for all displaced midshaft clavicle fractures in adults.

Acquired Adult Flatfoot: Pathophysiology, Diagnosis, and Nonoperative Treatment / 대한족부족관절학회지

Acquired adult flatfoot is a deformity characterized by a decreased medial longitudinal arch and a hindfoot valgus with or without forefoot abduction. The etiologies of this deformity include posterior tibial tendon dysfunction, rheumatoid arthritis, trauma, Charcot's joint, neurologic deficit, and damage to the medial spring ligament complex or plantar fascia. Among these, posterior tibial tendon dysfunction is the most well-known cause. Although posterior tibial tendon dysfunction has been regarded as a synonym of acquired adult acquired flatfoot, failure of the ligaments supporting the arch can also result in progressive deformity even without a posterior tibial tendon problem. The authors describe the pathophysiology, diagnosis, and nonoperative treatment of acquired adult flatfoot, focusing on posterior tibial tendon dysfunction.

Results with non-operative treatment in dorsolumbar fractures with no neurological deficit: A functional assessment.

Background: The purpose of this prospective study was to assess the functional outcome of conservative treatment with early ambulation of dorso-lumbar spine fractures with no neurological deficit. Aims & Objective: The purpose of this prospective study was to identify the risk factors for dorso-lumbar spine injuries, and to assess the efficacy of non-operative treatment with early ambulation, and functional outcome of the patients. Material and Methods: From October 2008 to June 2010, 48 consecutive patients with single- level thoracolumbar spinal injury, with no neurological deficit were managed non-operatively. A custom-made thoracolumbosacral orthosis was worn by all patients for six months, and early ambulation was recommended. Patients were evaluated as per TLICS score, and if score was <=4 with no neurological deficit then, they were treated with conservative treatment and included in the study. The Denis Pain and Work Scale were used to assess the clinical outcome. The average follow-up period was 6.5 months (range, 4 to 11 months). Statistical analysis done by observational descriptive statistics using SPSS 19.0. Results: Radiological parameters, such as Cobb’s angle, showed loss of fracture reduction, which was not statistically significant. However, the functional outcome was satisfactory in 40 out of 48 patients, with no complications recorded on completion of treatment. Conclusion: Conservative treatment with early mobilization using TLS orthosis had good results in patients with TLICS score <4. We support the concept that TLICS is a reliable and easy-to-use classification for the conservative treatment and prognosis of thoracolumbar spinal fractures.

Autologous transfusion of drained blood from abdomen for conservative treatment of blunt trauma of spleen / 中华急诊医学杂志

Objective To study the safety and feasibility of auto-transfusion of blood drained from patients own abdomen in patients with blunt trauma of spleen as conservative treatment.Methods From January 1,2008 to December 31,2010,94 patients were diagnosed to be blunt trauma of spleen.After careful assessment and series lab tests,44 patients were eligible to be non-operative treated.They were randomly (random number) into two groups in equal number (n =22).The patients of auto-transfusion group were transfused the blood drained from patients own abdomen,and the control group was transfused red blood cells from donors.The comparison of demographics,ISS (injury severity scores),AAST (American Association for the Surgery of Trauma) and lab findings between two groups before and after transfusion with t test and chi-square test.Then paired-samples t test was used to analyze the hemodynamics,blood components and blood clotting indexes of two groups before and after blood transfusion.Meanwhile t test was done as well to compare the differences in the above variables between two groups after transfusion.SPSS 10.0 version was used to analyze the collected data.Results There were no significant differences in demographics and physical condition between two groups.After blood transfusion,the hemodynamics and anemia of two groups were significantly improved,and there were no differences in the changes of the above variables between two groups.Conclusions Blood drained from patient own abdomen can be auto-transfused in patients with blunt trauma of spleen treated non-operatively as safe and efficient as transfusion of blood from donors.This study proves the autologous transfusionto to be an easy,feasible and economic measures in urgent situation as expected.

Comparative Study of Clinical and Radiologic Outcomes of Unstable Distal Radius Fractures in Patients 70 Years or Older: Nonoperative Versus Operative Treatment

PURPOSE: Clinical and radiologic results of operative versus nonoperative treatment were compared in patients 70 years or older who had an unstable distal radius fracture. MATERIALS AND METHODS: From March 2007 to April 2009, 49 patients who had an unstable distal radius fracture treated nonoperatively (22 patients) or operatively (27 patients) were investigated. The radiologic results between the two patient groups were compared based on bone union, dorsal tilt, radial inclination and radial shortening. The clinical results were compared based on disabilities of arm, shoulder & hand (DASH) score, the patient-rated wrist evaluation (PRWE) score, the grip strength and the motion range of the wrist joint. RESULTS: At the last follow-up examination, DASH score, PRWE score, the flexion, supination and radial deviation of wrist joint and the grip strength did not showed significant difference. Among the patients who received non-operative treatments, 18 of 22 showed radiologically recognizable deformation; average dorsal tilt of 11.9degrees, the average radial inclination of 18.9degrees, and average radial shortening of 3.8 mm. The patients who received operative treatments showed average volar tilt of 3.3degrees, radial inclination of 18.8degrees+/-3.7degrees, and radial shortening of 1.5 mm. Three patients showed radiologically recognizable deformation. CONCLUSION: Our results suggest that nonoperative treatment is initially recommended in patients with the age of 70 years or older who have an unstable distal radius fracture in terms of functional results.

Manejo terapéutico de pacientes con fractura del extremo distal de radio mayores de 60 años: revisión sistemática / Treatment of distal radius fractures in patients over 60 years old: a systematic review

The distal radius fracture is a fairly common clinical problem in elderly patients, treatment can be either surgical or conservative. We present a synthesis of evidence relating to compare the functional improvement of both treatment modalities, through a Systematic Review of randomized Clinical Trials. Objective: To determine whether there is scientific to endorse that functional improvement in the medium and long-term conservative versus surgical management in patients with fracture of the distal radius over 60 years. Search Strategy: Were included in Search Randomized Clinical Trials (RCTs), meta analysis (MT) and systematic Reviews (RS), the databases used were Medline, CINALH, Central (Cochrane), Lilacs and PEDro. Results: We selected three RCTs that met the eligibility criteria. Conclusions: There is limited evidence that surgical methods studied did not have better functional outcomes and long-term, compares with a closed reduction and cast. The SF-36 at 3-4 months, gives a DM of 3.01 (-1.6- 7.62), difference is not statistically significant (p = 0.54).

La fractura de radio distal es un problema clínico bastante frecuente en adultos mayores, el tratamiento puede ser de tipo quirúrgico o conservador. Realizaremos una síntesis de la evidencia, relativa a comparar la mejoría funcional de ambas modalidades terapéuticas, a través de una revisión sistemática de Ensayos Clínicos Aleatorizados. Objetivo: Determinar si existe evidencia científica que avale la mejoría funcional a mediano y largo plazo del manejo quirúrgico versus el conservador en pacientes con fractura del extremo distal del radio mayores de 60 años. Estrategia de Búsqueda: Se incluyeron en la búsqueda Ensayos Clínicos Aleatorizados (ECAs), Metaanálisis (MT) y Revisiones Sistemáticas (RS), las Bases de datos usadas fueron: Medline, CINALH, Central (Cochrane), Lilacs y PEDro. Resultados: Se seleccionaron 3 ECAs que cumplían con los criterios de elegibilidad. Conclusiones: Existe limitada evidencia que los métodos quirúrgicos estudiados no presentan mejores resultados funcionales a mediano y largo plazo, comparados con una reducción cerrada más yeso. El SF-36 al 3-4 mes, da una DM de 3,01 (-1,6 - 7,62), diferencia que no es estadísticamente significativa(p = 0,54).

Outcome of Nonoperative Treatment for Proximal Plantar Fasciitis: Comparative Analysis According to Plantar Fascia Thickness / 대한족부족관절학회지

PURPOSE: To evaluate the clinical outcome of proximal plantar fasciitis after nonoperative treatment, and also to find the correlation of the heel pain with the plantar fascia thickness measured by ultrasonography. MATERIALS AND METHODS: The study is based on 41 patients, 46 feet of the proximal plantar fasciitis that were treated conservatively with at least 12 months follow-up. All were treated with heel pad, Achilles and plantar fascia stretching and pain medications for at least 3 months. Heel ultrasonography was performed at the beginning of the treatment to measure the plantar fascia (PF) thickness and the echogenicity. PF thickness over 4 mm and less were grouped in to group A and B respectively to compare the clinical outcome. RESULTS: Average thickness of the PF at the calcaneal attach was 5.2 mm. Symptom duration before the treatment was average 13.2 month; group A being 14.6 months and group B being 9.0 months with no significant difference (p=0.09). As functional evaluation, Roles-Maudsley score improved from 3.4 initially to 2.3 at final follow-up, while morning heel pain also improved from average VAS pain score of 7.2 to 4.0. However Maudsley and VAS score both didn't show statistical difference between the 2 groups (p>0.05). CONCLUSION: Plantar fasciitis improved substantially with the nonoperative treatments. However, the 2 groups, divided according to 4 mm thickness by ultrasonography, didn't show significant difference in either symptom duration or in the clinical outcomes.

Efficacy of nonoperative management of blunt splenic injury in children

Background: Nonoperative treatment of blunt splenic injury in children has become routine standardization in Viet Nam. Objectives:This study aims to study the efficacy of nonoperative management (NOM) for blunt splenic injury (BSI) in children. Subjects and method: The records of all the patients treated in National Hospital of Pediatrics with final diagnosis blunt splenic injury between January 2000 and December 2006 were reviewed. The clinical signs, investigations, imaging studies, methods of treatment and results were analyzed. The splenic injuries were graded according to the American Association for the Surgery of Trauma (AAST). Results:There were 15 patients from one day to 12 years of age, with average injury grade 2.2. From 13 patients who were attempted NOM, only 2 patients (blunt liver injury - BLI grade 3 and 4) were operated thereafter because of continuing bleeding or worsening clinically, the remains of 12 recovered well with average hospitalized duration wasf 6 days. The NOM for BLI was successful in 11/13 (84.6%) in our series. Conclusion:NOM was highly efficient method and should be the standard initial approach for all the children with BLI. These patients must be closely monitored for prompt surgical treatment in case of NOM failure.

Effective comparison between nonoperative and operative treatment in calcaneal fractures / 中国矫形外科杂志

[Objective]To evaluate the effect of nonoperative and operative treatment in calcaneal fractures.[Method]Operative effect of 38 cases of calcaneal fracture of all kinds(42 foots)were analyzed.Accordind Essex-Loprestis classification,6 foots suffered type I tongue fracture,28 foots suffered compressed fracture(type Ⅱ),8 foots suffered serious comminuted fracture(type Ⅲ).All patients underwent open reduction interal fixation by Buttress plate(AO calcaneal fracture plate or simulated AO calcaneal fracture plate made domestically) from the extended "L" lateral approach.Postoperatively,no patient needed plaster fixation.All patients started non-weight-bearing fuctional exercise at 2-3days,gradual weight-bearing walking at 6-8 weeks.The result of operated group was compared with nonoperative treatment group.The follow-up period was from 10 months to 36 months,with an average of 17monthes.[Result]Assessed the effect by Maryland foot score,the base line included every foot.Total excellent and good rate in operative group was 93%,it was 100% in type I fracture group,96% in type Ⅱ fracture group,75% in type Ⅲ fracture group.The result of nonoperative treatment group was:total excellent and good rate was 67%,it was 92% in type I fracture group,77% in type Ⅱ fracture group,there was not excellent and good patients in type Ⅲ fracture group.[Conclusion]It is important to regain the flatness of subtalar joint and calcaneocuboid joint,maintain the normal shape of foot.The authors recommend that type Ⅱ and type Ⅲ fractures of calcaneus according Essex-Loprestis classification were treated with open reduction and interal fixation by Buttress plate.By selecting the appropriate approach,proper reducting and postoperative treating rightly,it is an ideal measure to treat calcaneal fracture by selection of treatment method acciding to patient's individual status and fracture type.

Distal radial fractures--Operative versus nonoperative treatment / 中华创伤骨科杂志

There is some evidence to suggest superior results of surgical treatment that includes open reduction internal fixation (ORIF) or percutaneous pin fixation (not including Kapandji pinning) to stabilize fracture fragments and improve functional ability compared with conservative treatment. However, larger studies with longer follow-up are needed to verify these results.

Ultravist(R) Test in Postoperative Small Bowel Obstruction

PURPOSE: To determine whether Ultravist(R) test can enable the surgeon to differentiate complete from partial small bowel obstruction in patients with adhesive small bowel obstruction and whether partial small bowel obstruction can be treated nonoperatively. METHODS: Ninety-two patients who had postoperative small bowel obstructions without any toxic signs underwent Ultravist(R) test. Ultravist(R) (40 ml) mixed with 40 ml of distilled water was administrated either orally or via nasogastric tube to each patient. Serial plain abdominal radiographs were taken 4, 6, and 8 hours later. RESULTS: A total of 58 patients (63%) whose contrast medium reached the colon within the first 8 hours were considered to have partial obstruction (test positive) and were successfully treated with intravenous hydration and nasogastric decompression. The remaining 34 patients (36.9%), in whom the contrast medium failed to reach the colon within the first 8 hours (test negative), were regarded as having complete obstruction. Twenty-three of those patients (67.6%) underwent surgery and the other 11 (32.4%) received conservative treatment. Adhesion bands with complete bowel obstruction were observed in all 23 surgical patients during laparotomy. All the patients with partial bowel obstruction were treated successfully with nonoperative methods. Positive Ultravist(R) test as an indicator for nonoperative treatment had a sensitivity of 84.5%, a specificity of 100%, an accuracy of 88% and a false negative rate of 12%. CONCLUSION: Ultravist(R) can be used to differentiate partial from complete intestinal obstruction. All patients with evidence of Ultravist(R) reaching the colon within 8 hours were treated successfully with non-operative methods.

Conservatively Treated Isolated Medial Collateral Ligament Injury of the Knee Joint / 대한정형외과학회잡지

PURPOSE: To determine the clinical results and healing potential of nonoperatively treated isolated medial collateral ligament injuries of the knee. MATERIALS AND METHODS: Fifty-four cases of isolated medial collateral ligament injuries of the knee, which were treated conservatively from Sept. 1993 to Aug. 1998 and followed up for at least one year at Konkuk University Medical Center MinJoong Hospital, were evaluated. Patients with previous knee injuries, knee operations, or general illness as well as with simultaneous knee fractures or other ligament injuries were excluded from the study. Immediate weight-bearing along with knee ROM and muscle strengthening excercise were allowed after the patient became accustomed to H-bar brace fitting. Thirty-three Grade II and 21 Grade I patients were given questionnaires and analyzed radiologically at an average of 44 months (range, 21-70 months) after injury. The methods used included three standardized knee scoring scales for subjective, functional, and objective or roentgenographic evaluations by Indelicato (1990) . RESULTS: Overall, 85.2 % good or excellent clinical results were obtained according to Indelicato's criteria at a short-term followup of a mean 44 months. Some residual medial laxity was common, and poor results were associated with underlying degenerative changes due to old age or from traffic accident. CONCLUSION: The outcome of the conservatively treated Grade I and II isolated medial collateral ligament injuries of the knee joint was generally good or excellent in 85.2 % of the patients. Advantages of the treatment included more rapid rehabilitation with less postoperative surgical complications, even though some residual medial laxity was common. Arthroscopy could also be useful in identifying other associated lesions such as mensicus or ACL tears.

Nonoperative Treatment of PDA Using the Duct-Occlud

PURPOSE: Among the several transcatheter devices of PDA occlusion, Rashikind device was the most extensively experienced, but it had risk of occluder embolism and incomplete occlusion of PDA, approximately 27%. The authors used Duct-Occlud , made of 0.028 inch stainless steel coil. The coil is double cone-shape in released state, and used in streched condition through 4F implantation catheter for ductus occlusion. We are to report the short-term result of PDA occlusion using Duct-Occlud. METHODS: Six patients with internal ductal diameter of less than 3.5mm were selected for ductus occlusion. The Duct-Occlud was selected as follows : the diameter of aortic end was same as aortic ampulla, and the length was slightly shorter than that of ductus. The streched coil was introduced into descending aorta through implantation catheter, and the remaining coil was released in ductus and pulmonary artery subsequently. Postprocedure aortic angiogram was obtained and echocardiography was performed at 1day, 1 week, 1 month and 3 month after the procedure. RESULTS: Except one hourglass type, all the other PDA were tunnel shaped. The range of internal diameter of ductus was 0.83-2.4mm, the length 5.36-P12.4mm, and Qp/Qs 1.04-1.67. Three cases required repositioniong of coils, while the others were successful in one procedure. The residual shunts were resolved at 1 day in most cases, but two cases in 1 month after the procedure. There were no complications, such as coil embolism, migration, or pulmonary stenosis. CONCLUSIONS: In small PDA with internal diameter of less than 3.5mm, transcatheter occlusion using Duct-Occlud is easy, safe and accurate, except with high cost.