Effectiveness of Non-operative Treatment of Symptomatic Accessory Navicular in Pediatric Patients

Category: Midfoot/Forefoot Introduction/Purpose: Initial management of symptomatic accessory naviculae in pediatric patients is nonoperative. Common first line treatments include casting, shoe wear modification, limiting strenuous activities, and nonsteroidal anti-inflammatories. When nonoperative treatments fail to mitigate symptoms, surgery is indicated. Surgical treatment of symptomatic accessory navicular bones has been extensively studied. However, the efficacy of nonoperative treatment for alleviating pain or preventing surgery in effected patients has not been established. We believe that nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, thus questioning whether surgery could be offered as first line treatment. Our study retrospectively reviews outcomes of adolescents treated non-operatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families. Methods: This is an IRB approved, retrospective study of adolescent patients diagnosed and treated non-operatively for symptomatic accessory navicular bones at Cincinnati Children’s Hospital Medical Center between the dates 8/1/2006 and 8/24/2016. Medical records were used to identify demographic information, type, duration, and total trials of conservative treatment, additional foot comorbidities, response to conservative management, and surgery if non-operative management failed. Included patients were under 18 years of age with medial sided foot pain, radiographic evidence of an accessory navicular, and had undergone at least 1 course of non-operative treatment. Patients with previously operated on accessory naviculars or other diagnosed painful foot conditions were excluded. Outcome measures consisted of pain relief, no surgical intervention, or need for surgical intervention. Available radiographic imaging for each patient was also used to identify type of accessory navicular and determine pes planus incidence. Statistical analysis using measures of central tendency was then performed. Results: 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with 78.2% females, and 22% males. 53 (32%) were left symptomatic accessory naviculae, 56 (33%) right, and 60 (36%) bilateral. Type II accessory naviculae were most frequent (72.7%), with Type I and Type III in 9.7% and 17.4%, respectively. 56% were chronic in nature, with 31% due to acute injury. Average number of non-operative trials was 2.08, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that did not require surgical intervention, but were without documented pain relief. Of those that achieved complete pain relief, average length of non-operative treatment was 8.03 months. Conclusion: Results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families. Further research is warranted to determine the necessary duration and type of non-operative treatment, among those most commonly used, that is most successful in providing pain relief.

Download Full-text

Occipital Neuralgia

10.1093/med/9780190271787.003.0001 ◽

2018 ◽

Author(s):

Andrea Dellaria ◽

Nirav N. Shah ◽

Helene Rubeiz

Keyword(s):

Pain Relief ◽

Local Anesthetic ◽

Medical Management ◽

Surgical Intervention ◽

International Headache Society ◽

Treatment Options ◽

Cervical Region ◽

Occipital Neuralgia ◽

Cranial Neuralgia ◽

Paroxysmal Pain

According to the International Headache Society, occipital neuralgia is classified as a cranial neuralgia. It is characterized by paroxysmal pain in the distribution of the greater, lesser, or third occipital nerve. The pain is typically located in the upper posterior cervical region and radiates to the vertex of the scalp, and it may be reproduced upon palpation of the involved nerve. The diagnosis of occipital neuralgia can definitively be made if the patients achieves pain relief after a local anesthetic nerve block. Occipital neuralgia is often idiopathic, but secondary structural etiologies may be identified in some cases. Treatment options range from medical management to surgical intervention.

Download Full-text

Urgent surgical intervention in pediatric patients with Chiari malformation Type I

Journal of Neurosurgery Pediatrics ◽

10.3171/ped-07/07/049 ◽

2007 ◽

Vol 107 (1) ◽

pp. 49-52 ◽

Cited By ~ 3

Author(s):

John C. Wellons ◽

R. Shane Tubbs ◽

Cuong J. Bui ◽

Paul A. Grabb ◽

W. Jerry Oakes

Keyword(s):

Chiari Malformation ◽

Pediatric Patients ◽

Surgical Intervention ◽

Type I ◽

Chiari Malformation Type I

Download Full-text

Meralgia paresthetica treated by injection, decompression, and neurectomy: a systematic review and meta-analysis of pain and operative outcomes

Journal of Neurosurgery ◽

10.3171/2020.7.jns202191 ◽

2021 ◽

pp. 1-11

Author(s):

Victor M. Lu ◽

S. Shelby Burks ◽

Rainya N. Heath ◽

Tizeta Wolde ◽

Robert J. Spinner ◽

...

Keyword(s):

Pain Relief ◽

Meta Analysis ◽

Treatment Options ◽

Outcome Data ◽

Cochrane Library ◽

Meralgia Paresthetica ◽

Multiple Treatment ◽

Operative Outcomes ◽

Complete Pain Relief ◽

The Cochrane Library

OBJECTIVEMeralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve (LFCN) and often presents with pain. Multiple treatment options targeting the LFCN can be pursued to treat the pain should conservative measures fail, with the most common options being injection, neurolysis, and neurectomy. However, their efficacy in causing pain relief and their clinical outcomes have yet to be directly compared. The aim of this study was to interrogate the contemporary literature and quantitatively define how these options compare.METHODSThe electronic databases Ovid Embase, PubMed, SCOPUS, and the Cochrane Library were interrogated from inception to May 2020 following the PRISMA guidelines. Candidate articles were screened against prespecified criteria. Outcome data were abstracted and pooled by random-effects meta-analysis of proportions.RESULTSThere were 25 articles that satisfied all criteria, reporting outcomes for a total of 670 meralgia paresthetica patients, with 78 (12%) treated by injection, 496 (74%) by neurolysis, and 96 (14%) by neurectomy. The incidence of complete pain relief was 85% (95% CI 71%–96%) after neurectomy, 63% (95% CI 56%–71%) after neurolysis, and 22% (95% CI 13%–33%) after injection, which were all statistically different (p < 0.01). The incidence of revision procedures was 12% (95% CI 4%–22%) after neurolysis and 0% (95% CI 0%–2%) after neurectomy, which were significantly lower than 81% (95% CI 64%–94%) after injection (p < 0.01). The incidences of treatment complications were statistically comparable across all three treatments, ranging from 0% to 5% (p = 0.34).CONCLUSIONSThere are multiple treatment options to target pain in meralgia paresthetica. The incidence of complete pain relief appears to be the greatest among the 3 interventions after neurectomy, accompanied by the lowest incidence of revision procedures. These findings should help inform patient preference and expectations. Greater exploration of the anatomical rationale for incomplete pain relief after surgical intervention will assist in optimizing further surgical treatment for meralgia paresthetica.

Download Full-text

Early Operative Versus Delayed or Nonoperative Treatment of Anterior Cruciate Ligament Injuries in Pediatric Patients

Journal of Athletic Training ◽

10.4085/1062-6050.51.5.11 ◽

2016 ◽

Vol 51 (5) ◽

pp. 425-427 ◽

Cited By ~ 26

Author(s):

Kristina L. Dunn ◽

Kenneth C. Lam ◽

Tamara C. Valovich McLeod

Keyword(s):

Anterior Cruciate Ligament ◽

Operative Treatment ◽

Pediatric Patients ◽

Cruciate Ligament ◽

Meta Analysis ◽

Meniscal Tear ◽

Return To Sport ◽

Nonoperative Treatment ◽

Level 3 ◽

Anterior Cruciate

Reference: Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014;42(11):2769–2776. Clinical Questions: In pediatric patients, does early operative treatment of an anterior cruciate ligament (ACL) injury result in decreased knee instability compared with delayed or nonoperative treatment? Data Sources: This review focused on the PubMed/MEDLINE and EMBASE databases. The following query searches were used: ACL or anterior cruciate ligament and young or child or children or pediatric or immature. Dates searched were not specified. A separate search was also conducted of abstracts published between 2009 and 2011 from the American Academy of Orthopaedic Surgeons; American Orthopaedic Society for Sports Medicine; International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; European Society of Sports Traumatology, Knee Surgery, and Arthroscopy; American Orthopaedic Association; Arthroscopy Association of North America; Pediatric Orthopaedic Society of North America; and American Academy of Pediatrics conferences. Study Selection: Available studies were included only if they were written in English; were of level 1, 2, or 3 evidence (grading taxonomy not stated); were cohort designs that compared nonoperative and operative treatments; involved an early versus delayed ACL reconstruction that could be prospective or retrospective; and reported primary outcome interest measures. Animal studies, basic science studies, case series, reviews, commentaries, and editorials were excluded from the review. Data Extraction: A systematic assessment tool, Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations, was used by 2 of the authors to independently grade the quality of each study that met the inclusion criteria. The tool focused on 6 areas: intervention and study description, sampling, measurement, analysis, interpretation of results, and other execution factors. This tool helped to ensure consistency, reduce bias, and improve the validity and reliability of preventive health care studies. Eleven studies met the inclusion criteria. Six studies compared nonoperative with operative treatment, and 5 studies compared early reconstruction (open physes) with delayed reconstruction (closed physes). Studies in this meta-analysis consisted of the following: four level-3 prospective studies, four level-3 retrospective studies, one level-2 retrospective study, one level-3 case-control study, and one level-3 study with both prospective and retrospective data collection. All of the studies included data related to patient demographics, treatment interventions, follow-up duration, presence of any meniscal symptoms, time to return to sport participation, patient-reported outcomes (International Knee Documentation Committee [IKDC], Lysholm, or Tegner scores), the need for a second surgical procedure, and any posttreatment problems. Main Results: Of those who chose the nonoperative route, 75% reported instability, whereas only 13.6% of those who had surgery reported instability. These data also showed that nonoperative or delayed-operative patients were 33.7 times more likely to report instability than the early operative group. Those who chose the nonoperative route had a 12 times greater risk (odds ratio = 12.2, 95% confidence interval = 1.55, 96.3) of developing a meniscal tear after the initial injury. Three studies included in the meta-analysis reported return to sport status, but only 2 studies provided adequate data for both operative and nonoperative patients. In 1 study, 92% of operative patients were able to return to sport, but only 43.75% of nonoperative patients were able to do so. The second study reported that all operative and nonoperative patients were able to return to the same level of sport after injury. Of those in the early operative group, 6% required a repeat surgical intervention for either an ACL rerupture or a meniscal tear, and 19% of those who initially chose nonoperative treatment eventually needed surgery to repair the ACL or meniscus. Findings favor the early operative group over the delayed operative and nonoperative groups based on IKDC scores. One study reported a significant difference in operative patients, with an IKDC mean score of 95 compared with 87 in the nonoperative group. Similarly, a different study reported a mean score of 94.6 in the early operative group compared with 82.4 in the delayed operative group and was stated to have met the minimal clinically important difference (MCID). The MCID was not met for the Lysholm and Tegner scores between operative and nonoperative patients. Conclusions: The results of this meta-analysis favor early operative treatment for pediatric patients with ACL tears over delayed or nonoperative treatment. Early operative treatment is initiated shortly after the injury, while the patient is still skeletally immature and the growth plates are open. Current evidence suggests that early ACL reconstruction will result in less knee instability and a more likely return to the preinjury activity level without affecting the growth plates or causing growth disturbances.

Download Full-text

Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses

The American Surgeon ◽

10.1177/000313481908500830 ◽

2019 ◽

Vol 85 (8) ◽

pp. 813-820

Author(s):

Ryan C. Pickens ◽

Stephanie Jensen ◽

Jesse K. Sulzer ◽

Maria Baimas-George ◽

Erin H. Baker ◽

...

Keyword(s):

Minimally Invasive ◽

Surgical Intervention ◽

Type I ◽

Type Ii ◽

Line Treatment ◽

First Line ◽

Algorithmic Approach ◽

Type Iii ◽

Minimally Invasive Surgical ◽

First Line Treatment

Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.

Download Full-text

Assessing the reliability of the modified Gartland classification system for extension-type supracondylar humerus fractures

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.13.190005 ◽

2019 ◽

Vol 13 (6) ◽

pp. 569-574 ◽

Cited By ~ 4

Author(s):

T. L. Teo ◽

E. K. Schaeffer ◽

E. Habib ◽

A. Cherukupalli ◽

A. P. Cooper ◽

...

Keyword(s):

Classification System ◽

Treatment Options ◽

Weighted Kappa ◽

Nonoperative Treatment ◽

Type I ◽

Elbow Fracture ◽

Type Ii ◽

Level Of Evidence ◽

Supracondylar Humerus Fractures ◽

Paediatric Orthopaedic

Purpose The Gartland extension-type supracondylar humerus (SCH) fracture is the most common paediatric elbow fracture. Treatment options range from nonoperative treatment (taping or casting) to operative treatments (closed reduction and percutaneous pinning or open reduction). Classification variability between surgeons is a potential contributing factor to existing controversy over treatment options for type II SCH fractures. This study investigated levels of agreement in extension-type SCH fracture classification using the modified Gartland classification system. Methods A retrospective review was conducted on 60 patients aged between two and 12 years who had sustained an extension-type SCH fracture and received operative or nonoperative treatment at a tertiary children’s hospital. Baseline radiographs were provided, and surgeons were asked to classify the fractures as type I, IIA, IIB or III according to the modified Gartland classification. Respondents were then asked to complete a second round of classifications using reshuffled radiographs. Weighted kappa values were calculated to assess interobserver and intraobserver levels of agreement. Results In all, 21 paediatric orthopaedic surgeons responded to the survey and 15 completed a second round of ratings. Interobserver agreement for classification based on the Gartland criteria between surgeons was substantial with a kappa of 0.679 (95% confidence interval (CI) 0.501 to 0.873). Intraobserver agreement was substantial with a kappa of 0.796, (95% CI 0.628 to 0.864) Conclusion Radiographic classification of extension-type SCH fractures demonstrated substantial agreement both between and within surgeon raters. Therefore, classification variability may not be a major contributing factor to the treatment controversy for type II SCH fractures and treatment variability may be due to differences in surgeon preferences. Level of Evidence III

Download Full-text

The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/2014.9.jns132779 ◽

2015 ◽

Vol 122 (1) ◽

pp. 169-179 ◽

Cited By ~ 13

Author(s):

Zachary J. Tempel ◽

Srinivas Chivukula ◽

Edward A. Monaco ◽

Greg Bowden ◽

Hideyuki Kano ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Anticoagulation Therapy ◽

Gamma Knife Radiosurgery ◽

Low Risk ◽

Type I ◽

The Third ◽

Complete Pain Relief ◽

Pain Outcomes

OBJECT Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain. METHODS A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes. RESULTS Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months. CONCLUSIONS A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.

Download Full-text

Soft tissue density within the foramen magnum, a predictor for surgical intervention in pediatric patients with Chiari malformation type I

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.6.peds19744 ◽

2020 ◽

Vol 26 (6) ◽

pp. 671-675

Author(s):

William Fuell ◽

Reem Elwy ◽

Thomas Harkey ◽

Matthew Carey ◽

Gregory W. Albert

Keyword(s):

Soft Tissue ◽

Pediatric Patients ◽

Surgical Intervention ◽

Foramen Magnum ◽

Type I ◽

Soft Tissue Density ◽

Tonsillar Herniation ◽

Chiari Malformation Type I ◽

Tissue Density ◽

Cerebellar Tonsils

OBJECTIVEChiari malformation type I (CMI) is diagnosed as herniation of the cerebellar tonsils by at least 5 mm below the foramen magnum. However, the degree of tonsillar herniation is a poor predictor of the need for decompression surgery. Exploration for an alternative morphological predictor for surgical intervention could provide greater insight into the development of an appropriate treatment plan for these patients. To investigate this issue, the authors calculated the soft tissue density within the foramen magnum as a measure of impaction of the cerebellar tonsils. Soft tissue density within the foramen magnum and degree of tonsillar herniation were then assessed for their correlation with the need for surgical intervention.METHODSThe authors conducted a retrospective, longitudinal chart review of pediatric patients with CMI. Those who had undergone surgical intervention were considered symptomatic and those who had been treated conservatively, as asymptomatic. Soft tissue density was found by dividing the soft tissue occupancy of the foramen magnum (brainstem and cerebellar tonsils) by the total area of the bony foramen magnum. The predictive value of these two measurements for the need of surgery was determined.RESULTSOf the 465 patients seen for CMI at the authors’ institution between July 1, 2011, and May 31, 2017, 80 underwent surgical intervention and 385 were asymptomatic. The average tissue density was significantly greater in the surgical group than in the asymptomatic group (83.3% and 78.6%, respectively, p < 0.0001). The average tonsillar descent for surgical patients was 10.8 mm compared to 9.8 mm for asymptomatic patients (p = 0.140). The point-biserial correlation coefficient was assessed, and soft tissue density was found to positively correlate with the need for surgical intervention (rpb = 0.199, p = 0.0001), whereas tonsillar herniation did not correlate with the need for surgery (rpb = 0.083, p = 0.115). Additionally, the degree of tonsillar herniation did not correlate with soft tissue density (r = 0.09), indicating that soft tissue density is an independent morphological parameter.CONCLUSIONSThe study findings suggest that the need for surgical intervention in CMI patients is positively correlated with increasing soft tissue density within the foramen magnum, whereas the degree of tonsillar herniation did not show a correlation with the need for surgical intervention. Additionally, soft tissue density is a factor independent of the degree of tonsillar herniation. Further investigation of tissue density within the foramen magnum is needed in the hope of discovering a clinically applicable parameter that would indicate a need for surgical intervention in patients with CMI.

Download Full-text

Single-Stage Reconstruction of Perforated Choledochal Cyst: Case Report and Review of the Literature

The American Surgeon ◽

10.1177/000313480507100506 ◽

2005 ◽

Vol 71 (5) ◽

pp. 398-401 ◽

Cited By ~ 5

Author(s):

Dion L. Franga ◽

Charles G. Howell ◽

John D. Mellinger ◽

Robyn M. Hatley

Keyword(s):

Choledochal Cyst ◽

Surgical Intervention ◽

Treatment Options ◽

Rare Event ◽

Single Stage ◽

Western World ◽

Recent Experience ◽

Type I ◽

Endoscopic Retrograde

Choledochal cysts represent a rare disease in the Western world. We reviewed our recent experience with a case of perforated choledochal cyst, define the currently accepted treatment options, and review the literature of this unusual disease. An 11-month-old girl presented with abdominal pain and distention as well as non-bilious vomiting. Subsequent workup included endoscopic retrograde cholangiopancreatography revealing a perforated type I choledochal cyst. She underwent single-stage excision and reconstruction with a Roux- en-Y hepaticojejunostomy. Perforated choledochal cyst is a rare event, and prompt surgical intervention is warranted. Single-stage cystectomy and Roux- en-Y reconstruction is possible in select patients. A thorough understanding of the pathophysiology, management, and follow-up is required.

Download Full-text

Osteochondral Lesions of the Talus

Foot & Ankle Orthopaedics ◽

10.1177/2473011418779559 ◽

2018 ◽

Vol 3 (3) ◽

pp. 247301141877955 ◽

Cited By ~ 10

Author(s):

John R. Steele ◽

Travis J. Dekker ◽

Andrew E. Federer ◽

Jordan L. Liles ◽

Samuel B. Adams ◽

...

Keyword(s):

Operative Treatment ◽

Cartilage Repair ◽

Satisfactory Result ◽

Treatment Options ◽

Lesion Size ◽

Nonoperative Treatment ◽

Osteochondral Lesions ◽

Appropriate Treatment ◽

Promising Treatment

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Download Full-text