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Osteonecrosis, also known as avascular necrosis or AVN, is characterized by a stereotypical pattern of cell death and a complex repair process of bone resorption and formation. It is not the necrosis itself but rather the resorptive component of the repair process that results in loss of structural integrity and subchondral fracture. Most likely, a common pathophysiological pathway exists involving compromised subchondral microcirculation. Decreased femoral head blood flow can occur through three mechanisms: vascular interruption by fractures or dislocation, intravascular occlusion from thrombi or embolic fat, or intraosseous extravascular compression from lipocyte hypertrophy or Gaucher cells. In this review, we emphasize etiologic relationships derived mostly from longitudinal cohort studies or meta-analyses whose causal relationships to osteonecrosis can be estimated with confidence. Understanding risk factors and pathophysiology has therapeutic implications since several treatment regimens are available to optimize femoral head circulation, interrupt bone resorption, and preserve the subchondral bone.

The assessment for safety and effectiveness of surgical interventions in the management of diabetic foot ulcers (DFUs) in comparison to non‐surgical approaches was performed. A comprehensive search was performed across PubMed, MEDLINE, Cochrane Library and EMBASE in order to identify case–control studies, randomized controlled trials (RCTs), observational studies, cohort studies and observational studies pertaining to DFU treatments. Studies conducted in English language and focusing on wound healing rates, recurrence rates, time to healing and complication management met the inclusion criteria. There were six studies included in this meta‐analysis. Surgical procedures, such as debridement, revascularization and skin transplantation, demonstrated significantly superior efficacy in promoting wound healing (84%) and shorter duration of healing (6 weeks) in comparison to non‐surgical approaches, including off‐loading, wound dressings and pharmacological therapies. Surgical interventions for DFUs resulted in a wound recovery rate of 84%, a significantly higher mean rate than non‐surgical approaches (60%) that was observed. In addition, it was observed that the surgical group experienced considerably reduced average healing period of 9 weeks, in contrast to the non‐surgical group's mean healing period of 12 weeks. Nevertheless, it is imperative to acknowledge that surgical procedures were notably correlated with a heightened occurrence of complications, such as amputations, which transpired in 19% of instances. Surgical interventions for DFUs may provide superior short‐term results with regard to healing rates and recovery time, as indicated by this meta‐analysis. However, they are additionally correlated with the heightened likelihood of complications. Although non‐surgical techniques offered comparatively secure option, they were also less reliable. Individualized treatment modalities should be chosen in consideration of patient‐specific factors and comparative advantages and disadvantages.

Background As the incidence of ATR is increasing the risk of ruptures being missed escalates and more injuries are suspected to become chronic. This study aimed to assess the incidence and causes of delayed diagnosis in chronic ATR. Additionally, the patient-reported outcome of surgical versus non-surgical treatment following delayed presentation was evaluated. Methods The study is of patients with chronic ATR treated at the Sahlgrenska University Hospital between 2015 and 2020. Patients were identified using specific International Classification of Diseases (ICD) codes for ATR and included all patients in whom the treatment had been delayed for more than 14 days. The patients who accepted to participate in the study completed the Achilles tendon Total Rupture Score (ATRS) and a questionnaire regarding recovery rate in percentage. Results Out of the 958 patients with ATR, 102 were identified as chronic, comprising 11% of the overall dataset. A total of 75 patients were included. Patients with chronic injury exhibited higher age, BMI, and comorbidity rates compared with patients with acute ruptures. Fifty-two (84%) patients delayed seeking medical attention. The rates of patients initially receiving an incorrect diagnosis was low, with 10 (1%) directly associated with trauma and 28 (3%) during later medical visits. Patients that were surgically treated ( n  = 57) for their chronic Achilles tendon rupture yielded significantly higher median (IQR) ATRS scores; 77 (50 ; 92) vs. 34 (23 ; 82) and recovery rates; 85% (70 ; 95) vs. 40% (20 ; 78) compared with patients treated with a non-surgical approach ( n  = 18). Conclusions This study reveals that chronic ATRs constitute a significant portion of all ATR. These were primarily due to “patient’s delay” rather than the relatively rare misdiagnosis. Patient-reported outcomes, such as ATRS scores and self-reported recovery, exhibit considerable variability. Surgical intervention gave superior patient reported outcome compared with non-surgical treatment for patients affected by a chronic Achilles tendon rupture.

The review describes the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling technique, and (4) the overall outcomes of these procedures. Core decompression has optimal outcomes when used in the earliest, precollapse disease stages. More recent studies have reported excellent outcomes with percutaneous drilling. Furthermore, adjunct treatment methods combining core decompression with growth factors, bone morphogenic proteins, stem cells, and bone grafting have demonstrated positive results; however, larger randomized trial is needed to evaluate their overall efficacy.

Background Ankylosing spinal disorders (ASD) increase the risk of unstable cervical spine fractures, posing a significant mortality risk. Surgery is recommended for patients with neurological deficits, but the effectiveness of non-surgical treatment in those without deficits remains unclear. This study aimed to compare survival rates between surgical and non-surgical treatments of ASD-related cervical fractures in a matched cohort. Methods The study analyzed data from the Swedish Fracture Registry (SFR) on adult patients treated for ASD-related cervical spine fractures between January 2015 and December 2021. Preoperative variables included age, sex, trauma type, neurological function, fracture morphology, and treatment method. Propensity score matching was conducted to compare outcomes between treatment groups, ensuring balanced comparison groups regarding age, sex, type of trauma, time from injury to admission, fracture type, level of injury, and neurological function. Results In total, 357 adult patients with ASD-related cervical spine fractures were analyzed. Among them, 186 were treated surgically and 171 non-surgically. Treatment failure and conversion so surgical treatment was seen in 3.4% of the non-surgically treated patients. Most patients were male (80%), with a median age of 75 years. Fractures were mainly caused by low-energy trauma (69%). Most patients (92%) were ambulatory (Frankel grade D or E). In the unmatched analysis, surgically treated patients had significantly lower 1-year mortality rates (13% vs. 22%; p  < 0.001), but after matching, there were no longer any difference between the two groups (16% vs. 22%; p  = 0.44). These findings were also validated on Kaplan–Meier analysis. Multivariable logistic regression analysis identified high age as the only predictor for 30-day mortality (OR 1.14 [95% CI 1.09—1.22], p  < 0.001). Conclusion Following propensity score matching, surgical and conservative management result in similar mortality outcomes for neurologically intact patients with ASD fractures. Age, rather than treatment approach, emerged as a stronger predictor of overall mortality. Nonetheless, treatment decisions should also consider other clinical outcomes beyond mortality, emphasizing the need for an individualized approach until more robust evidence is available.

Osteonecrosis of femoral head is a rare but disabling condition that usually results in progressive femoral head collapse and secondary arthritis necessitating total hip arthroplasty if not treated appropriately in early stages. However, early diagnosis is challenging as the onset of disease is insidious and the symptoms and signs are usually minimal and nonspecific until it becomes advanced. Of several diagnostic modalities, magnetic resonance imaging (MRI) is considered the imaging method of choice with the highest sensitivity and specificity, while detection of potential risk factors is very important as well. Many investigators have developed several different classification systems; however, there still is controversy regarding the optimal classification system. Diagnostic methods and the evolution of different classification systems will be reviewed in this paper.

Purpose To investigate the radiographic and clinical outcomes of non-surgical treatment for medial meniscus posterior root tear (MMPRT), and prognostic factors for osteoarthritis (OA) progression and clinical failure. Methods A prospectively collected database was retrospectively reviewed for patients who were diagnosed with acute medial meniscus posterior root tear (MMPRT) between 2013 and 2021 and treated non-surgically for more than 2 years. Patient demographic characteristics and clinical outcomes including pain numeric rating scale (NRS), International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity scale were evaluated. For radiographic evaluation, knee radiographs were obtained to assess the angle of knee alignment and Kellgren–Lawrence (K–L) grade during the first and annually follow-up visits. Baseline magnetic resonance (MR) images were reviewed for the presence of medial meniscus extrusion, bone marrow edema, subchondral insufficiency fracture of medial femoral condyle, and cartilage lesion. The OA progression group was defined as patients who experienced a worsening of one or more grades in the K–L classification system. Prognostic factors were evaluated for OA progression and conversion to total knee arthroplasty (TKA). Results Ninety-four patients (90 female and 4 male) with a mean age of 67.0 ± 7.3 years (range, 53–83 years) were followed for a mean of 46.1 ± 22.1 months (range, 24.1–170.5). During the follow-up period, no significant differences in clinical scores were observed, and there were also no significant differences between the groups with and without OA progression. Overall, 12 patients (13%) underwent TKA at a mean of 20.7 ± 16.5 months (range, 8–69 months) and 34 patients (36%) demonstrated OA progression at a mean time of 24 ± 15 months (range, 12–62). The subchondral insufficiency fracture was a prognostic factor for OA progression ( p  = 0.045 for knee radiograph and p  = 0.019 for MR) and conversion to TKA (RR, 4.08 [95% CI 1.23–13.57]; p  = 0.022). Conclusions Non-surgical treatment for acute medial meniscus posterior root tear did not result in any significant change in clinical outcomes from the initial to the final follow-up. The rate of conversion to arthroplasty was 13%, and the rate of osteoarthritis progression was 36%. Furthermore, subchondral insufficiency fracture was found to be a concomitant prognostic factor correlated with OA progression and conversion to arthroplasty. This information can provide insights for physicians when discussing treatment options with patients, particularly regarding the use of non-surgical treatment and may contribute as a source for future studies of medial meniscus posterior root tear. Level of evidence IV.

Background The surgical rate for distal radius fractures is steadily rising despite limited evidence of its benefits over non-surgical treatment. Using a natural experimental approach, we aimed to compare patient-reported outcomes following surgical versus non-surgical treatment of distal radius fractures. Methods Registered in the Swedish Fracture Register by 36 Swedish hospitals from 2013 to 2018, we included a cohort of 13,356 fractures on 13,031 patients aged 18 years or older with distal radius fractures Arbeitsgemeinschaft fur Osteosynthesefragen (AO) 23-A2.1–2, A3, and C1-C3. The observational study utilized differences in the frequency of surgical treatment across hospitals as a source of random treatment assignment and a natural experiment. We assumed that all hospitals encountered a similar range of fractures each year. Therefore, the annual frequency of surgery per hospital was used as a proxy for randomization between surgical and nonsurgical treatment, regardless of each patient's actual treatment. The outcome was the individual Patient Reported Outcome Measures (PROM) at 1 year, with the Arm and Hand Function Index from the Short Musculoskeletal Function Assessment (SMFA) as the primary measure. Results The surgical rate per hospital year ranged from 7 to 66%. Surgical treatment was associated with lower Arm and Hand Function Index scores in comminuted intraarticular fractures of type C2 (11.9 units, p =  0.004) and type C3 (19.4 units, p =  0.029). There was a tendency for a positive association with surgical treatment in dorsally angulated extraarticular fractures (23A2.2), but the difference of 5.1 units ( p =  0.079) was below the Minimal Clinically Important Difference (MCID). In other extra-articular fractures (23-A2.1 and 23-A3) and simple intra-articular fractures (23-C1), the benefits of surgical treatment were small and also not statistically significant. Several sensitivity analyses were conducted to test the study design, and all supported the primary results. Conclusions In this comparison of surgical and non-surgical treatment for distal radius fractures across hospitals with varying surgical rates, comminuted intra-articular distal radius fractures (AO 23-C2/C3) treated surgically were associated with better one-year patient-reported outcomes than those treated non-surgically.

Objectives To compare surgical (ST) and non-surgical (NST) debridement for the treatment of peri-implantitis in a two-center randomized trial. Materials and methods Forty-five individuals with 63 implants with probing depth (PPD) ≥5mm, bleeding on probing (BOP), and radiographic bone loss ≥2mm were included. In the NST (30 implants), submucosal debridement was performed. In the ST (33 implants), a mucoperiosteal flap was raised and surfaces were decontaminated only by debridement as performed in NST. Clinical parameters and radiographs were compared at baseline and after 12 months. Means and standard errors were reported. Results PPD considering all implant sites reduced significantly in NST from 4.14±0.25 to 3.25±0.18mm. In ST, PPD also significantly changed (3.74±0.22 to 3.00±0.29mm). No significant differences were observed between the two groups. For deep sites (≥7mm), PPD was 7.82±0.20mm at baseline and reduced to 5.10±0.30mm in NST, while in ST group, it was 7.11±0.11mm and changed to 5.22±0.91mm (between-groups p value=0.51). BOP significantly reduced from ~60 to 35% of all sites in both groups, without significant differences between them. When sites with radiographic bone level ≥3mm at baseline were analyzed, there was a significant difference between groups in bone gain after 12 months in favor of ST (ST=0.78±0.30mm compared to NST=0.25mm±0.13; p =0.03). Conclusions Surgical and non-surgical debridement for the treatment of peri-implantitis present similar clinical outcomes. Bone levels were better improved in ST than NST for sites with higher initial bone loss. Clinical relevance The treatment of peri-implantitis is still a challenge in clinical practice, since less than half of affected implants achieve health after surgical or non-surgical debridement. Considering the lack of clinically relevant differences between these two treatments, non-surgical debridement should be considered the first therapeutic choice for peri-implantitis, mainly mild to moderate cases.

Cervical myelopathy is the most common cause of acquired spinal cord compromise. The concept of degenerative cervical myelopathy (DCM), defined as symptomatic myelopathy associated with degenerative arthropathic changes in the spine axis, is being introduced. Given its progressive nature, treatment options have to be chosen in a timely manner. Surgical options include anterior discectomy and fusion (ACDF), anterior corpectomy and fusion (ACCF), arthroplasty (in highly select cases), posterior laminectomy with/without fusion, and laminoplasty. Indications for each should be carefully considered in individual patients. Riluzole, a sodium-glutamate antagonist, is a promising option to optimize neurologic outcomes post-surgery and is being examined in the CSM-Protect Randomized Controlled Trial. Preoperative risk assessment is mandatory for prognostication. Sagittal alignment is known to play an important role to optimize surgical outcome. Guidelines for optimal management of DCM are in process. In principle, all but the mildest cases of DCM should be offered surgery for optimal outcome.