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Conservative & Adjunct

Non-pharmacological and interventional modalities for spinal pathology, focusing on biopsychosocial pain management and functional restoration to avoid surgical intervention.

Overview

The most compelling indication for spinal orthoses remains the management of traumatic spine injury [1]. While therapeutic modalities have expanded, concurrent efforts aim to better define which are truly effective [2]. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted [3]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [23].

LIPUS treatment should be considered as a conservative non-surgical treatment option to potentially reduce the socioeconomic impact and improve the quality of life of patients with instrumented, infected, and fragility non-unions [4]. Most data indicate a positive effect for use of direct current stimulation in spinal fusion, but further studies are necessary to determine its appropriateness as an adjuvant [26]. Despite ample evidence supporting the efficacy of opioid-sparing, multimodal strategies, adoption has been slow [12]. Firm guidelines for perioperative management of rheumatoid medications are difficult to obtain, and treatment must be individualized to each patient with respect to limiting the risk of postoperative complications versus disease flare [25].

Any conclusion regarding the comparison of acute repairs and non-operative management for complete proximal hamstring avulsions is limited due to the dearth of non-operative management studies and the high risk of bias [13]. Prophylactic vacuum-assisted incisional dressings appear reasonable for patients at risk of complications but do not provide benefit in routine cases [16]. Long-term suppressive oral antibiotics may be considered for chronic periprosthetic joint infections in patients who are not surgical candidates, refuse surgery, or for whom surgery is not expected to improve functional outcomes [17]. Manual edema mobilization techniques should be considered in conjunction with conventional therapies in cases of excessive edema or when edema has not responded to conventional treatment alone [7], though manual edema mobilization is not advocated as a routine intervention [7].

Anatomy & Pathophysiology

Osseous & Spinal Mechanics

Spinal orthoses are most compellingly indicated for the management of traumatic spine injury [1]. The second edition of The Milwaukee Brace includes significant revisions to roentgenogram recommendations, indications for non-operative treatment, and management of cervical kyphosis and round-back [32]. Percutaneous surgical treatment of thoracolumbar fractures in ankylosing spondylitis patients can improve pain, neurological function, and kyphotic deformity with effects similar to traditional methods [46]. Overall bone metabolism of the operated intervertebral disc space at six weeks has the highest diagnostic accuracy for predicting fusion status at one year after posterior lumbar interbody fusion [35]. Preoperative planning for pedicle screw insertion in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [52]. Sex differences in baseline kyphosis, bone mineral density, spine strength, fractures, and DISH do not affect treatment response to targeted kyphosis-specific exercise and posture training in community-dwelling older adults [51].

Kinematics & Neuromuscular Control

Regular wear of a lumbosacral orthosis for three weeks in healthy subjects results in neuromuscular changes, specifically measured as alterations in trunk stiffness, damping, muscle activation patterns, and spine compression forces [38]. A range of wearable technologies and biofeedback modalities exist to modulate spine motor control, though standardized reporting and further research are needed to establish clinical efficacy [39]. There is no need for additional training to improve postural control in adolescents with idiopathic scoliosis compared to their healthy peers [58]. Posterior and posterior superior labral (PPS) injuries produce alterations in glenohumeral kinematics with implications for joint instability, increased joint loading, and potential joint damage [45]. Dynamic taping has the potential to be clinically beneficial before engaging in exercises for individuals with symptomatic rotator cuff tendinopathy [57].

Pathophysiology & Adjunct Modalities

Individuals with chronic musculoskeletal pain consider biological factors such as musculoskeletal structural changes to be the main cause of their condition [44]. Evidence for the use of relative motion orthosis in non-surgically managing adult and pediatric trigger finger is absent [19]. Innovative methodologies ensuring patient safety in gene therapy and tissue engineering can potentially lead to new treatment strategies for musculoskeletal conditions [59]. A simple, effective arm-traction apparatus has been devised to relieve discomfort by enabling elevation to an inclined or sitting position while maintaining traction alignment [60].

Classification

Spinal Trauma: Spinal orthoses are most compellingly indicated for the management of traumatic spine injury [1].

Coxa Vara: Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5].

Acute Compartment Syndrome: Acute compartment syndrome is a clinical emergency requiring vigilance, prompt diagnosis, and treatment [8]. Risk factors for acute compartment syndrome include high-energy injuries, specific fracture patterns, and younger age [8]. Current diagnostic methods for acute compartment syndrome show discrepancies [8].

De Quervain's Disease: Classification of patients based on pre-treatment symptom severity assists in selecting the most efficacious treatment for De Quervain's disease [18]. Minimal symptoms: Splintage and NSAIDs are effective [18]. Mild to severe symptoms: Steroid injection is the initial treatment of choice [18].

Calcific Tendinopathy: Factors associated with calcium reabsorption in the shoulder include the Gartner classification, disease duration, and blood flow around calcium deposits [50].

Patellar Dislocation: Operative treatment for recurrent patellar dislocation achieved good results [34]. In some cases of recurrent patellar dislocation, functional scores remain inferior following operative treatment [34].

Other Considerations: There appears to be little consensus on nomenclature when discussing various PRP/PRGF preparations, making investigation difficult [11]. Prophylactic vacuum-assisted incisional dressings appear reasonable for patients at risk of complications but do not provide benefit in routine cases [16]. The use of BoNT-A for the management of Raynaud phenomenon is an off-label, experimental use that is not FDA-approved but may have a role in the minimally invasive management of the condition [21]. The 1.5-stage revision does not show inferior results compared to the two-stage technique [31]. The 1.5-stage revision reduces the number of additional surgical procedures compared to the two-stage technique [31]. The difference in morbidity between groups in iliac crest bone graft procurement was attributable to the use of the modified incision [54]. The STarT Back Tool is utilized as a stratification tool for targeted treatment in a group intervention for patients with low back pain [55].

Clinical Presentation

The most compelling indication for spinal orthoses remains the management of traumatic spine injury [1]. Concurrent efforts continue to define which therapeutic modalities are truly effective despite an increase in available options [2]. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted [3]. Low intensity pulsed ultrasound (LIPUS) treatment should be considered as a conservative non-surgical treatment option to potentially reduce the socioeconomic impact and improve the quality of life of patients with instrumented, infected, and fragility non-unions [4].

Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. Classification of patients based on pre-treatment symptom severity assists in selecting the most efficacious treatment for De Quervain's disease [18]. Splintage and NSAIDs are effective for minimal symptoms in De Quervain's disease [18], while steroid injection is the initial treatment of choice for mild to severe De Quervain's disease [18].

Acute Compartment Syndrome: This condition is a clinical emergency requiring vigilance, prompt diagnosis, and treatment [8]. Current diagnostic methods for acute compartment syndrome show discrepancies [8]. Risk factors for acute compartment syndrome include high-energy injuries, specific fracture patterns, and younger age [8]. Cast Syndrome: Death is a possibility in cast syndrome unless there is early recognition of the condition and vigorous therapy is instituted [10].

Edema Management: Manual edema mobilization techniques should be considered in conjunction with conventional therapies in cases of excessive edema or when edema has not responded to conventional treatment alone [7]. Manual edema mobilization is not advocated as a routine intervention [7]. Pain and Inflammation: Subjects reported a significant increase in wrist joint flexibility carried over to 2 hours after superficial heat modality treatment [37]. Superficial heat modalities demonstrate the potential of these modalities as pain management adjuncts [37].

Injections and Procedures: The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years [6]. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection [22]. Cooled radiofrequency ablation of the sacroiliac joint is a simple procedure that can be done in less than 30 min [20] and is capable of providing significant pain relief for patients with sacroiliac joint dysfunction [20].

Adjuncts and Experimental Therapies: There is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery [9]. Despite ample evidence supporting the efficacy of opioid-sparing, multimodal strategies, adoption has been slow [12]. There appears to be little consensus on nomenclature when discussing various PRP/PRGF preparations, making investigation difficult [11]. The use of BoNT-A for the management of Raynaud phenomenon is an off-label, experimental use that is not FDA-approved [21], though it may have a role in the minimally invasive management of the condition [21].

Investigations

Plain radiography: The second edition of The Milwaukee Brace includes significant revisions to roentgenogram recommendations, indications for non-operative treatment, and management of cervical kyphosis and round-back [32]. Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5].

MRI: Early MRI investigation is prudent for high-energy injuries associated with traumatic posterior dislocation of the shoulder [56]. Patients with weakness in external rotation or abduction after posterior shoulder dislocation may have rotator cuff injury [56].

Bone scan: Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year after posterior lumbar interbody fusion [35].

Other Considerations: Spinal orthoses are most compellingly indicated for the management of traumatic spine injury [1]. There is a concurrent effort to better define which therapeutic modalities are truly effective, despite an increase in the number of available modalities [2]. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted [3]. The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years [6]. Acute compartment syndrome is a clinical emergency requiring vigilance, prompt diagnosis, and treatment [8]. Current diagnostic methods for acute compartment syndrome show discrepancies [8]. Risk factors for acute compartment syndrome include high-energy injuries, specific fracture patterns, and younger age [8]. There appears to be little consensus on nomenclature when discussing various PRP/PRGF preparations, making investigation difficult [11]. Any conclusion regarding the comparison of acute repairs and non-operative management for complete proximal hamstring avulsions is limited due to the dearth of non-operative management studies and the high risk of bias [13]. Cooled radiofrequency ablation of the sacroiliac joint is a simple procedure that can be done in less than 30 min [20]. Cooled radiofrequency ablation of the sacroiliac joint is capable of providing significant pain relief for patients with sacroiliac joint dysfunction [20]. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection [22]. Low-intensity pulsed ultrasound (LIPUS) treatment results in significantly greater progress toward bone healing compared to no LIPUS treatment in subjects with established delayed unions of the tibia [33]. Individualised radial extracorporeal shock wave therapy (rESWT) for symptomatic calcific shoulder tendinopathy requires support from randomised controlled trials [36]. A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy will contribute to better decision making in the treatment of cervical radiculopathy [48]. 3D-printed percutaneous guides in drilled decompression of femoral head necrosis reduce operative time, fluoroscopy, and guide needle adjustments [53]. 3D-printed percutaneous guides in drilled decompression of femoral head necrosis are more effective in preventing the progression of femoral head necrosis to advanced stages compared to traditional surgery under fluoroscopy [53].

Treatment

Non-Operative

Spinal orthoses are most compellingly indicated for the management of traumatic spine injury [1]. Low intensity pulsed ultrasound (LIPUS) treatment should be considered as a conservative non-surgical treatment option to potentially reduce the socioeconomic impact and improve the quality of life of patients with instrumented, infected, and fragility non-unions [4]. Percutaneous needle fasciotomy for primary Dupuytren's contracture showed a significant change in total passive extension deficit after 2 years, with the best results for correction of total passive extension deficit occurring in MCP joint contractures [27]. Extracorporeal shock wave therapy (ESWT) and high-intensity laser therapy (HILT) are effective non-invasive options for treating calcaneal spur-related symptoms, with ESWT providing slightly greater functional benefits than HILT [42]. Recent literature supports a trial of corticosteroid injections followed by A1 pulley release for diabetics who fail nonoperative treatment, as diabetic status does not change long-term failure rates after injection [14]. Leukocyte-rich platelet-rich plasma (L-PRP) and surgery produce equivalent functional outcomes for the management of refractory tennis elbow, though surgery may result in lower pain scores at 12 months compared to L-PRP injection [15]. Evidence for the use of relative motion orthosis in the non-surgical management of adult and pediatric trigger finger is absent [19].

Pain Management

Despite ample evidence supporting the efficacy of opioid-sparing, multimodal strategies, adoption of these strategies in upper extremity surgery has been slow [12]. There is currently insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery [9]. A study protocol describes a trial designed to compare the effects of five different spinal cord stimulation (SCS) modalities in patients with complex regional pain syndrome to determine which frequency is most effective in terms of pain reduction [43].

Adjuncts

Most data indicate a positive effect for the use of direct current stimulation in spinal fusion, but further studies are necessary to determine its appropriateness as an adjuvant [26]. The authors recommend the use of peripherally inserted silicone-elastomer catheters in orthopaedic patients who need prolonged intravenous therapy [40]. Recommendations exist to use only normal saline instead of antiseptic solutions for irrigation of penetrating hand wounds and to avoid high-pressure irrigation for these injuries [41].

General Considerations

There is a concurrent effort to better define which therapeutic modalities are truly effective, despite an increase in the number of available modalities [2]. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted [3]. Any conclusion regarding the comparison of acute repairs and non-operative management for complete proximal hamstring avulsions is limited due to the dearth of non-operative management studies and the high risk of bias [13]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [23]. Firm guidelines for perioperative management of rheumatoid medications are difficult to obtain, and treatment must be individualized to each patient with respect to limiting the risk of postoperative complications versus disease flare [25]. Evaluation for coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5].

Complications

Other Considerations: Spinal orthoses are most compellingly indicated for the management of traumatic spine injury [1], though concurrent efforts continue to better define which therapeutic modalities are truly effective despite an increase in available options [2]. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted [3]. Low intensity pulsed ultrasound (LIPUS) treatment should be considered as a conservative non-surgical treatment option to potentially reduce the socioeconomic impact and improve the quality of life of patients with instrumented, infected, and fragility non-unions [4]. Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years [6]. Manual edema mobilization techniques should be considered in conjunction with conventional therapies in cases of excessive edema or when edema has not responded to conventional treatment alone, but manual edema mobilization is not advocated as a routine intervention [7]. Death is a possibility in cast syndrome unless there is early recognition of the condition and vigorous therapy is instituted [10]. Recent literature supports a trial of corticosteroid injections followed by A1 pulley release for diabetics who fail nonoperative treatment, as diabetic status does not change long-term failure rates after injection [14]. Leukocyte-rich platelet-rich plasma (L-PRP) and surgery produce equivalent functional outcomes for the management of refractory tennis elbow, though surgery may result in lower pain scores at 12 months compared to L-PRP [15]. Prophylactic vacuum-assisted incisional dressings appear reasonable for patients at risk of complications but do not provide benefit in routine cases [16]. Long-term suppressive oral antibiotics may be considered for chronic periprosthetic joint infections in patients who are not surgical candidates, refuse surgery, or for whom surgery is not expected to improve functional outcomes [17]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes regarding the effects of transcutaneous vagus nerve stimulation on chronic low back pain [24]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes (PRO) or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up [28]. Although contracture may recur following enzymatic (collagenase) treatment of moderate and severe Dupuytren contractures, few patients pursue further treatment within 1 year [29]. Direct exchange can yield a rate of success comparable with that of delayed exchange for the treatment of infection after total hip replacement if antibiotic-loaded cement and appropriate postoperative antibiotics are used [30]. The improvement in outcomes observed in instrument-assisted soft tissue mobilization versus myofascial release therapy for chronic neck pain may not have been caused by the intervention due to the lack of a control group [49].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or driving across the provided studies. However, patients avoiding operative intervention for lumbar radicular pain after nerve root injection typically remain non-operative for at least one year, implying a prolonged period of conservative management [6]. For diabetic patients failing nonoperative treatment, a trial of corticosteroid injections is supported prior to A1 pulley release [14].

Full activity (months): Functional outcomes for refractory tennis elbow treated with L-PRP or surgery are equivalent, though surgery may yield lower pain scores at 12 months [15]. Percutaneous needle fasciotomy for primary Dupuytren's contracture demonstrates significant changes in total passive extension deficit after 2 years, with the best correction observed in MCP joint contractures [27]. Patients with medial knee overload or arthritis of two years or greater do not experience inferior outcomes at mid-term follow-up after high tibial osteotomy compared to those with shorter symptom duration [28].

Complete recovery / outcome plateau (months): Long-term outcomes for recurrent patellar dislocation show that the 1.5-stage revision does not yield inferior results compared to the two-stage technique, though functional scores may remain inferior in some cases [31, 34]. Direct exchange for infection after total hip replacement can achieve success rates comparable to delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are utilized [30]. For chronic periprosthetic joint infections in non-surgical candidates, long-term suppressive oral antibiotics are a viable consideration [17].

Rehabilitation protocol: High-quality studies targeting non-surgical treatment for conditions related to excessive anterior pelvic tilt are warranted as an evidence-based alternative to surgical interventions [3]. LIPUS treatment should be considered for instrumented, infected, and fragility non-unions to potentially reduce socioeconomic impact and improve quality of life [4]. LIPUS also results in significantly greater progress toward bone healing compared to no treatment in subjects with established delayed unions of the tibia [33]. For cast syndrome, early recognition and vigorous therapy are critical to prevent death [10].

Functional milestones: Recent literature supports that diabetic status does not alter long-term failure rates after injection for diabetics who fail nonoperative treatment [14]. Forty-seven (96 per cent) of forty-nine shoulders achieved a good clinical result after distal release of deltoid muscle contracture [62]. Although contracture may recur following enzymatic (collagenase) treatment of moderate and severe Dupuytren contractures, few patients pursue further treatment within 1 year [29].

Other Considerations: High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes regarding transcutaneous vagus nerve stimulation for chronic low back pain [24]. The 1.5-stage revision reduces the number of additional surgical procedures compared to the two-stage technique [31]. Operative treatment for recurrent patellar dislocation achieved good results, while in some cases the functional scores remain inferior [34].

Key Evidence

  • [L5] The most compelling indication for their use remains the management of traumatic spine injury. (10.5435/00124635-201011000-00003)
  • [L4] The authors aim to characterize commonly used modalities and provide the evidence available that supports their continued use, noting that while the number of modalities has increased, there is a concurrent effort to better define which are truly effective. (10.1016/j.jhsa.2011.12.042)
  • [L2] High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted. (10.1302/2058-5241.5.190017)
  • [L4] LIPUS treatment should be considered as a conservative non-surgical treatment option to potentially reduce the socioeconomic impact and improve the quality of life of these unfortunate patients. (10.1186/s12891-021-04322-5)
  • [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
  • [L4] The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years. (10.2106/jbjs.e.00278)
  • [L2] Manual edema mobilization techniques should be considered in conjunction with conventional therapies in cases of excessive edema or when edema has not responded to conventional treatment alone; however, manual edema mobilization is not advocated as a routine intervention. (10.1016/j.jht.2017.05.011)
  • [L3] Currently, there is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery. (10.2106/jbjs.19.01439)
  • [L5] There appears to be little consensus on nomenclature when discussing various PRP/PRGF preparations, making investigation difficult. (10.1016/j.jse.2010.07.004)
  • [L5] Despite ample evidence supporting the efficacy of opioid-sparing, multimodal strategies, adoption has been slow. (10.1016/j.jhsa.2019.03.013)
  • [L4] Any conclusion regarding comparison is limited due to the dearth of non-operative management studies and the high risk of bias. (10.1136/jisakos-2016-000105)
  • [L4] Recent literature supports a trial of corticosteroid injections followed by A1 pulley release for diabetics who fail nonoperative treatment, as diabetic status does not change long-term failure rates after injection. (10.1016/j.jhsa.2018.03.045)
  • [L2] L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. (10.1177/1758573218809467)
  • [L5] Prophylactic vacuum-assisted incisional dressings appear reasonable for patients at risk of complications but do not provide benefit in routine cases. (10.1016/j.arth.2018.09.066)
  • [L5] Long-term suppressive oral antibiotics may be considered for chronic periprosthetic joint infections in patients who are not surgical candidates, refuse surgery, or for whom surgery is not expected to improve functional outcomes. (10.1016/j.arth.2018.09.034)
  • [L4] Classification of patients based on pre-treatment symptom severity assists in selecting the most efficacious treatment; splintage and NSAIDs are effective for minimal symptoms, while steroid injection is the initial treatment of choice for mild to severe disease. (10.1054/jhsb.2001.0568)
  • [L1] Although used in practice, evidence for the use of relative motion orthosis is absent. (10.1016/j.jht.2023.05.016)
  • [L4] It is a simple procedure that can be done in less than 30 min and is capable of providing significant pain relief for patients with sacroiliac joint dysfunction. (10.1186/s12891-023-06344-7)
  • [L5] The use of BoNT-A for the management of Raynaud phenomenon is an off-label, experimental use that is not FDA-approved but may have a role in the minimally invasive management of the condition. (10.1016/j.jhsa.2011.07.011)
  • [L4] Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. (10.1302/0301-620x.100b10.bjj-2018-0461.r1)
  • [L1] Therefore, high-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes. (10.1186/s12891-024-07569-w)
  • [L5] Firm guidelines are difficult to obtain, and treatment must be individualized to each patient with respect to limiting the risk of postoperative complications versus disease flare. (10.1016/j.jhsa.2012.04.015)
  • [L4] Most data indicate a positive effect for use of direct current stimulation, but further studies are necessary to determine its appropriateness as an adjuvant to spinal fusion. (10.5435/00124635-200303000-00002)
  • [L4] The treatment showed a significant change in total passive extension deficit after 2 years, with the best results in correction of MCP joint contractures. (10.1177/1753193411407245)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L4] Although contracture may recur, few patients pursue further treatment within 1 year. (10.1016/j.jhsa.2020.06.012)
  • [L4] The experience suggests that direct exchange can yield a rate of success comparable with that of delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are used. (10.2106/00004623-199807000-00004)
  • [L1] The 1.5-stage revision does not show inferior results compared to the two-stage technique and reduces the number of additional surgical procedures. (10.1016/j.arth.2025.10.075)
  • [L5] The second edition of The Milwaukee Brace successfully updates the authors' experiences and recommendations for the use of the Milwaukee brace, with significant revisions to roentgenogram recommendations, indications for non-operative treatment, and management of cervical kyphosis and round-back. (10.2106/00004623-198163030-00042)
  • [L1] These findings demonstrate significantly greater progress toward bone healing after LIPUS treatment compared to no LIPUS treatment in subjects with established delayed unions of the tibia. (10.1186/1471-2474-11-229)
  • [L3] Operative treatment for recurrent patellar dislocation achieved good results, while in some cases the functional scores remain inferior. (10.1186/s12891-022-05527-y)
  • [L2] Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year. (10.1186/s13018-025-05814-z)
  • [L4] The authors recommend randomised controlled trials to support these findings. (10.1186/s12891-017-1873-x)
  • [L4] Subjects reported significant increase in wrist joint flexibility carried over to 2 hours after treatment, demonstrating the potential of these modalities as pain management adjuncts. (10.1177/17589983251384978)
  • [L4] The study documented neuromuscular changes in healthy subjects during a 3-week period while they regularly wore a LSO, specifically measuring trunk stiffness, damping, muscle activation patterns, and spine compression forces. (10.1186/1471-2474-11-154)
  • [L1] The review identifies a range of wearable technologies and biofeedback modalities used to modulate spine motor control, highlighting the need for standardized reporting and further research to establish clinical efficacy. (10.1186/s12891-024-07867-3)
  • [L4] The authors recommend the use of these catheters in orthopaedic patients who need prolonged intravenous therapy. (10.2106/00004623-199504000-00010)
  • [L5] The authors agree with recommendations to use only normal saline instead of antiseptic solutions and to avoid high-pressure irrigation. (10.1177/1753193412443610)
  • [L1] ESWT and HILT are effective non-invasive options for treating calcaneal spur with ESWT providing slightly greater functional benefits. (10.1186/s13018-025-05812-1)
  • [L2] This study protocol describes a trial designed to compare the effects of five different SCS modalities in patients with CRPS to determine which frequency is most effective in terms of pain reduction. (10.1186/s12891-015-0650-y)
  • [L4] Biological factors such as musculoskeletal structural changes were considered the main cause of the condition. (10.1186/s12891-025-09243-1)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
  • [L1] The outcomes of this study will contribute to better decision making in the treatment of cervical radiculopathy. (10.1186/s12891-020-3188-6)
  • [L2] However, we did not use a control group, indicating that the improvement in outcomes may not have been caused by the intervention. (10.1186/s12891-023-06540-5)
  • [L3] Factors associated with calcium reabsorption include the Gartner classification, disease duration, and blood flow around calcium deposits. (10.1016/j.jse.2024.07.056)
  • [L1] Despite sex differences in baseline kyphosis, BMD, spine strength, fractures and DISH, sex did not affect treatment response. (10.1186/s12891-017-1862-0)
  • [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
  • [L3] It reduces operative time, fluoroscopy, and guide needle adjustments, and is more effective in preventing the progression of femoral head necrosis to advanced stages compared to traditional surgery under fluoroscopy. (10.1186/s12891-025-08561-8)
  • [L3] The difference in morbidity between the groups was attributable to the use of the modified incision. (10.2106/00004623-199705000-00016)
  • [L3] This paper details the rationale, design, methods, planned analysis and operational aspects of a study examining the utility of the STarT Back Tool as a 'stratification tool for targeted treatment' in a group intervention. (10.1186/1471-2474-14-342)
  • [L4] The authors suggest that patients with weakness in external rotation or abduction after posterior dislocation may have rotator cuff injury and that early MRI investigation is prudent for high-energy injuries. (10.1177/03635465030310060301)
  • [L2] Therefore, Dynamic taping has the potential to be clinically beneficial before engaging in exercises. (10.1016/j.jht.2023.12.003)
  • [L4] Therefore, there is no need for additional training to improve postural control in these adolescents with idiopathic scoliosis. (10.1186/s12891-024-08210-6)
  • [L5] Innovative methodologies that ensure patient safety can potentially lead to many new treatment strategies for musculoskeletal conditions. (10.5435/00124635-200201000-00003)
  • [L5] A simple, effective apparatus has been devised for relieving the discomfort of a patient whose arm is in traction, enabling elevation to an inclined or sitting position while maintaining traction alignment. (10.2106/00004623-195032020-00027)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)

See Also

References

[1] Spinal Orthoses. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201011000-00003

[2] Therapeutic Modalities—An Updated Review for the Hand Surgeon. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.12.042

[3] Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.190017

[4] Low intensity pulsed ultrasound (LIPUS) use for the management of instrumented, infected, and fragility non-unions: a systematic review and meta-analysis of healing proportions. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04322-5

[5] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[6] Nerve Root Blocks in the Treatment of Lumbar Radicular Pain. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00278

[7] Effectiveness of edema management techniques for subacute hand edema: A systematic review. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.05.011

[8] Chapter 8 Acute Compartment Syndrome. 2021.

[9] Complementary and Alternative Medicine for Postoperative Pain. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01439

[10] POSSIBLE CAST SYNDROME: Report of a Case.. The Journal of Bone and Joint Surgery. American Volume. 1955.

[11] PRP or PRGF? Standardized definitions are needed. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.07.004

[12] Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 2: Surgeon as Prescriber. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.03.013

[13] Complete proximal hamstring avulsions: is there a role for conservative management? A systematic review of acute repairs and non-operative management. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000105

[14] Management of Diabetic Trigger Finger. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.03.045

[15] Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218809467

[16] General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.09.066

[17] Hip and Knee Section, Treatment, Antimicrobial Suppression: Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.09.034

[18] Treatment of De Quervain’s Disease: Role of Conservative Management. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0568

[19] Orthotic intervention options to non-surgically manage adult and pediatric trigger finger: A systematic review. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.05.016

[20] Cooled radiofrequency ablation of the sacroiliac joint a retrospective case series. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06344-7

[21] Recent Advances for the Management of Raynaud Phenomenon Using Botulinum Neurotoxin A. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.07.011

[22] Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b10.bjj-2018-0461.r1

[23] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[24] Effects of transcutaneous vagus nerve stimulation on chronic low back pain: a systematic review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07569-w

[25] Perioperative Management of Rheumatoid Medications. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.04.015

[26] Use of Electrical Bone Stimulation in Spinal Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200303000-00002

[27] Percutaneous needle fasciotomy for primary Dupuytren’s contracture. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411407245

[28] Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.03.003

[29] Outcomes and Early Recurrence Following Enzymatic (Collagenase) Treatment of Moderate and Severe Dupuytren Contractures. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.06.012

[30] Direct-Exchange Arthroplasty for the Treatment of Infection after Total Hip Replacement. An Average Ten-Year Follow-up. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199807000-00004

[31] 2025 ICM: Abbreviated Two- and 1.5-Stage. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.075

[32] The Milwaukee Brace. Ed. 2.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163030-00042

[33] Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-229

[34] Preoperative serum calcium could be a prognostic factor for surgical treatment of recurrent patellar dislocation: a retrospective study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05527-y

[35] 18F-fluoride PET/CT as an early predictor of bony fusion after posterior lumbar interbody fusion– a prospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05814-z

[36] Individualised radial extracorporeal shock wave therapy (rESWT) for symptomatic calcific shoulder tendinopathy: a retrospective clinical study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1873-x

[37] Duration of superficial heat modality on wrist and finger range of motion: A quasi-experimental study. Hand Therapy. 2025. DOI: 10.1177/17589983251384978

[38] The effects of a three-week use of lumbosacral orthoses on trunk muscle activity and on the muscular response to trunk perturbations. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-154

[39] Wearable technology mediated biofeedback to modulate spine motor control: a scoping review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07867-3

[40] Long-term intravenous therapy with use of peripherally inserted silicone-elastomer catheters in orthopaedic patients.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199504000-00010

[41] Re: Franz T, Vögelin E. Aseptic tissue necrosis and chronic inflammation after irrigation of penetrating hand wounds using Octenisept®. J Hand Surg Eur. 2012, 37: 61–4. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412443610

[42] Comparison of extracorporeal shock wave therapy and high-intensity laser therapy in the treatment of calcaneal spur-related symptoms: clinical outcomes and functional improvement. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05812-1

[43] Comparison of tonic spinal cord stimulation, high-frequency and burst stimulation in patients with complex regional pain syndrome: a double-blind, randomised placebo controlled trial. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0650-y

[44] Why do you think you still have pain? Individuals’ beliefs on the biopsychosocial factors that contribute to their chronic musculoskeletal pain: a qualitative exploration. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09243-1

[45] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[46] Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03378-w

[48] A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3188-6

[49] Instrument–assisted soft tissue mobilization versus myofascial release therapy in treatment of chronic neck pain: a randomized clinical trial. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06540-5

[50] Factors associated with resorption of calcific deposits in the shoulder with extracorporeal shock wave therapy. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.056

[51] Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1862-0

[52] Three-dimensional morphological analysis of the thoracic pedicle and related radiographic factors in adolescent idiopathic scoliosis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05799-4

[53] 10-year follow-up results of the initial application of 3D-printed percutaneous guides in drilled decompression of femoral head necrosis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08561-8

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