Amol Saxena

Articular Talar Injuries in Athletes Results of Microfracture and Autogenous Bone Graft

Background The treatment options of talar osteochondral lesions are numerous. Although studies show these treatments have been used with varying success, the ability to return to activity (RTA), including sports after treatment of talar dome injuries, have not been well documented. Hypothesis A treatment plan that uses microfracture for Hepple stage 2 through 4 lesions and autogenous bone grafting for Hepple stage 5 lesions for athletes with articular lesions of the talus will produce a high rate of return to athletic activity. Study Design Case series; Level of evidence, 4. Methods Preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and RTA were assessed prospectively 2 to 8 years after surgery in high-demand (athletic) patients with articular injuries to the talar dome treated according to the above protocol over a 6-year period. Results There were 26 microfracture procedures and 20 bone grafts to the talus. The AOFAS scores for both microfracture (preoperative, 54.6; postoperative, 94.4) and bone graft (preoperative, 46.1; postoperative, 93.4) patients improved significantly. The RTA for the entire group was 17.0 ± 5.3 weeks; for those undergoing microfracture, RTA was 15.1 ± 4.0 weeks; and for bone grafting, it was 19.6 ± 5.9 weeks. The RTA for the bone graft group was significantly slower than that of the microfracture group. Anterolateral lesions had significantly faster RTA and higher postoperative scores compared with other lesion locations. Arthroscopically treated lesions had similar postoperative AOFAS scores to those who had arthrotomy and did not have significantly faster RTA. Forty-four (96%) “excellent/good” AOFAS scores were achieved overall for talar lesions, with the same percentage of return to sport. Conclusions Talar bone grafting required a longer time to return to activity than microfracture in high-demand patients, but both groups had similar postoperative AOFAS scores. When applied to appropriate lesions, both techniques allow athletic patients to return to sports.

The Effect of Foot Orthoses on Patellofemoral Pain Syndrome

In a retrospective review of 102 patients treated for chondromalacia pa-tellae and patellofemoral pain syndrome/retropatellar dysplasia (PFPS/RPD), the effectiveness of semiflexible foot orthoses was investigated. The combined disorders were diagnosed in 89.3% of the patients. Subjects were 46 women and 54 men, aged 12 to 87 years (mean, 37.9 years; SD, 15.9), who exhibited excessive forefoot varus or rearfoot varus. The initial screening and clinical diagnosis were based on an examination by an orthopedist. Particular attention was directed to patellar crepitation, patellofemoral malalignment, Q-angle measurements, limitation of range of motion, and knee effusion. Patients were evaluated for the onset and duration of patellofemoral pain and degree of knee joint disease. Semiflexible orthoses for each subject were fabricated, based on a clinical lower extremity biomechanical examination. At their follow-up visit, 76.5% were improved and 2% were asymptomatic, showing a significant decrease in the level of pain with orthoses intervention (chi-square P <.001). Although multiple treatment modalities are used for these patients, the results suggest that the use of semiflexible orthoses is significant in reducing symptoms of PFPS/RPD.

Navicular Stress Fractures: A Prospective Study on Athletes

Background: Navicular stress fractures of the foot often are difficult to diagnose and treat. Methods: Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender. Results: Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fifteen of 16 competitive athletes returned to full competition, including all who had ORIF. Conclusions: Navicular stress fractures can take 4 months to heal with nonoperative or operative treatment. Surgery should be considered for more severe injuries, which can be assessed by CT scan.

Lapidus Bunionectomy: Early Evaluation of Crossed Lag Screws versus Locking Plate with Plantar Lag Screw

UNLABELLED We compared outcomes of the Lapidus bunionectomy fixated with crossed lag screws versus a locking plate with a plantar lag screw. Forty patients who underwent Lapidus bunionectomy between August 2001 and May 2006 were evaluated in a combined retrospective and prospective fashion. Crossed lag screws were used in 19 of the patients, and a locking plate with a plantar lag screw was used in 21 of the patients. Other than fixation, the only interventional difference pertained to postoperative weight bearing, where those receiving the plate initiated full weight bearing on the operated foot at 4 weeks postoperative, as compared to 6 weeks for those receiving crossed screws. Overall, the mean preoperative AOFAS hallux score was 41.75 +/- 2.52, and the postoperative score was 90.48 +/- 8.41 (P < .0001). The overall mean preoperative first intermetatarsal angle was 15.3 degrees +/- 2.32 degrees , and long term the angle was 5.03 degrees +/- 2.86 degrees (P < .0001). When comparisons were made based on the method of fixation, use of an adjunct Akin osteotomy and surgery performed before 2003 were statistically significantly associated with crossed screw fixation, and the preoperative AOFAS score was statistically significantly higher in the locking plate fixation group. There were no statistically significant differences related to postoperative complications between the 2 fixation groups. In conclusion, the Lapidus bunionectomy fixated with a locking plate and a plantar lag screw allows earlier weight bearing in comparison with crossed lag screws, without a difference in complications. LEVEL OF CLINICAL EVIDENCE 2.

Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries.

BACKGROUND A retrospective review of one surgeons practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. METHODS We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. RESULTS A total of 219 surgical cases were available for review (140 males and 70 females; mean +/- SD age at the time of surgery, 46.5 +/- 12.6 years; age range, 16-75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03). CONCLUSIONS Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated.BACKGROUND Computed tomography, ultrasonography, and magnetic resonance imaging are useful in the diagnosis of tears of the Achilles tendon, but none are capable of detecting early or small tears. Herein, we applied diffraction-enhanced imaging, a radiographic technique that detects x-ray attenuation and x-ray refraction, to the imaging of compromised Achilles tendons. METHODS Diffraction-enhanced imaging was used to detect incomplete surgically induced tears of the Achilles tendon in nine cadaveric human feet and ankles. RESULTS Complete and significant partial tears were detectable in diffraction-enhanced images as x-ray refraction changes. CONCLUSIONS Although still in the experimental stages, diffraction-enhanced imaging may eventually prove useful for the diagnosis of Achilles tendon tears.

Peroneal tendon injuries: An evaluation of 49 tears in 41 patients

Forty-one patients sustaining 49 tears of the peroneal tendons were evaluated prospectively a minimum of 1 year after surgical treatment. Preoperative and postoperative function and activity were assessed by using the American Orthopedic Foot and Ankle (AOFAS) score. Mean age at the time of surgery was 44.0 +/- 11.7 years. Mean follow-up after the index surgery was 35.5 +/- 22.2 months. There were 17 women and 24 men. One woman had bilateral surgery 1 year apart. There were a total of 18 tears of the peroneus longus tendon; 11 of these were isolated, whereas 7 had a combined tear with peroneus brevis. There 31 peroneus brevis tears; 24 of these were isolated and 7 were combined. Using 3-way analysis of variance, there were no significant differences in return to activity or postoperative AOFAS scores among those with a longus, brevis, or combined tear. The mean return to activity for peroneus longus, peroneus brevis, and combined tears were 3.2, 3.6, and 3.7 months, respectively. The mean postoperative AOFAS scores were 90.6, 90.8, and 84.3 respectively. The mean preoperative AOFAS score was 52.0 +/- 16.8. The mean postoperative score was 89.7 +/- 10.3 (P <.00001). Using this scoring system, there were 24 excellent, 12 good, 4 fair, and 2 poor scores. Three patients underwent additional surgery. Fourteen of 16 athletes returned to full sporting level. The average return to activity for the entire group was 3.49 +/- 1.15 months.

Return to Activity after Sesamoidectomy in Athletically Active Individuals

Sesamoidectomy of the first metatarsophalangeal joint in athletically active patients may be indicated in cases of chronic sesamoiditis resistant to nonsurgical care or symptomatic displaced fractures or nonunion. Painful scar, hallux deviation, and delayed return to activity are all potential complications. These need to be considered especially when performing surgery in the athletically active individual. Twenty-six sesamoidectomies in 24 patients (21 females and 3 males) were reviewed for type of sesamoidectomy, incision location, time to return to activity, and complications. Mean age was 35.4 years (range, 16–68 years) with mean follow-up 86.4 months. Eleven athletes (defined as professional or varsity level sports) operated on had a mean return to activity of 7.5 weeks (range, 4–10 weeks), while 13 “active” patients had a mean return to activity of 12.0 weeks. This difference was statistically significant using the t-test, (p <.02). There were 10 fibular and 16 tibial sesamoids excised. Complications included one hallux varus and two cases of postoperative scarring with neuroma-like symptoms, all associated with fibular sesamoidectomy; there was one case of hallux valgus deformity with tibial sesamoidectomy. Despite the functional importance of tibial and fibular sesamoids, athletically active individuals can return to sports after a sesamoidectomy as early as 7.5 weeks.

The Valenti procedure for hallux limitus/rigidus

The results of 12 Valenti procedures on 11 patients are presented. Preoperative hallux dorsiflexion was 12.9 degrees; postoperatively, patients achieved 40.4 degrees of dorsiflexion. The Valenti procedure is a useful arthroplasty for grades II and III hallux limitus/rigidus.

The ludloff osteotomy: A critical analysis

Fourteen Ludloff (oblique shaft) osteotomies were performed to reduce the first intermetatarsal angle on 12 female patients whose average age was 47 years. Average reduction of the first intermetatarsal angle was 6.5 degrees (postoperative average, 9.4 degrees). Average hallux abductus angle reduction was 16.7 degrees (postoperative average, 13.4 degrees). These reductions were statistically significant (P < or = 0.05). Average first metatarsal shortening was 1.4 mm. No transfer lesions nor lesser metatarsal stress fractures were noted. One patient (a 30+ pack/year smoker) sustained a delayed union. The average American Orthopedic Foot and Ankle rating score was 92.3 out of 100. Average follow-up was 48 months. This procedure is a viable alternative to closing base wedge osteotomies.

Plantar Fascia Ruptures in Athletes

Objective To educate sports medicine practitioners as to length of time for an athlete to return to activity after sustaining a rupture of the plantar fascia. Methods Athletic patients sustaining plantar fascia ruptures and subsequent treatment were reviewed. Diagnosis was based on clinical findings, although radiographic studies were done. Patients were treated for 2 to 3 weeks with a below-knee or high- top boot, nonweightbearing, with an additional 2 to 3 weeks of weightbearing in the boot. Patients used physical therapy. Results Eighteen athletes, including 6 elite athletes, were evaluated. Mean age was 40.9 ± 13.2 years. There were 12 males and 6 females. Mean postinjury follow-up was 42 months. Duration of prior plantar fascia symptoms ranged from 0 to 52 weeks. All but 2 ruptures were of the medial portion. Four patients had injections prior to rupture. Five patients wore orthoses preinjury; 14 wore orthoses postinjury. All patients returned to activity after 2 to 26 weeks (mean, 9.1 ± 6.0 weeks). Running athletes predominantly composed the cohort; others played tennis, volleyball, and basketball. Conclusion Using the treatment protocol, patients sustaining plantar fascia rupture can achieve favorable results with complete return to activity. None of the 18 patients sustained reinjury, had postinjury sequelae, or necessitated surgery, contrary to other studies.