George H. Theodore

Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases.

PURPOSE The purpose of this study was to identify outcomes and outcome predictors of arthroscopic debridement with osteochondral bone stimulation (microfracture) for osteochondral lesions of the ankle. METHODS One hundred five consecutive patients with osteochondral lesions of the ankle who underwent ankle arthroscopy with microfracture were prospectively followed up for a mean of 31.6 +/- 12.1 months. Study patients were evaluated at 6 weeks, 3 months, 6 months, 12 months, and annually after surgery. Assessments via a visual analog scale for pain during daily activities and sport activity, the Roles and Maudsley score, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system were obtained at each visit. Outcome predictors were analyzed by logistic regression model. RESULTS There were no failures of treatment with lesions smaller than 15 mm. In contrast, only 1 patient met the criteria for success in the group of lesions greater than 15 mm. Statistical analysis revealed that increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affected outcome. The presence of instability and the presence of anterolateral soft-tissue scar were correlated with a successful outcome. CONCLUSIONS This study found a strong correlation between lesion size and success across its entire population. For lesions smaller than 15 mm, regardless of location, excellent results were obtained. In addition, increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affect outcome. The presence of instability and anterolateral soft-tissue scar correlated with a successful outcome. LEVEL OF EVIDENCE Level IV, prognostic case series, prognostic study.

Extracorporeal Shock Wave Therapy for the Treatment of Plantar Fasciitis

One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, doubleblind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

Extrakorporale Stoßwellentherapie beim symptomatischen Fersensporn – eine Übersicht

ZusammenfassungExtrakorporale Stoßwellen werden seit Jahren in Europa zur Behandlung von Insertionstendinopathien wie der plantaren Fasziitis mit klinischem Erfolg eingesetzt. Bislang existierte jedoch kein Wirksamkeitsnachweis anhand placebokontrollierter Studien.Der Beitrag gibt eine Übersicht über konservative und operative Behandlungsmethoden und beleuchtet den Wirksamkeitsnachweis dieser bisher gängigen Therapiemethoden.Zusätzlich werden die Ergebnisse einer prospektiven randomisierten placebokontrollierten multizentrischen Studie zum Nachweis der Effektivität und Sicherheit der ESWA beim Fersensporn dargestellt. Die Resultate der Untersuchung zeigen, dass bei zuvor konservativ erfolglos behandelten Patienten durch eine einmalige Stoßwellenanwendung eine statistisch signifikante Verbesserung (p=0,0149) des morgendlichen Anlaufschmerzes als Hauptzielkriterium eintritt [Therapiegruppe: Reduktion von 7,7 auf 3,4 Punkte auf der visuellen Analogskala (VAS); Placebogruppe: Reduktion von 7,7 auf 4,1 Punkte auf der VAS]. Die Analyse der Daten des Scores nach Roles u. Maudsley mit dem exakten Test nach Fisher zeigte mit 61,6% vs. 39,7% sehr guter und guter Einschätzungen ein signifikant besseres Ergebnis der Therapiegruppe (p=0,0128). Therapiebedingte Nebenwirkungen (lokale Schwellung, Petechien) waren selten. Aufgrund der Daten wurde im Januar 2002 die FDA-Zulassung für das verwendete Stoßwellengerät erteilt.AbstractExtracorporeal shock wave application (ESWA) has been successfully used for years in routine clinical management of plantar fasciitis. So far no clinical trails have shown the efficiency in placebo-controlled protocols.This paper presents an overview of conservative and operative treatment modalities with respect to their efficacy.Results of a prospective randomized placebo-controlled double-blind multicenter trial to show efficiency and safety of ESWT are presented. In patients treated conservatively without success, a single shock wave application can improve the condition significantly compared with placebo treatment (p=0.0149). The Roles and Maudsley score also showed a significant improvement between the groups, with 61.6% good or excellent results in the verum group and 39.7% in the placebo group (p=0.0128). Therapy-related side effects (local swelling, petechia) are rare. The data presented in this study led to FDA approval in January 2002 of the shock wave device used.

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.

UNLABELLED Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome. LEVEL OF CLINICAL EVIDENCE 2.

Tenosynovitis of the flexor hallucis longus in a long-distance runner.

Chronic inflammation of the flexor hallucis longus (FHL) tendon can result in stenosing tenosynovitis. This condition has been well documented in ballet dancers. It usually presents as posteromedial ankle pain, worsened by plantarflexion activities. Although conservative therapy benefits most patients, some recalcitrant cases may require surgical intervention. This is the first case report that describes the occurrence of this condition in a runner with an anomalous flexor hallucis longus muscle.

Sesamoidectomy for Hallux Sesamoid Fractures

Foreword Preface Preliminaries Introduction The Cauchy problem The initial-value problem The initial-boundary-value problem for the quarter plane with temperature-boundary specification The initial-boundary-value problem for the quarter plane with heat-flux-boundary specification The initial-boundary-value problem for the semi-infinite strip with temperature-boundary specification and heat-flux-boundary specification The reduction of some initial-boundary-value problems for the semi-infinite strip, to integral equations: some exercises Integral equations Solutions of boundary-value problems for all times and periodic solutions Analyticity of solutions Continuous dependence upon the data for some state-estimation problems Some numerical methods for some state-estimation problems Determination of an unknown time-dependent diffusivity a(t) from overspecified dataBackground: Hallux sesamoid fractures are challenging to treat. Symptomatic nonunion is a common problem after nonoperative treatment. Surgical fixation of the fracture can result in successful union, but is technically challenging and can be associated with prolonged return to activities (RTA). Sesamoidectomy is an alternative surgical option that may provide reliable outcomes and allow an earlier RTA in athletes. The purpose of this case-series study was to evaluate a cohort of athletic patients with a hallucal sesamoid fracture treated with sesamoidectomy. Methods: A total of 24 patients with 24 sesamoid fractures that failed to respond to nonoperative measures were treated surgically with sesamoidectomy. Patients’ age, level of activity, fractured bone, surgical approach, time required to RTA, and postoperative complications were recorded. Pre- and postoperative pain was assessed with a visual analog scale ranging from zero (no pain) to 10 (intense pain). Five patients were classified as elite athletes playing at an intercollegiate level and 19 were classified as active individuals performing an athletic activity at least three times per week. The mean patient age was 32.2 ± 10.4 (range, 17 to 54) years. The 24 patients were reviewed at a mean follow-up of 35 ± 21 (range, 8 to 70) months. Results: A total of 22/24 patients (91.6%) returned to activities at a mean time of 11.6 ± 3.87 (range, 8 to 24) weeks. Mean preoperative pain level was 6.2 ± 1.4 and the pain level improved after treatment to a mean of 0.7 ± 1. One patient developed a symptomatic hallux valgus deformity after the resection of the medial sesamoid. Conclusions: This case series demonstrates good results after sesamoidectomy for sesamoid fractures in athletic individuals with reliable pain relief and RTA within 11.6 weeks. Progressive hallux valgus remains a concern after medial sesamoidectomy, with an incidence of 1 in 24 cases in this study. Level of Evidence: IV, Retrospective Case Series

Epidemiology and Outcomes of Lisfranc Injuries Identified at the National Football League Scouting Combine

Background: Lisfranc injuries are challenging to treat and may have a detrimental effect on athletic performance. Purpose: (1) Determine the epidemiological characteristics of Lisfranc injuries at the annual National Football League (NFL) Scouting Combine, (2) define player positions at risk for these injuries, and (3) evaluate the impact that these injuries and radiographic findings have on NFL draft position and performance. Study Design: Cohort study; Level of evidence, 3. Methods: All players who sustained a Lisfranc injury prior to Combine evaluation between 2009 and 2015 were evaluated. The epidemiological characteristics, player positions affected, treatment methods, and number of missed collegiate games were recorded. Radiographic outcomes were analyzed via Combine radiograph findings, while NFL performance outcomes were assessed for all Lisfranc injuries (2009-2013) compared with matched controls in the first 2 years of play. Results: A total of 41 of 2162 (1.8%) Combine participants were identified with Lisfranc injuries, of whom 26 of 41 (63.4%) were managed operatively. Players who underwent surgery were more likely to go undrafted compared with players managed nonoperatively (38.5% vs 13.3%, operative vs nonoperative management, respectively; P = .04) and featured a worse NFL draft pick position (155.6 vs 109; P = .03). Lisfranc-injured players when compared with controls were noted to have worse outcomes in terms of NFL draft position (142 vs 111.3, Lisfranc-injured players vs controls, respectively; P = .04), NFL career length 2 years or longer (62.5% vs 69.6%; P = .23), and number of games played (16.9 vs 23.3; P = .001) and started (6.8 vs 10.5; P = .08) within the first 2 years of their NFL career. Radiographs demonstrated that 17 of 41 (41.5%) athletes had residual Lisfranc joint displacement greater than 2 mm compared with the contralateral foot. Lisfranc-injured athletes with greater than 2 mm residual displacement, when compared with matched controls, had worse draft position (156.9 vs 111.2 for Lisfranc-injured players vs controls, respectively; P = .009) and fewer games played (14.4 vs 23.3; P = .001) and started (3.1 vs 10.5; P = .03). Moreover, athletes with greater than 2 mm residual displacement featured worse outcomes across all assessed NFL variables versus athletes with residual displacement of 2 mm or less. Conclusion: Lisfranc injuries identified at the NFL Combine have an adverse effect on an NFL athlete’s draft status, draft position, and overall play during initial NFL seasons. In particular, residual displacement of the Lisfranc joint has a detrimental effect on the first 2 seasons of NFL play and may lead to long-lasting negative effects on the athlete’s career.

Stress Fractures in Athletes

Abstract Stress fractures that occur in the young active population typically represent an overuse injury, and may lead to prolonged periods of restriction from play if they are not treated appropriately. Several risk factors have been identified and must be addressed when treating these patients. Low-risk stress fractures can be successfully treated with activity restriction and a stepwise return to sport. Several pharmacologic and nonoperative treatment modalities have been described. However, high-risk stress fractures are more difficult to treat because they may have an increased rate of delay and nonunion, and often require surgical stabilization. When treating an athlete with a stress fracture, the objective is a safe and quick return to sport; therefore, special considerations must be made in this population, particularly when dealing with the in-season athlete.

Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg

Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.