Johnny Lin

Etiologic Factors Associated with Symptomatic Achilles Tendinopathy

Background: The purpose of this study was to determine if a statistical association exists between Achilles tendinopathy (also referred to as tendinosis) and obesity, diabetes mellitus, hypertension, the supplemental use of estrogen, and exposure to local or systemic steroids. Methods: From July, 1997, to February, 2003, 82 patients with a diagnosis of Achilles tendinopathy were identified. The diagnosis of Achilles tendinopathy was confirmed by a review of medical records, radiographs, and MRI. There were 44 women and 38 men with an average age of 50 (range 27 to 77) years. For the parameters of obesity, hypertension, diabetes, steroid exposure, and the use of estrogen compounds, all patients were analyzed both cumulatively and stratified into subgroups by gender and age. Chi-square 2 times 2 tables were used to compare the observed prevalence of the parameters in patients with Achilles tendinopathy to the expected prevalence of these disorders and exposures in the population at large. Results: Cumulatively, 98% percent (43 of 44 women; 29 of 38 men) had hypertension, diabetes, obesity, and steroid or estrogen exposure. Seventy-six percent of men (29) had hypertension, diabetes, and obesity, or steroid exposure. Sixty-eight percent of women (15 of 22) had a history of hormone replacement therapy and 44% (8 of 15) had a positive history for use of oral contraceptives. When compared with published national data using Chi-square analysis, the association between tendinopathy and hormone replacement therapy and oral contraceptives was found to be statistically significant with p-values of 0.01 and 0.001, respectively. For both women and men, obesity was statistically associated with Achilles tendinopathy with p-values of 0.025 and. 001, respectively. Hypertension was statistically associated with Achilles tendinopathy only for women. Diabetes mellitus and Achilles tendinopathy were found to have a statistical association only for men younger than 44 years old Conclusions: Obesity, hypertension, and steroids have as their end-organ effect a diminution of local microvascularity. The significant correlation of these factors with Achilles tendinopathy suggests the importance of their effect on microvascularity in the development of Achilles tendinopathy.

Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year Followup:

Background: There are few long-term studies on the non-operative treatment of Stage II Posterior Tibial Tendon Dysfunction (PTTD). The purpose of this study is to describe the natural history and determine the efficacy of non-operative treatment of Stage II PTTD using clinical outcome scores. Materials and Methods: Patients with Stage II PTTD treated with a Double Upright Ankle Foot Orthosis (DUAFO) with a minimum followup of 7 years were identified retrospectively. Patients were evaluated with the AOFAS Ankle/Hindfoot Score, SF-36, Foot Function Index (FFI), Visual Analog Scale (VAS) for pain, and a custom questionnaire in addition to a comprehensive physical examination. Results: Thirty-three feet in 32 patients were included with an average followup of 8.6 years. Success defined as being brace-free and avoiding surgery was 69.7%. Five patients (15.2%) were unable to completely wean from a brace. Five patients went on to surgery. The mean AOFAS and FFI score was 78.4 and 18.4, respectively. Compared to national norms, SF-36 subscores for each age sub-category showed no significant difference in any of the age groups (p < 0.05). Average VAS pain scale score was 1.9. Satisfaction was rated as “satisfied” in 20 patients (60.6%), “satisfied with minor reservations” in 11 patients (33.3%), partially satisfied in one (3.0%), and “unsatisfied” in one (3.0%). None of the patients rated as “satisfied with major reservations”. Conclusion: Treatment of Stage II PTTD with a DUAFO has been shown to be a viable alternative to surgery with a high likelihood of adequate function, avoidance of surgery, and being brace-free at 7- to 10-year followup.

Revision MTP Arthrodesis for Failed MTP Arthroplasty

Introduction. Although the gold standard to address hallux rigidus that fails conservative treatment is an arthrodesis, some surgeons have attempted to use arthroplasty to improve range of motion and to simulate a normal joint. When these implants do fail, a salvage MTP arthrodesis is the only surgical option for these patients. This research aims to outline various methods to arthrodese the MTP joint in salvage situations. Methods. We retrospectively looked at patients who underwent a first-MTP fusion after failure of an implant arthroplasty. All fusions involved either bone allograft or autograft and internal fixation. The patients were assessed clinically, radiographically, and with the Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) clinical questionnaire preoperatively and postoperatively. Results. In all, 11 patients met the inclusion criteria. The average age of patients at the time of the salvage MTP arthrodesis was 57 years. The interval time between primary surgery and revision arthrodesis was on average 84.2 months. There was a high reoperation rate, with 7 operative procedures occurring per 12 arthrodeses (58%). The average time to radiographic fusion was 6.9 ± 4.8 months; 41.7% of patients had a delayed union (>6 months to fusion). Two patients had symptomatic nonunions (16.7%). All the patients had an improvement in their AOFAS MTP-IP score. Conclusion. Although salvage arthrodeses for failed arthroplasties generally have favorable satisfaction rates and are a powerful tool in treating this painful condition, they are fraught with complications. They unite slower, have a significantly higher reoperation rate, and have lower AOFAS scores than primary fusions. Levels of Evidence: Therapeutic, Level IV—Case series

Treatment of Hallux Rigidus with Cheilectomy Using a Dorsolateral Approach

Background: Degenerative arthritis of the hallux metatarsophalangeal (MTP) joint can be treated in a variety of ways depending on the severity of the disease. If nonoperative treatment fails, then surgical treatment of Stage I and II has traditionally been cheilectomy. The purpose of this paper was to determine the potential advantages of cheilectomy using a less conventional dorsolateral approach. Materials and Methods: Twenty feet in 20 patients were included in the study with an average age of 53.8 (range, 29 to 69) years. The average followup was 2.8 years. Patient charts and radiographs were reviewed to determine preoperative patient characteristics and clinical-radiographic stage. All patients who qualified for the study were asked to return for evaluation using clinical examination, radiographs, and the AOFAS outcome score. Comparisons were made between preoperative and postoperative values using appropriate statistical analysis. Results: The mean AOFAS score improved from 53.5 to 84.0 (p < 0.001). The mean range of motion arc improved from 45 to 58 degrees (p < 0.001). Clinical-radiographic stage progressed in 50%. The most common complication was numbness in the first web space (40%). This loss was imperceptible in all patients until asked during the exam. No patients progressed to fusion during the followup period. Conclusion: Using a dorsolateral approach to perform a cheilectomy is a viable alternative to the more traditional dorsal technique. No obvious advantage over the traditional technique was identified.

Influence of Surgeon Volume on Inpatient Complications, Cost, and Length of Stay Following Total Ankle Arthroplasty.

Background: Increased surgeon volume may be associated with improved outcomes following operative procedures. However, there is a lack of information on the effect of surgeon volume on inpatient adverse events and resource utilization following total ankle arthroplasty (TAA). Methods: A retrospective cohort study of TAA patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. High-volume surgeons were considered as those with volume ≥90th percentile of surgeons performing TAA. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital charges between surgeon volume categories. Results: A total of 4800 TAA patients were identified. The 90th percentile for surgeon volume was 21 cases per year. Mean length of stay was 2.8 ± 2.3 days and mean hospital charges were

Tendon transfers for Achilles reconstruction.

45 963 ±

Trends in the Management of Achilles Tendon Ruptures in the United States Medicare Population, 2005-2011

43 983. On multivariate analysis, high-volume surgeons had decreased overall complications (OR 0.5, P = .034) and rate of medial malleolus fracture (OR 0.1, P = .043), decreased length of stay (–0.9 days, P < .001), and decreased hospital charges (–

Particulated Juvenile Articular Cartilage Allograft Transplantation for Osteochondral Talar Lesions

20 904, P < .001). Conclusions: Surgeons with volume ≥90th percentile had a decreased rate of complications, decreased length of stay, and reduced hospital charges compared to other surgeons. Level of Evidence: Level III, comparative study.

Chronic Ankle Pain and Swelling in a 25-year-old Woman: An Unusual Case

Tendon transfers are commonly used in the foot and ankle to restore function in neglected ruptures, reconstruct degenerated tendons, and correct deformity. The Achilles tendon is commonly afflicted by these problems because of the dominant role it plays in the mechanics of gait and running and its inherently poor blood supply. This article discusses the general principles of tendon transfers with regard to Achilles tendon function, the surgical techniques involved, and published results using these techniques. The goal is to provide the orthopedic foot and ankle surgeon with a wide variety of techniques to solve both the straightforward Achilles tendon problem as well as the difficult revision case.

Time related effects of non-steroidal anti-inflammatory drugs on Achilles tendinopathy in a murine model:

Background: Achilles tendon ruptures are one of the most commonly treated injuries by orthopaedic surgeons and general practitioners. Achilles tendon ruptures have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any other ground sport that requires speed and agility; however, with a more active elderly population, these tears are becoming more common in older patients. Purpose: To report trends in nonoperative and operative treatment of Achilles tendon tears in the United States from 2005 to 2011 in patients registered with a large Medicare database. Study Design: Descriptive epidemiological study. Methods: Patients who underwent nonoperative and operative treatment of Achilles tendon ruptures by either primary repair or primary repair with graft (International Classification of Diseases 9 [ICD-9] diagnosis code 727.67, Current Procedural Terminology [CPT] codes 27650 and 27652) for the years 2005 to 2011 were identified using the PearlDiver Medicare Database. Demographic and utilization data available within the database were extracted for patients who underwent nonoperative as well as operative treatment for Achilles tendon ruptures. Statistical analysis involved Student t tests, chi-square tests, and linear regression analyses, with statistical significance set at P < .05. Results: From 2005 to 2011, there were a total of 14,127 Achilles tendon ruptures. Of these, 9814 were managed nonoperatively, 3531 were treated with primary repair, and 782 were treated with primary repair with graft. The incidence of Achilles tendon increased from 0.67 per 10,000 in 2005 to 1.08 per 10,000 in 2011 (P < .01). There was no significant difference in the number of Achilles ruptures between males (6636) and females (7582) (P > .05). There was an increase in the overall number of Achilles tendon ruptures over time (1689 in 2005 compared with 2788 in 2011; P < .001) but no difference in the percentage of Achilles ruptures treated operatively (P > .05). Older patients were more likely to be treated nonoperatively (P < .05). No differences in operative versus nonoperative treatment were seen between yearly quarter (P > .05), sex (P > .05), or region (P > .05). Conclusion: The incidence of Achilles tendon ruptures is increasing with time, but the trend in operative and nonoperative treatment has not changed between 2005 and 2011. Older patients, especially those older than 85 years, are more likely to be treated nonoperatively. No differences in treatment patterns were seen based on sex, region, or yearly quarter.