Justin D. Orr

The incidence of plantar fasciitis in the United States military.

BACKGROUND Although plantar fasciitis is the most common cause of heel pain, little has been reported on the incidence rates of this disorder. We sought to determine the incidence rate and demographic risk factors of plantar fasciitis in an ethnically diverse and physically active population of United States military service members. METHODS A query was performed with use of the Defense Medical Epidemiology Database for the International Classification of Diseases, Ninth Revision, Clinical Modification, code for plantar fasciitis (728.71). Multivariate Poisson regression analysis was used to estimate the rate of plantar fasciitis per 1000 person-years, while controlling for sex, race, rank, service, and age. RESULTS The overall unadjusted incidence rate of plantar fasciitis was 10.5 per 1000 person-years. Compared with men, women had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.96 (95% confidence interval, 1.94 to 1.99). The adjusted incidence rate ratio for black service members compared with white service members was 1.12 (95% confidence interval, 1.09 to 1.12). With junior officers as the referent category, junior enlisted, senior enlisted, and senior officer rank groups had a significantly increased adjusted incidence rate ratio for plantar fasciitis: 1.20 (95% confidence interval, 1.18 to 1.23), 1.19 (95% confidence interval, 1.17 to 1.22), and 1.56 (95% confidence interval, 1.52 to 1.61), respectively. Compared with service members in the Air Force, those in the Army and Marines had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.85 (95% confidence interval, 1.82 to 1.87) and 1.28 (95% confidence interval, 1.25 to 1.30), respectively. The adjusted incidence rate ratio for the age group of forty years old or more compared with the twenty to twenty-four-year-old group was 3.42 (95% confidence interval, 3.34 to 3.51). CONCLUSIONS Female sex; black race; junior enlisted, senior enlisted, and senior officer rank groups; service in the Army or Marines; and increasing age are all risk factors for plantar fasciitis.

Isolated Spring Ligament Failure as a Cause of Adult-Acquired Flatfoot Deformity

Background: Adult-acquired flatfoot deformity is usually secondary to failure of the tibialis posterior tendon, with secondary injury to the surrounding osseous-ligamentous complex. Rarely, patients may present with a normal tibialis posterior tendon and an isolated injury of the plantar calcaneonavicular, or spring, ligament. The current study describes the clinical presentation and operative management of 6 patients with isolated spring ligament ruptures who presented with symptomatic flexible flatfoot deformities. Methods: Six consecutive patients with unilateral flatfoot deformities secondary to spring ligament failure were operatively treated at one institution between 2003 and 2010. All patients presented with symptomatic flatfoot deformities recalcitrant to conservative management. No patients had previous flatfoot reconstructive surgery, but all had undergone some combination of orthotic use, immobilization, or activity modifications prior to operative treatment. In each case, intraoperative findings demonstrated a tear of the spring ligament complex with a normal tibialis posterior tendon. To address the deformities, spring ligament repairs and adjunctive flatfoot reconstructions were performed. A retrospective chart study was performed to document patient presentation, demographics, and outcomes. Results: Average patient age was 42 years. All 6 patients were female. All patients presented with medial foot pain for a mean of 27 months prior to presentation. Spring ligament abnormality was demonstrated in all 5 patients who received preoperative magnetic resonance imaging. Intraoperatively, all 6 patients demonstrated spring ligament tears and no significant tibialis posterior tendon abnormality. All 6 patients underwent spring ligament repairs with or without adjunctive flatfoot reconstructions. At mean follow-up of 13 months, all but 1 patient were pain-free without orthotics, and all patients were without residual deformity. There was a single patient with delayed bone graft healing and no other minor or major complications in this series. Conclusions: Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities. In this study, although preoperative magnetic resonance imaging was not required, it identified a suspected spring ligament tear in all cases in which it was used. Thorough intraoperative exploration can identify an injury to the spring ligament and a normal tibialis posterior tendon. Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management. Level of Evidence: Level IV, retrospective study.

Incidence of Osteochondral Lesions of the Talus in the United States Military

Background: Osteochondral lesion of the talus (OCLT) is frequently described as an uncommon diagnosis; however, little is known of its incidence. In light of increased awareness combined with the continued evolution of radiologic and treatment modalities, more attention has been given to this diagnosis. Serving a young, athletic population with unique occupational requirements, we have perceived an increase in the diagnosis of OCLTs. The goal of this study was to determine the incidence of OCLTs in an active duty military population, as well as demographic risk factors for OCLTs. Methods: We performed a query of the Defense Medical Epidemiology Database (DMED) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for OCLTs which in the Armed Forces Health Longitudinal Technology Application (AHLTA) system is uniquely assigned the code 732.5. An overall injury incidence was calculated, in addition to multivariate analysis to determine independent risk factors among the following demographic considerations: gender, race, rank, branch of military service, and age. Year of diagnosis was also considered. Results: The overall incidence rate for the 10-year period (1999 to 2008) was 27 OCLTs per 100,000 person-years. Significant demographic risk factors were female gender, white race, enlisted rank, service in the Army and Marines, and age greater than 20 years. Incidence rate was 16 per 100,000 in 2002, with steady annual increases resulting in an incidence rate of 56 per 100,000 person-years in 2008, corresponding to the years of active involvement in global combat operations. Conclusion: The incidence of OCLTs in the active duty military population was higher with female gender, white race, enlisted rank, increased age, and Army or Marine service. Level of Evidence: IV, Retrospective Series

Management and prevention of acute and chronic lateral ankle instability in athletic patient populations

Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significant long-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and non-anatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation.

Objective: The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF). Methods: The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures. Results: Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m2 (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19–15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13–4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95–19.35), open wound (OR: 5.04; 95% CI: 2.25–11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31–6.93), and smoking (OR: 2.85; 95% CI: 1.42–5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m2, bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes. Conclusions: Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Chronic Exertional Compartment Syndrome in a Physically Active Military Population

Background: Chronic exertional compartment syndrome (CECS) is a common source of lower extremity pain in physically active military service members. While anatomic risk factors of CECS have been proposed, there is no existing study that evaluates the correlation of demographic and occupational risk factors and the overall incidence rate of CECS in an active military population. Hypothesis: Young, enlisted service members in the United States (US) ground military forces would demonstrate higher incidence rates of CECS in the study population because of greater exposure to at-risk dismounted activity on the battlefield and in training. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: A retrospective study of all US active military service members with diagnosed nontraumatic exertional compartment syndrome of the lower extremity (code 729.72 in the International Classification of Diseases, 9th Edition) between 2006 and 2011 was performed using the Defense Medical Epidemiology Database. Demographic and occupational risk factors such as sex, age, race, branch of military service, and military rank were individually subcategorized, and cumulative and subgroup incidence rates of CECS were calculated using a multivariate Poisson regression model. Results: A total of 4100 diagnosed cases of CECS were identified within an at-risk population of 8,320,201, which correlates to an incidence rate of 0.49 cases per 1000 person-years. The annual adjusted incidence rate of CECS increased from 0.06 cases per 1000 person-years in 2006 to 0.33 cases per 1000 person-years in 2009. Increasing chronological age, female sex, white race, junior enlisted rank, and Army service were significantly correlated with an elevated risk for CECS. Conclusion: This study systematically evaluated the epidemiology of CECS among an idealized subset at risk for this condition. Sex, age, race, military rank, and branch of service were all important factors associated with the incidence of CECS in this physically active population.

Anatomic location and morphology of symptomatic, operatively treated osteochondral lesions of the talus.

Background: Historically, osteochondral lesions of the talus (OCLTs) were thought to occur most commonly in the anterolateral and posteromedial talar dome; however, new classification systems are able to describe OCLT location more precisely. A recent magnetic resonance imaging (MRI) study introduced a novel nine-zone anatomic grid of the talar dome, demonstrating that most OCLTs occur in the central portion of the medial and lateral talar dome, with medial lesions being more common as well as larger in depth and surface area. The current study sought to determine if similar location and morphology patterns were consistent in symptomatic, operatively treated OCLTs. Materials and Methods: The preoperative MRI images of 65 consecutive patients who underwent operative management for symptomatic OCLTs at a single institution were reviewed using a previously described nine-zone anatomic grid of the talar dome to determine location frequency, morphology, and Hepple et al. MRI staging classification characteristics. All patients were active-duty service members in the United States Armed Forces. The cohort consisted of 60 (92%) males and 5 (8%) females with an overall mean patient age of 34 (range, 19 to 58) years. Statistical analyses were performed, and significant differences are reported. Results: The most common location for symptomatic, operatively treated OCLTs was the central third of the lateral talar dome, followed by the central third of the medial talar dome. Anterolateral and posteromedial lesions accounted for relatively few OCLTs. Compared with lateral OCLTs, medial OCLTs were significantly larger in transverse and anteroposterior diameters and surface area, but no significant differences existed with regard to lesion depth. Overall, the majority of lesions were MRI stage II; however, stage II lesions were more likely located laterally, whereas stage III lesions were more likely located medially. Conclusions: With regard to symptomatic, operatively treated OCLTs, the results of the current study parallel current evidence that posteromedial and anterolateral OCLTs are not the most common locations of OCLTs. As well, medial OCLTs were larger in surface area than lateral OCLTs, but no differences existed with regard to lesion depth. It is interesting that operatively treated OCLTs were twice as commonly located in the centrolateral third rather than the centromedial third of the talar dome. Level of Evidence: IV (Retrospective Chart Study)

Jones Fracture Fixation: A Biomechanical Comparison of Partially Threaded Screws Versus Tapered Variable Pitch Screws

Background: Stabilization of fifth metatarsal Jones fractures with intramedullary screw fixation is the most common method for surgical fixation when operative treatment is indicated. Conventional partially threaded screws of various diameters are routinely used for Jones fracture fixation. Recently, the use of tapered variable pitch screws has become popular, but information regarding their performance in Jones fracture fixation is limited. No previous studies have compared conventional and tapered variable pitch screws in Jones fracture fixation under physiologic cyclic loading conditions. Purpose: To determine whether biomechanical differences exist between appropriately sized conventional partially threaded screws and tapered variable pitch screws under physiologic cyclic loading conditions with regard to Jones fracture fixation. Study Design: Controlled laboratory study. Methods: Simulated Jones fractures were created in 23 matched pairs of fresh-frozen fifth metatarsals. One bone from each pair was stabilized with a conventional partially threaded screw and the contralateral bone with a tapered variable pitch screw. Initial compression, as well as fracture site compression, angulation, and bending stiffness, was compared between groups throughout 1000 physiologic cyclic loads. Results: Conventional partially threaded screws obtained significantly greater initial compression compared with tapered variable pitch screws. Significantly greater compression was maintained throughout cyclic loading with conventional screw fixation compared with tapered variable pitch screws. Fracture site angulation was significantly greater using tapered variable pitch screws from the tenth load cycle through completion of cyclic loading. Despite a trend toward increased fracture site bending stiffness when using conventional screws, no difference in fixation stiffness was demonstrable between the 2 screw types. Conclusion: In this cadaveric Jones fracture fixation model, conventional partially threaded screws provided improved fracture site compression and decreased fracture site angulation but offered no advantage in improving fracture site stiffness compared with tapered variable pitch screws. These results provide empirical evidence to guide implant selection decision making for operative fixation of Jones fractures. Clinical Relevance: While the use of tapered variable pitch screws is a potential alternative for fixation of fifth metatarsal Jones fractures, conventional partially threaded screws may provide better biomechanical stability, the effect of which on fracture healing is unknown.

Painful bone marrow edema syndrome of the foot and ankle.

Background: Bone marrow edema syndrome (BMES) of the foot and ankle is an uncommon and often undiagnosed disorder that, to our knowledge, has not previously been reported in the orthopaedic literature. The current study reviews a consecutive series of patients who were seen with this musculoskeletal disorder in order to highlight the clinical presentation and diagnostic imaging characteristics specific to this disorder. Materials and Methods: A retrospective chart study was performed involving 601 patients who underwent magnetic resonance (MR) imaging of the foot and ankle at our institution from April 2005 to April 2006. We identified 14 patients whose MR imaging demonstrated findings consistent with BMES. Results: All 14 patients demonstrated characteristic diffuse, irregularly increased signal intensity on T2-weighted MR imaging and variable areas of decreased signal intensity on T1-weighted MR images in an average of three bones within the foot and ankle. Average patient age was 16.4 (range, 10 to 27) years, and no patient reported a history of prior trauma. Eight patients received treatment for an incorrect initial diagnosis with two of those patients undergoing surgical procedures. Twelve patients were successfully treated with supportive nonoperative therapy for an average length of 19.4 months. Four patients had followup MR imaging demonstrating signal changes consistent with their clinical improvement/changes. Conclusion: BMES of the foot and ankle is a clinical disorder seen in younger patients with a clinical history of prolonged foot and ankle pain of unknown etiology and without prior trauma. MR findings from this series are consistent with previous descriptions in the radiology literature. Furthermore, MR imaging can be utilized to monitor the progression or resolution of this disorder. Proper diagnosis and treatment may prevent further unnecessary diagnostic testing or surgical procedures. Level of Evidence: IV, Retrospective Case Series

Quantification of Posterior Ankle Exposure through an Achilles Tendon-Splitting versus Posterolateral Approach:

Background: The optimal surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon-splitting approach would provide greater exposure to the posterior ankle than the posterolateral approach. Methods: Forty surgical approaches were performed from twenty fresh-frozen cadavers. Achilles tendon-splitting and posterolateral approaches were performed using a randomized crossover design for surgical sequence. Six landmarks (medial malleolus, ankle joint, subtalar joint, incisura fibularis, lateral malleolus and medial gutter) were identified by direct visualization or palpation. A calibrated digital photograph was taken and Image J (http://rsb.info.nih.gov/ij/) was used to calculate the surface area of the distal tibia and talus exposed in neutral and dorsiflexion. Results: Using a posterolateral approach, the average distal tibia exposed was 11.3cm2 in neutral and 10.2 cm2 in dorsiflexion. The average talus exposed was 2.0 cm2 in neutral and 2.4 cm2 in dorsiflexion. Using an Achilles tendon-splitting approach, the average exposed distal tibia was 33% more (15.0 cm2) in neutral and 43% more (14.6 cm2) in dorsiflexion. The average talus exposed was 47% more (3.0 cm2) in neutral and 76% more (4.2 cm2) in dorsiflexion. All increases in exposure were statistically significant. The medial malleolus was visualized in 19 tendon-splitting and six posterolateral approaches. The medial gutter was visualized in 20 tendon-splitting and 13 posterolateral approaches. These differences were statistically significant. All other landmarks could be visualized through both approaches. Conclusion: The Achilles tendon-splitting approach provided significantly greater exposure of the posterior distal tibia and talus compared to the posterolateral approach. Clinical Relevance: Prospective studies will help determine if the tendon-splitting approach is a safe and clinically useful approach for surgeries in which direct access to the entire posterior ankle and subtalar joint are required.