Minton Truitt Cooper

Epidemiology of athletic head and neck injuries.

In this article, we review the available data on sporting injuries to the head and neck and discuss sport-specific injury risk and prevention strategies, as well as the costs of head and neck injuries.

A Comparison of Outcomes of Particulated Juvenile Articular Cartilage and Bone Marrow Aspirate Concentrate for Articular Cartilage Lesions of the Talus.

Background. Articular cartilage lesions of the talus remain a challenging clinical problem because of the lack of natural regeneration and limited treatment options. Microfracture is often the first-line therapy, however lesions larger than 1.5 cm2 have been shown to not do as well with this treatment method. Methods. The objective of this retrospective study was to evaluate the outcomes of iliac crest bone marrow aspirate concentrate/collagen scaffold (ICBMA) and particulated juvenile articular cartilage (PJAC) for larger articular cartilage lesions of the talus. Fifteen patients undergoing ICBMA or PJAC for articular cartilage lesions of the talus from 2010 to 2013 were reviewed. Twelve patients, 6 from each treatment option, were included in the study. American Orthopaedic Foot and Ankle Surgeons (AOFAS), Foot and Ankle Ability Measure (FAAM), and Short Form–12 (SF-12) outcome scores were collected for each patient. Results. The mean age was 34.7 ± 14.8 years for ICBMA and 31.5 ± 7.4 years for PJAC. Lesion size was 2.0 ± 1.1 cm2 for ICBMA and 1.9 ± 0.9 cm2 for PJAC. At a mean follow-up of 25.7 months (range, 12-42 months), the mean AOFAS score was 71.33 for ICBMA and 95.83 for PJAC ( P = .019). The FAAM activities of daily living subscale mean was 77.77 for ICBMA and 97.02 for PJAC (  P = .027). The mean FAAM sports subscale was 45.14 for ICBMA and 86.31 for PJAC ( P = .054). The SF-12 physical health mean was 47.58 for ICBMA and 53.98 for PJAC ( P = .315). The SF-12 mental health mean was 53.25 for ICBMA and 57.8 for PJAC ( P = .315). One patient in treated initially with ICBMA underwent revision fixation for nonunion of their medial malleolar osteotomy, which ultimately resulted in removal of hardware and tibiotalar arthrodesis at 2 years from the index procedure. Conclusion. In the present analysis, PJAC yields better clinical outcomes at 2 years when compared with ICBMA for articular cartilage lesions of the talus that were on average greater than 1.5cm2. Levels of Evidence: Therapeutic, Level IV: Retrospective, Case series

Acute Achilles Tendon Ruptures: Does Surgery Offer Superior Results (and Other Confusing Issues)?

Management of acute Achilles tendon rupture is controversial. Although in the past open surgery was considered the gold standard, recent studies have shown improved outcomes with nonoperative management, leading to an increase in popularity of this treatment option. Percutaneous techniques have gained attention and seem to offer excellent results. In addition, as with many other orthopedic conditions, significant concerns and questions exist as to whether or not chemoprophylaxis is indicated in these patients.

Subcaptial oblique fifth metatarsal osteotomy versus distal chevron osteotomy for correction of bunionette deformity: a cadaveric study.

The aim of this study was to compare a distal subcapital oblique fifth metatarsal with a distal chevron osteotomy for correction of bunionette deformity. Materials and methods. Twenty cadaveric feet were randomly assigned to undergo either a subcapital oblique or chevron osteotomy of the distal fifth metatarsal. Radiographic measurements, including 4–5 intermetatarsal angle (IMA), fifth metatarsophalangeal angle (5-MPA) and foot width, were compared between the 2 groups. Results. Foot width and 5-MPA was significantly decreased in both groups with no difference between the groups. The 4–5 IMA was not significantly altered in either group. Conclusion. Decrease in foot width and 5-MPA was similarly achieved with either distal chevron or subcapital oblique osteotomy of the fifth metatarsal in normal cadaveric specimens. No significant difference was found between the 2 techniques in any of the radiographic parameters measured. Levels of Evidence: Cadaveric, Level V

Patient-Related Risk Factors for Periprosthetic Ankle Joint Infection: An Analysis of 6977 Total Ankle Arthroplasties

&NA; Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a devastating complication that often results in explantation to resolve the infection. The purpose of the present investigation was to determine the patient‐related risk factors for PJI after TAA. A national insurance database was queried for patients undergoing TAA using the Current Procedural Terminology and International Classification of Diseases, ninth revision, procedure codes from 2005 to 2012. Patients undergoing TAA with concomitant fusion procedures or more complex forefoot procedures were excluded. PJI within 6 months was then assessed using the International Classification of Diseases, ninth revision, codes for diagnosis or treatment of postoperative PJI. Multivariate binomial logistic regression analysis was performed to evaluate the patient‐related risk factors for PJI. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor, with p < .05 considered statistically significant. A total of 6977 patients were included in the present study. Of these 6977 patients, 294 (4%) had a diagnosis of, or had undergone a procedure for, PJI. The independent risk factors for PJI included age <65 years (OR 1.44; p = .036), body mass index <19 kg/m2 (OR 3.35; p = .013), body mass index >30 kg/m2 (OR 1.49; p = .034), tobacco use (OR 1.59; p = .002), diabetes mellitus (OR 1.36; p = .017), inflammatory arthritis (OR 2.38; p < .0001), peripheral vascular disease (OR 1.64; p < .0001), chronic lung disease (OR 1.37; p = .022), and hypothyroidism (OR 1.32; p = .022). The independent patient‐related risk factors identified in the present study should help guide physicians and patients considering elective TAA and develop risk stratification algorithms that could decrease the risk of deep, postoperative infection. &NA; Level of Clinical Evidence: 3

Small Toes, Huge Problems: Dealing With Lesser Toe Deformities

To me, one of the most difficult problems to treat is second metatarsophalangeal (MTP) joint pain. A 45-year-old male presents with 6 weeks of pain at the second MTP joint, with a sudden onset while playing Frisbee. On examination, he has normal alignment of the forefoot, no swelling, and no sagittal plane instability of the second MTP joint. Radiographs are normal. How would you manage this initially, and how would you counsel him about his prognosis?

Regenerative Medicine and Surgery in the Foot and Ankle Practice

The term “regenerative medicine” has been a hot topic in orthopaedic subspecialties for the past several years. From treating professional and collegiate athletes to the weekend warrior, patients often present to orthopaedic clinics with the request for “regenerative” therapies. While many of these therapies have shown promise, the lack of evidence-based medicine has created confusion for both the practitioner and the patient. A lack of understanding of both the science and outcomes has created a situation where therapies are misused and misunderstood. In this roundtable discussion, 2 foot and ankle surgeons with tremendous experience in regenerative medicine discuss topics related to both the office setting and the operating room.

S822.899—ICD-10 Ankle Fracture Sequelae: How to Manage It and How to Avoid It in Difficult Situations:

It is clear that not all ankle fractures are created equally, and often this is determined by patient factors. What may appear to be a straightforward fracture pattern may be made exponentially more challenging if it occurs in a patient with diabetic neuropathy. Equally challenging can be the management of poor outcomes after ankle fracture management. In this roundtable discussion, we will discuss several cases that illustrate these issues with Dr Joseph Park, an orthopaedic foot and ankle surgeon, and Dr Seth Yarboro, an orthopaedic traumatologist. Case 1: Patient is a 70-year-old diabetic male who sustained a bimalleolar ankle fracture in a ground-level fall. He has a below knee amputation on the contralateral side from prior foot infection, but has been a community ambulator. Due to his diabetes, he was initially managed in a splint and referred to several different providers who declined to operate. X-rays 2 months after the injury are shown in Figure 1A and B. Cooper: Tell us how you approach ankle fractures in a diabetic patient with neuropathy? Is there any standard preoperative testing that you routinely obtain? What about hardware, how would you have stabilized this initially? What about at this point? Park: Although it is tempting to treat diabetic patients nonoperatively, I have found that the complications that may result from closed treatment often require much bigger surgeries than the initial ankle fracture fixation. Since the goals of surgery are to obtain a plantigrade foot that allows the patient to transfer in a CROW boot or AFO (ankle and foot orthosis) brace, this changes the definition of clinical success. We typically obtain hemoglobin A1c and medicine/cardiology clearance for these patients preoperatively. Again, even if the A1c is above the 7.5%, we typically target for elective cases, and I feel that an ankle ORIF (open reduction and internal fixation) is a much better option than a complex TTC (tibiotalocalcaneal) fusion or BKA (below the knee amputation). In general, I try to use distal fibular anatomic locking plates and transsyndesmotic screws to further augment fixation. For medial malleolar fractures, a hook plate or periarticular plate may allow 773392 FASXXX10.1177/1938640018773392Foot & Ankle SpecialistFoot & Ankle Specialist research-article2018

Update on Lateral Ankle Instability

Hunt: The diagnosis of lateral ankle instability is typically arrived at by a careful history and physical examination. I do not routinely obtain stress radiographs, but I do perform stress fluoroscopy in clinic when confirmation of the diagnosis is necessary, and to differentiate between ankle and subtalar joint instability. Mangone: I evaluate lateral ankle instability with manual testing using the standard anterior drawer and tilt tests. I also will occasionally perform stress fluoroscopy in a patient whose subjective complaints are greater than their manual testing findings. I agree that fluoroscopic stress testing sometimes also helps identify subtalar instability if the ankle joint remains stable within the mortise. Miller et al (Foot and Ankle International, April 2016) published on increased sensitivity of the rotational instability versus anterior translational instability. How do you use this in your practice and does it change your management if someone demonstrates only rotational versus translational instability?

End-Stage Osteoarthritis of the First Metatarsophalangeal Joint: What Has Changed in Our Practice?

Advances are abound in foot and ankle surgery. Each month new technologies are used in patients, research is expanding to provide better care for our patients, and new procedures are being described to treat the most challenging of problems. While all of this makes it extremely exciting to perform foot and ankle surgery today, it is still extremely important for surgeons to revisit how they treat pathologies that maybe are not as “exciting” as some of the newly described techniques. One of these pathologies is arthritis of the first metatarsophalangeal joint. All foot and ankle surgeons, no matter the location, are sure to treat this condition on a daily basis. In this roundtable discussion, two tremendous surgeons, Dr Jack Schuberth and Dr Graham Hamilton, will provide us with an update on how they are managing this surgical problem in their practices.