Monique Chambers

Foot and Ankle: Conservative Management, Operative Management, and Return to Sport

Foot and ankle injuries are one of the most common injuries within the athletic population. For masters athletes, years of repetitive motions inevitably contribute to degeneration of the most dependent structures of the body, the foot and ankle. As a result, competitive activity results in injuries related to stress and fatigue. Particularly, acute rupture of the Achilles tendon and/or chronic tendinopathy can lead to decreased performance and the need for operative intervention. Similarly, the plantar fascia may become irritated and inflamed and require intensive therapy or surgery for the athlete to continue high-level performance. Overuse and persistent load may cause debilitating stress fractures that are difficult to manage. Many of these conditions are managed through conservative measures and an emphasis on maintenance to control the symptoms of the respective condition. However, the masters athlete represents a unique population that may require surgical intervention once all other measures have been exhausted to allow them to continue high-level activity, even in a mature period of life.

Arthroplasty or Arthrodesis in the CJR Era: Medical Resource Utilization for Patients with Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis can be a debilitating disease that results in decreased daily activity and chronic morbidity. Many patients elect for surgical intervention to minimize pain and improve function. To curb costs associated with the increasing demand for total joint arthroplasty (TJA) in the growing elderly Medicare population, CMS announced the Comprehensive Care for Joint Replacement (CJR) model, which included total ankle arthroplasty. To provide continued quality care and cost containment, it is necessary to determine the optimal surgical intervention for patients that could fall within the CJR program. Therefore, we sought to determine the impact of surgical fixation on functional outcomes, systemic utilization, and medical expenditures for patients with ankle arthritis. Methods: We reviewed a prospectively collected and maintained database to identify all patients who underwent a total joint replacement from April 2016 to September 2017. Patients were identified based on DRG codes for primary arthritis of a lower extremity joint, then specifically for foot and ankle, as well as CPT codes for ankle arthroplasty (27702) or ankle arthrodesis (27870/28725). Functional outcomes were assessed based on insurance type. The cohorts were matched for age, comorbidities, and gender. Statistical analysis was performed using chi-squared and paired t-test to assess for differences in patient reported outcomes. Descriptive statistical analysis was used to assess for differences in cost between the cohorts. Results: A total of 573 patients were included.There were 48 replacements and 47 fusions. Arthrodesis procedures costs approximately

The role of biologic in foot and ankle trauma—a review of the literature

6,500 less per case than the system costs for patients who underwent arthroplasty procedures. The average length of stay for patients who underwent total ankle arthroplasty was 1.6 days compared to outpatient surgical centers utilized for most arthrodesis patients. Overall, patients reported improved pain and a 30.96 increase in FAAM scores. Most patients had a global rate of change that was “very much better” or “much better” (68%). Based on insurance type, patients who underwent a total ankle replacement in the CJR program had improved outcomes and lower cost than patients commercially insured. Conclusion: With the CJR, there is greater emphasis on the optimal intervention for elective operations. There should be coordinated efforts to optimize quality care, while minimizing financial waste within the healthcare system. The price differential suggests an annual potential for financial savings as high as

Editorial Commentary: Adult Stem Cell Potential to Enhance Healing of the Anterior Cruciate Ligament

325,000 for a system that supports intervention for ~50 cases per year. As such, these results suggest that arthroplasty may be optimal for patients with severe symptomatic ankle arthritis, while most patients have adequate relief with an ankle fusion. More importantly, quality improvement efforts should focus on the impact of surgical intervention on functional activity.

Bone Bruise Patterns in Skeletally Immature Patients With Anterior Cruciate Ligament Injury: Shock-Absorbing Function of the Physis:

Purpose of reviewThe use of biologics in orthopedics is becoming increasingly popular as an adjuvant in healing musculoskeletal injuries. Though many biologics involved in the management of foot and ankle injuries are used based on physician preference, reports of improved outcomes when combined with standard operative treatment has led to further clinical interest especially in foot and ankle trauma.Recent findingsThe most recent studies have shown benefits for biologic use in patients predisposed to poor bone and soft tissue healing. Biologics have shown benefit in treating soft tissue injuries such as Achilles ruptures as well as the complications of trauma such as non-unions and osteoarthritis.SummaryBiologics have shown some benefit in improving functional and pain scores, as well as reducing time to heal in foot and ankle traumatic injuries, with particular success shown with patients that have risk factors for poor healing. As the use of biologics continues to increase, there is a need for high-level studies to confirm early findings of lower level reports.

Clinical Outcomes of Screw Fixation for Ligamentous Injuries to the Ankle Syndesmosis in Athletes

Even with the most accurate individualized, anatomic approach to anterior cruciate ligament (ACL) reconstruction, the potential for graft failure still exists, with reported retear rates as low as 5%, and even higher in female athletes or patients reconstructed with allograft. ACL graft healing is dependent on several factors, including anatomic placement, appropriate graft choice, proper technique, recovery time, and the biological environment of nature. If the double-bundle concept is followed and individualized for each patients anatomic morphology, the ACL will biologically reform. The use of adult stem cells may help to contribute to the biological environment and aid in a faster healing time and quicker return to the preoperative state. There is a need for long-term studies and further research in human models to determine the optimal indication and environment for tissue healing with stem cell treatment.

Patient Reported Outcomes in Athletes following ORIF of Jones Fracture

Background: Bone bruises are frequently found on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury and have been related to the force associated with the trauma. Yet, little is known about the bone bruise distribution pattern of skeletally immature (SI) patients, as the presence of an open physis may play a role in energy dissipation given its unique structure. Purpose: To describe and compare the location and distribution of tibial and femoral bone bruises, observed on MRI, between 2 groups of ACL-injured knees: the first group with an open physis and the second with a closed physis. Additionally, based on the bone bruise distribution pattern, the secondary aim of the study was to propose a new classification of bone bruise in SI patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted to identify all cases of primary ACL tears in patients ≤16 years old, with MRI within 6 weeks of injury between January 2012 and December 2016. Overall, 106 patients were identified: 53 with open physis (skeletally immature [SI] group) and 53 with closed physis as control (skeletally mature [SM] group). MRI scans were reviewed to assess for the presence and location of bone bruises. Longitudinal bone bruise distribution was described as epiphyseal and metaphyseal in both femur and tibia. The proposed classification for tibia and femur has 2 parts: the location of the bone bruise in the (I) lateral, (II) medial, or (III) medial and lateral parts of the bone; and if the bone bruise (a) does not or (b) does cross the physis. For the tibia, if the bone bruise is also present in the central portion, a letter C is added. Results: The SI group had significantly fewer bone bruises cross the physis and extend into the metaphysis than did the SM group for both the tibia (25% vs 85%, respectively; P < .0001) and the femur (4% vs 42%; P < .0001). The most common patterns observed in the SI group were type IIICa in the tibia (medial/lateral and central, not extending into the metaphysis: 42%) and type Ia in the femur (lateral, not extending into the metaphysis: 59%). Conclusion: The data from this study shows that patients with an open physis at the occurrence of an acute ACL rupture have unique bone bruise patterns as compared with those with a closed physis. In the SI patients, the bone bruise pattern is significantly less frequently observed in the tibial and femoral metaphysis.

Treatment of End-Stage Hallux Rigidus and Impact of Arthrodesis versus Arthroplasty on Patient Reported Outcomes

Category: Sports Introduction/Purpose: Injuries to the ankle syndesmosis are commonly seen in the general population as well as in athletes [1]. Literature is mixed on the effectiveness of the two fixation techniques – rigid screw and suspensory fixation [2]. Specifically, data is lacking in an athletic population. Hypothesis: We hypothesize that in patients treated with rigid screw fixation, athletes will have a higher incidence of hardware-associated pain, screw breakage, and screw removal compared to non-athletes. Methods: This study was a retrospective review of a patients from eight orthopedic surgeons within the UPMC system. All patients underwent surgical stabilization of the ankle syndesmosis with a rigid screw. Exclusion criteria included age <15 years or >45 years, polytrauma, injury to the ankle articular surface, neurological impairment, chronic medical conditions, and other disabilities. Athlete status was assigned based on mention of participation in athletic activity at the high school level or higher in the electronic medical record. The incidence of hardware-associated pain, screw breakage, and screw removal in athletes vs. non- athletes were evaluated using chi-squared and fisher’s exact tests. tests. Results: Fifty-five patients met the eligibility criteria. Of these patients, 21 athletes were identified with 34 being non-athletes. In terms of patient characteristics, the athlete group was 90% male, 48% right sided injury, and with an average age of 26.6 (SD 6.8). The non-athlete group was 59% male, 47% right sided injury, and with an average age of 33.6 (SD 6.6). Athletes were observed to have higher incidence of hardware-associated pain (6 (29%) vs. 6 (18%), p=0.341), screw breakage (8 (38%) vs. 8 (24%), p=0.248), and screw removal (19 (90%) vs. 23 (68%), p=0.100) compared to non-athletes in this study. However, only the comparison for screw removal approached statistical significance. Conclusion: The results suggest that even in an age matched population, athletes may have higher incidence of screw removal. This study did not have sufficient power to demonstrate a statistical difference in hardware-associated pain or screw breakage, although these did occur at a higher rate in the athlete population. A larger study will be needed to demonstrate statistical significance. Nevertheless, these results suggest that it may make sense to use the suspensory fixation method in athletes in order to avoid a second surgery for hardware removal.

Phalangeal Osteotomy…To Perform or Not to Perform: Changes in Functional Outcomes of Patients with Moderate to Severe Hallux Rigidus Undergoing Cheilectomy

Category: Lesser Toes, Midfoot/Forefoot, Sports Introduction/Purpose: Treatment of fractures to the 5th metatarsal metaphyseal-diaphyseal junction, known as Jones’ fractures, can present challenges in the elite athlete significantly prolonging return to play. Non-operative treatments in elite athletes result in a high incidence of nonunion and secondary fracture. Primary screw fixation remains the standard of care for athletes. However, delayed union and nonunion are still very common despite surgical fixation due to the fracture occurring in a watershed area with decreased healing potential. Bone marrow aspirate concentrate (BMAC) is an autologous source of hematopoeitic and mesenchymal stem cells that has been used in the treatment of poor healing fractures. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes. Methods: This study was a retrospective review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were assessed preoperatively and postoperatively to determine their pain outcomes based on their visual analog score (VAS). Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant. Results: A total of 16 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 22.2 years (range 19–26). There were 9 males and 7 females included in the study. Type of athlete ranged across various sport activities, with all patients functioning at a collegiate and/or professional level of elite athletics. The mean visual analog score for pain decreased from 6.2 preoperatively (range 3-8) to 2.75 postoperatively (range 1-6 p = 0.06). All patients have returned to elite competitive sport activity with reports of minimal to no pain. Conclusion: Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.

Jones Fracture in the Elite Athlete: Patient Reported Outcomes following Fixation with BMAC

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a degenerative disease of the first metatarsophalangeal joint. Severe, end-stage hallux rigidus can become debilitating with surgical intervention becoming necessary once conservative measures and shoe modifications have failed. Joint salvage procedures include metatarsal phalangeal (MTP) arthrodesis and MTP arthroplasty. The purpose of this study was to assess for differences in patient reported outcomes in two cohorts who underwent fusion or joint reconstruction. Methods: This study was a retrospective review of prospectively collected data of 385 patients from an academic medical institution. Patients who underwent surgical intervention from July 2015 to November 2016 were identified based on CPT codes for MTP arthrodesis (28750) and arthroplasty (28293). We extracted outcome scores including SF12-M, SF12-P, FAAM, and VAS scores. Exclusion criteria included poly-trauma, revision procedures, and lack of pre and post-operative outcome scores. Mann- Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups, with significance define by a p-value of 0.05. Results: A total of eighteen patients met the inclusion criteria, with 6 who underwent arthroplasty and 12 arthrodesis. The average age was 63.7 amongst the cohort, with a total of 16 female and 2 males. Patients who underwent arthrodesis had better outcomes across all parameters. When comparing preoperative and postoperative scores, arthrodesis patients showed greater improvement of SF12-M (arthrodesis 9 vs arthroplasty -2, p=0.05), and SF12-P (9 vs -16, respectively p=0.05) scores. Arthroplasty patients were more likely to have a decrease in their SF-12 scores. VAS scores and FAAM scores showed no statistical difference between the two cohorts. Postoperative VAS scores were worse in 33% of arthroplasty patients despite surgical intervention, compared to 10% of arthrodesis patients. Conclusion: Our results suggests that both procedures provide a statistically significant difference in pain with several patients having a Global Rate of Change that is “very much better”. However, fusion of the metatarsophalangeal joint results in improved pain and functional outcomes for patients with severe hallux rigidus. These findings are consistent with current reports in the literature, which are mostly case series reports. Larger studies are needed to provide appropriate power and better support the findings of this study.