Sandra E. Klein

Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review

Background As one of the purposes of anterior cruciate ligament reconstruction (ACLR) is to return athletes to their preinjury activity level, it is critical to understand variables influencing return to sport. Associations between return to sport and variables representing knee impairment, function and psychological status have not been well studied in athletes following ACLR. Purpose The purpose of this review was to summarise the literature reporting on variables proposed to be associated with return to sport following ACLR. Study design Systematic review. Methods Medline, EMBASE, CINAHL and Cochrane databases were searched for articles published before November 2012. Articles included in this review met these criteria: (1) included patients with primary ACLR, (2) reported at least one knee impairment, function or psychological measure, (3) reported a return to sport measure and (4) analysed the relationship between the measure and return to sport. Results Weak evidence existed in 16 articles suggesting variables associated with return to sport included higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher Marx Activity score, higher athletic confidence, higher preoperative knee self-efficacy, lower kinesiophobia and higher preoperative self-motivation. Conclusions Weak evidence supports an association between knee impairment, functional and psychological variables and return to sport. Current return to sport guidelines should be updated to reflect all variables associated with return to sport. Utilising evidence-based return to sport guidelines following ACLR may ensure that athletes are physically and psychologically capable of sports participation, which may reduce reinjury rates and the need for subsequent surgery.

Surgeon Practices regarding Operative Treatment of Posterior Malleolus Fractures

Background: Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures. Materials and Methods: Web-based questionnaires were emailed to members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and treatment preferences for five clinical scenarios with different fracture characteristics. Four hundred one respondents completed the survey (20% response rate). Ninety eight (24%) subjects had received specialty training in orthopaedic trauma, 199 (50%) in foot and ankle (F&A) surgery and six (2%) in both orthopaedic trauma and F&A surgery. Ninety five (24%) had either no or other specialty training. Results: The most frequently reported indication for fixation was not based on a fragment size threshold, but rather was “depends on stability and other factors” (56%). Trauma surgeons, those with less than 10 years experience, and those who treated more than five ankles fractures per month were significantly more likely to use factors other than size for indications (p =0.026,<0.01, and <0.01, respectively). Despite this general response, fragment size still affected treatment decisions. A fragment comprising 50% of the articular surface was indicated for fixation by 97% of respondents, while a size of 10% would be treated by only 9% of respondents. For a posterior fragment with 20% articular involvement and a small free osteochondral fragment, fixation was deemed necessary by 44% of respondents. There were no differences in fellowship training, years of experience in practice, or ankle fracture volume per month in these three situations. A larger proportion of trauma trained surgeons considered fixation necessary compared to F&A trained surgeons in this case (p=0.028). When posterior malleolus fixation was indicated for a large fragment, direct open reduction using the flexor hallucis longus –peroneal tendon interval was the most commonly selected approach in all cases. Trauma-trained surgeons were significantly more likely to choose antiglide plate fixation compared to screw-only fixation (p <0.05). Conclusion: In this survey study of trauma and F&A surgeons, significant variation existed regarding most aspects of posterior malleolar ankle fracture treatment. Most notably, factors other than fragment size most impacted surgical indications. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. Level of Evidence: IV, Cross-sectional Survey Study

Radiographic Findings in the Shoulder and Elbow of Major League Baseball Pitchers

Background Changes in the dominant shoulder and elbow of professional pitchers have been noted on radiographs, magnetic resonance imaging scans, and ultrasound studies. The relationship of these findings to future injury and to time lost from play has not been identified. Hypothesis Degenerative changes of the shoulder and elbow are common findings on the radiographs of asymptomatic Major League Baseball pitchers. The changes are cumulative with increased pitching. These findings are not predictive of time on the disabled list. Study Design Cohort study (prognosis); Level of evidence, 4. Methods Fifty-seven asymptomatic Major League Baseball pitchers participating in the St Louis Cardinals spring training camp underwent routine preseason radiographic screening of their dominant shoulder and elbow between 1986 and 1998. Radiographs were reviewed for osteophytes, cystic changes, joint-space narrowing, and loose bodies. All findings were recorded as present or absent. Public baseball records were reviewed for arm dominance, age, years of professional pitching, professional innings pitched, shoulder or elbow injury or surgery, and time on the disabled list. These factors were statistically evaluated for their possible association with findings seen on preseason radiographs. Results Shoulder radiographs were available for 57 pitchers, and elbow radiographs were available for 56 pitchers. Both groups had an average age of 29 years. The average number of radiographic findings was 3 for the shoulder and 7 for the elbow. Comparing pitchers on the disabled list for a shoulder or elbow injury with those not on the disabled list demonstrated no significant difference in the age, number of seasons pitched, or number of innings pitched between the 2 groups. When individual radiographic findings were compared, no single finding was predictive of disabled list status (P > .05 in all cases). The sum of radiographic findings for the shoulder was significantly correlated with the number of innings pitched in professional baseball (Pearson correlation coefficient, 0.46; P = .0004). The elbow data showed a similar correlation (Pearson correlation coefficient, 0.38; P = .003). When select individual radiographic findings were evaluated for an association with the number of innings pitched, the presence of acromioclavicular joint findings in the shoulder and radial head osteophytes and radioulnar joint findings in the elbow increased with an increase in innings pitched (P < .05). Conclusion Professional pitchers develop degenerative changes over time in both the shoulder and elbow of their dominant (pitching) arm due to chronic repetitive stresses placed across the joints. These findings do not predict time spent on the Major League Baseball disabled list.

Intraosseous and Extraosseous Arterial Anatomy of the Adult Navicular

Background: The etiology of navicular stress fractures is a topic of interest due to the implications in high-level athletes. Previous studies suggest an avascular zone in the central one-third of the bone as a potential causative factor. This study investigated the extraosseous and intraosseous arterial anatomy of the adult navicular. Methods: Sixty legs from 30 cadavers were amputated below the knee. India Ink and Wards Blue Latex were injected into the anterior tibial, peroneal, and posterior tibial arteries. The specimens were frozen, thawed to room temperature, and the skin was sharply dissected away. The soft tissues were chemically debrided, leaving the bones, interosseous ligaments, and casts of the extraosseous blood vessels. The vascular supply to the navicular was elucidated in 55 specimens. The navicular was then cleared using a modified Spälteholz technique; the intraosseous vascularity was reviewed in 54 specimens. Results: Medial tarsal branches of the dorsalis pedis consistently supplied the dorsal navicular (96.4%). Lateral tarsal branches of varying size and distribution patterns also supplied the dorsal navicular. The medial plantar bone received small branches from the superficial branch of the medial plantar artery. Thirty of 54 specimens had a diffuse intraosseous vascular supply throughout the bone. Only six (11.8%) specimens had an avascular zone in the central third of the navicular extending to the dorsal cortex. Conclusion: The dorsalis pedis and posterior tibial arteries branch to supply blood flow to the navicular. In the majority of these specimens the navicular had a dense intraosseous vascular supply throughout it. Clinical Relevance: If diminished vascular supply is a contributing factor to navicular stress fracture, our results suggest that a relatively small proportion of individuals is prone to their development. Biomechanical or other clinical factors may play a more prominent role in the development of navicular stress fractures than previously suspected.

Vascular Anatomy of the Tibiofibular Syndesmosis

BACKGROUND Injuries to the tibiofibular syndesmosis commonly cause prolonged ankle pain and disability. Syndesmotic injuries are associated with slower healing rates compared with rates for other ankle ligament injuries and typically result in longer time away from sports. To our knowledge, the vascular supply to the syndesmosis and its clinical implication have not previously been studied. The purpose of this study was to describe the vascular supply to the tibiofibular syndesmosis with use of a method of chemical debridement of cadaveric specimens. METHODS Twenty-five matched pairs of adult cadaver legs, fifty legs total, were amputated below the knee. India ink, followed by Ward Blue Latex, was injected into the anterior tibial, peroneal, and posterior tibial arteries under constant manual pressure to elucidate the vascular supply of the ankle syndesmotic ligaments. Chemical debridement was performed with 6.0% sodium hypochlorite to remove soft tissue, leaving bones, ligaments, and casts of the vascular anatomy intact. The vascular supply to the syndesmosis was evaluated and recorded. RESULTS The anterior vascularity of the syndesmosis was clearly visualized in forty-three of fifty specimens. The peroneal artery supplied an anterior branch (the perforating branch) that perforated the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provided the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provided additional contribution to the anterior ligaments in the remaining sixteen specimens (37%). CONCLUSIONS The location of the perforating branch of the peroneal artery places it at risk when injury to the syndesmosis extends to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel would result in loss of the primary blood supply to the anterior ligaments.

Clinical presentation and self-reported patterns of pain and function in patients with plantar heel pain.

Background: Plantar heel pain is a common disorder of the foot. The purpose of this study was to explore the relationship between duration of symptoms in plantar fasciitis patients and demographic factors, the intensity and location of pain, extent of previous treatment, and self-reported pain and function. Methods: The charts of patients presenting with plantar heel pain between June 2008 and October 2010 were reviewed retrospectively and 182 patients with a primary diagnosis of plantar fasciitis were identified. Patients with symptoms less than 6 months were identified as acute and patients with symptoms greater than or equal to 6 months were defined as having chronic symptoms. Comparisons based on duration of symptoms were performed for age, gender, body mass index (BMI), comorbidities, pain location and intensity, and a functional score measured by the Foot and Ankle Ability Measure (FAAM). Results: The two groups were similar in age, BMI, gender, and comorbidities. Pain severity, as measured by a visual analog scale, was not statistically significant between the two groups (6.6 and 6.2). The acute and chronic groups of patients reported similar levels of function on both the activity of daily living (62 and 65) and sports (47 and 45) subscales of the FAAM. Patients in the chronic group were more likely to have seen more providers and tried more treatment options for this condition. Conclusion: As plantar fasciitis symptoms extend beyond 6 months, patients do not experience increasing pain intensity or functional limitation. No specific risk factors have been identified to indicate a risk of developing chronic symptoms. Level of Evidence: III, Retrospective Comparative Study

The intraosseous and extraosseous vascular supply of the fifth metatarsal: implications for fifth metatarsal osteotomy.

Background: Osteotomies of the fifth metatarsal may disrupt the nutrient artery and result in nonunion. The location of the nutrient artery foramen relative to the location of common osteotomies has not been described. The goal of this study was to describe the vascular supply of the proximal fifth metatarsal, including the artery of origin of the nutrient artery and the location of the nutrient artery foramen. Methods: Fifty-six adult cadaver specimens were amputated below the knee. The anterior tibial, posterior tibial, and peroneal arteries were injected with India ink and Ward’s Blue Latex. The specimens were frozen for 48 hours and then thawed to room temperature. The soft tissues were débrided with sodium hypochlorite, and the extraosseous vascularity was recorded. The fifth metatarsal was then removed and the intraosseous vascular anatomy elucidated using a modified Spälteholz technique. Results: The dorsalis pedis, posterior tibial, and peroneal arteries branch in predictable patterns to supply the fifth metatarsal. The nutrient artery arose from the fourth plantar metatarsal artery in 100% of specimens and inserted into the plantar medial diaphysis in 83% of specimens. The nutrient artery foramen was an average of 26.8 mm (range, 19-40) from the medial aspect of the base of the fifth metatarsal. Conclusions: When an operative approach to the fifth metatarsal is planned, care should be taken to avoid stripping the bone on the plantar and medial aspects. Clinical Relevance: Osteotomies placed within the proximal 40 mm of the bone carry a risk of disrupting the nutrient artery, resulting in possible nonunion.

Relative mortality in U.S. Medicare beneficiaries with Parkinson disease and hip and pelvic fractures.

BACKGROUND Parkinson disease is a neurodegenerative disease that affects gait and postural stability, resulting in an increased risk of falling. The purpose of this study was to estimate mortality associated with demographic factors after hip or pelvic (hip/pelvic) fracture in people with Parkinson disease. A secondary goal was to compare the mortality associated with Parkinson disease to that associated with other common medical conditions in patients with hip/pelvic fracture. METHODS This was a retrospective observational cohort study of 1,980,401 elderly Medicare beneficiaries diagnosed with hip/pelvic fracture from 2000 to 2005 who were identified with use of the Beneficiary Annual Summary File. The race/ethnicity distribution of the sample was white (93.2%), black (3.8%), Hispanic (1.2%), and Asian (0.6%). Individuals with Parkinson disease (131,215) were identified with use of outpatient and carrier claims. Cox proportional hazards models were used to estimate the risk of death associated with demographic and clinical variables and to compare mortality after hip/pelvic fracture between patients with Parkinson disease and those with other medical conditions associated with high mortality after hip/pelvic fracture, after adjustment for race/ethnicity, sex, age, and modified Charlson comorbidity score. RESULTS Among those with Parkinson disease, women had lower mortality after hip/pelvic fracture than men (adjusted hazard ratio [HR] = 0.63, 95% confidence interval [CI]) = 0.62 to 0.64), after adjustment for covariates. Compared with whites, blacks had a higher (HR = 1.12, 95% CI = 1.09 to 1.16) and Hispanics had a lower (HR = 0.87, 95% CI = 0.81 to 0.95) mortality, after adjustment for covariates. Overall, the adjusted mortality rate after hip/pelvic fracture in individuals with Parkinson disease (HR = 2.41, 95% CI = 2.37 to 2.46) was substantially elevated compared with those without the disease, a finding similar to the increased mortality associated with a diagnosis of dementia (HR = 2.73, 95% CI = 2.68 to 2.79), kidney disease (HR = 2.66, 95% CI = 2.60 to 2.72), and chronic obstructive pulmonary disease (HR = 2.48, 95% CI = 2.43 to 2.53). CONCLUSIONS Mortality after hip/pelvic fracture in Parkinson disease varies according to demographic factors. Mortality after hip/pelvic fracture is substantially increased among those with Parkinson disease.

Corticosteroid Injections in the Treatment of Foot & Ankle Disorders: An AOFAS Survey

Background: Evidence-based guidelines for the use of injectable corticosteroids are lacking, and the true incidence of complications is unknown. Materials and Methods: The 2007–2008 AOFAS membership (969 members) was electronically queried to identify corticosteroid injection practices for certain clinical entities and rates of complications. One hundred ninety-seven surveys were returned. Eleven clinical diagnoses were evaluated for number of injections per year per respondent, rate of injection, plans to change injection pattern, and use of immobilization. Thirteen possible complications were analyzed for observed frequencies and total number of complications. Results: Those in practice less than 5 years showed the lowest rate of injections at 14.1 per month, which increased to 26.1 for those in practice 6 to 10 years. An overall average of 20.6 injections per month per clinician was reported. Injections for midsubstance Achilles tendinopathy was largely avoided as demonstrated by a 98% no-inject rate. Insertional Achilles tendonitis was similar, albeit lower with an 88% no-inject rate. Non-Achilles tendonitis showed a varied response for injections. Posterior tibial tendonitis was injected 26% of the time, whereas peroneal tendonitis was injected 54% of the time. Complications including skin depigmentation were observed most frequently (5.1%), followed by atrophy (4%), flare reaction (3.5%), MTPJ dislocation (2.7%), plantar fascia rupture (1.5%), and heel pad atrophy (1.4%). Conclusion: Despite many case reports of complications, our survey indicates that the incidence of complications was perceived to be low and generally related to the injection site (skin depigmentation, atrophy, flare reaction).

Short-Term Radiographic Analysis of Operative Correction of Adult Acquired Flatfoot Deformity

Background: Multiple procedures have been described to treat stage II (flexible) deformities driven by the clinical presence of “mild” versus “severe” deformity. The purpose of this study was to identify the radiographic correction after bony realignment procedures and to compare preoperative measures with postoperative measures to better understand the clinical application of these procedures. Methods: Seventy-two feet in 68 patients treated for stage II deformity between January 1999 and December 2010 were available for retrospective chart review. The average age of the patients was 55 years, and final radiographs were evaluated at an average of 9 months postoperatively. All patients had a flexor digitorum longus transfer to the navicular and bony realignment. Radiographic parameters measured included lateral talus-first metatarsal angle, medial cuneiform-floor distance, calcaneal pitch, anteroposterior talus-second metatarsal angle, and talonavicular coverage angle. Differences in pre- and postoperative measurements and between group comparisons were analyzed. Results: Three patient groups were identified: medial displacement calcaneal osteotomy (group 1), lateral column lengthening (group 2), and both medial displacement calcaneal osteotomy and lateral column lengthening (group 3). The lateral talus-first metatarsal angle mean difference was 5.1 degrees in group 1, 16.2 degrees in group 2, and 16.5 degrees in group 3. The talonavicular coverage angle mean difference was 5.7 degrees in group 1, 24.2 degrees in group 2, and 19.4 degrees in group 3. Changes in pre- to postoperative measures were statistically significant for all groups for the parameters measured. The pairwise group comparison revealed a statistically significant difference in the correction obtained in group 3 compared with that of group 1. Conclusion: Clinical and radiographic parameters are a consideration when choosing bony realignment procedures to reconstruct a flexible flatfoot deformity. In the treatment of more severe deformities, lateral column lengthening resulted in a greater radiographic improvement in alignment. A medial displacement osteotomy alone is also a valuable tool to correct these deformities although it provided a different level of correction compared with the lateral column lengthening. Level of Evidence: Level III, comparative case series.