Decision-Making and Management of Tarsal Coalition in the Young Adult Patient: A Critical Analysis Review.

¼ Tarsal coalitions most commonly affect the calcaneonavicular and talocalcaneal joints in up to 13% of the general population. They alter the mechanics of the subtalar joint, limiting inversion and eversion, and place excessive stress on neighboring joints causing pain, recurrent ankle sprains, and/or progressive pes planus during the adolescent growth spurt.¼ While many coalitions are identified on radiographs, advanced imaging with computed tomography or magnetic resonance imaging is sometimes required. These advanced imaging modalities also serve an essential role for surgical planning to quantify coalition involvement, identify fibrous or cartilaginous coalitions, and aid in determining the degree of deformity within the foot.¼ Surgical treatment is reserved for feet with persistent activity-related pain not relieved by prolonged attempts at nonoperative management, which include nonsteroidal anti-inflammatory drugs, shoe orthotics, and periods of non-weight-bearing in a cast. These conservative modalities may be successful in up to 85% of cases.¼ For adolescent patients, recent surgical options attempt to avoid arthrodesis and focus on coalition resection and interposition grafting with or without deformity correction. The ultimate decision is based on the location of the pain, the size and histology of the coalition, the health of the posterior subtalar facet, the degree of flatfoot deformity, and the presence of degenerative changes in the subtalar and/or adjacent joints.¼ While many studies focus on subtalar motion and gait kinematics, the critical outcomes remain pain relief and future need for arthrodesis, which may be related not only to resection of the coalition but assessment of deformity, including after the resection has been performed.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in National Football League Players.

Background: Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions. Purpose/Hypothesis: The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR. Study Design: Descriptive epidemiology study. Methods: All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions. Results: Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%). Conclusion: The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.

Medical Malpractice Trends in Foot and Ankle Surgery.

Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Forty-nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

The Impact of COVID-19 on Surgical Volume and Productivity at an Academic Orthopaedic Surgery Department.

COVID-19 pandemic rapidly progressed, resulting in temporary cessation of elective surgery in the U.S. The goal of this study was to evaluate the impact of COVID-19 on surgical volume, charges, work relative value units (WRVUs), and net receipts at an academic orthopaedic surgery department. Volume of cases per month decreased from 745 cases in February to 173 cases in April, with a 75% decrease in charges and a 73% decrease in WRVUs. The largest decreases in productivity were in Sports (92% decrease in charges and WRVUs), Pediatrics (88% decrease in charges, 87% decrease in WRVUs), and Joints (81% decrease in charges, 78% decrease in WRVUs). Oncology was least impacted (27% decrease in charges, 20% decrease in WRVUs). Recovery after shutdown was rapid, with charges and WRVUs returning to pre-COVID levels by June. Productivity of the Sports, Pediatrics and Joints were most impacted, while Oncology, Hand, and Trauma were least impacted. (Journal of Surgical Orthopaedic Advances 31(4):226-229, 2022).

Do intra-articular knee injuries detected by preoperative MRI affect the clinical management of extensor mechanism ruptures?

OBJECTIVES: We sought to determine the prevalence of intra-articular findings at the time of extensor mechanism injury that required subsequent surgical intervention. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Sixty-seven knees in 66 nonconsecutive patients (mean age 53.6 years, 95.6% male) with extensor mechanism injury and preoperative magnetic resonance imaging (MRI) before undergoing open primary surgical repair. MAIN OUTCOME MEASUREMENTS: Patellar or quadriceps tendon rupture, high or low injury energy level, and age above or below 45 years were used to stratify patients. The primary outcome was additional surgery for intra-articular injury. Demographics, comorbidities, mechanism and location of injury, and internal derangements based on MRI findings were also collected. RESULTS: Fifty-one knees (76.1%) had quadriceps tendon injury, 13 knees (19.4%) had patellar tendon injury, and 3 knees (4.6%) had both. Thirty-four knees (50.7%) had intra-articular pathology and 3 (4.5%) required additional surgery, including 1 knee (7.7%) with patellar tendon injury and 2 knees (3.9%) with quadriceps tendon injury. Patellar tendon injuries were more commonly associated with cruciate ligament injury (P < .01) and occurred in younger patients (P < .001) than quadriceps tendon injury. CONCLUSIONS: 50.7% of cases with extensor mechanism injury had intra-articular pathology but only 4.5% required additional surgery. The results of our study suggest that preoperative MRI is unlikely to be of significant clinical utility in most extensor mechanism injuries but should be considered in cases of patellar tendon rupture in younger patients where the incidence of concomitant cruciate ligament injury is higher. LEVEL OF EVIDENCE: Diagnostic Level III.

Management of Anterior Tibialis Tendon Ruptures.

Anterior tibialis tendon ruptures, while relatively infrequent ruptures, are commonly identified in delayed fashion, which can lead to significant impairments in patient gait and function. Surgical treatment is typically required to restore ankle dorsiflexion function and proper gait. Depending on various patient-specific factors, tendon quality and excursion, and chronicity, a range of treatment options are available to manage these patients, from nonsurgical care to surgical treatment. Surgical options include direct repair, local tendon transfer, autograft tendon reconstruction, and allograft tendon reconstruction. Additional procedures may need to be considered. Despite the variety of described surgical procedures, limited evidence-based guidelines are available to direct surgeons in the most optimal treatment for their patients. In addition to the relevant anatomy, biomechanics, and pathoanatomy, the reconstructive armamentarium is detailed and reviewed here, along with outcomes and potential complications, to guide surgeons in the most appropriate treatment for their patients.

Intermediate-term Patient-Reported Outcomes and Radiographic Evaluation Following Intramedullary- vs Extramedullary-Referenced Total Ankle Replacement.

BACKGROUND: The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR). METHODS: From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12). RESULTS: The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P < .0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P = .6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P < .0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P > .05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up. CONCLUSION: The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018.

BACKGROUND: The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants. MATERIALS AND METHODS: The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. RESULTS: Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion. CONCLUSION: Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants. LEVEL OF EVIDENCE: Level IV; Case Series from Large Database Analysis; Treatment Study.

Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide.

BACKGROUND: We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides. METHODS: A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses. RESULTS: The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort. CONCLUSION: Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Intraoperative Conversion to Five-Strand Hamstring Autograft Configuration Significantly Increases Anterior Cruciate Ligament Graft Diameter Independent of Patient Characteristics.

Intraoperative conversion of a four-strand hamstring autograft to a five-strand configuration during an anterior cruciate ligament (ACL) reconstruction has been reported. However, the expected change in graft size and the dependence on patient characteristics are currently not well described. The purpose of this study was to determine the effective change in hamstring graft diameter and reliance on patient characteristics when intraoperatively converting a four-strand hamstring autograft into a five-strand configuration during an ACL reconstruction. A prospective, paired cohort study design was used to measure individual hamstring autograft diameter intraoperatively using traditional four-strand configuration followed by a five-strand configuration. All hamstring tendons included were long enough to consider a five-strand configuration. Five-strand hamstring autograft increased graft diameter in all patients. Hamstring tendon graft diameter increased by an average of 0.99 mm (95% confidence interval [CI]: 0.84-1.11) in the five-strand configuration compared with the traditional four-strand configuration (mean: 7.8 mm). There was no significant difference in the average increase in graft diameter between males (1.04 mm) and females (0.92 mm) (p = 0.323). Eighty-three percent (95% CI: 57.8-95.6) of average graft diameters ≤ 8 mm in the four-strand configuration achieved an average graft diameter of >8 mm in the five-strand configuration, and 70% (95% CI: 35.4- 91.9) of four-strand configuration average diameters < 8 mm achieved an average graft diameter > 8.0 mm in the five-strand configuration. Five-strand hamstring autograft reliably increased intraoperative hamstring tendon autograft diameter, with an average of 1 mm, compared with traditional four-strand configuration. This increase in diameter is independent of sex and remained significant when controlling for age, laterality, body mass index, and semitendinosus length.

Analysis of 408 Total Ankle Arthroplasty Adverse Events Reported to the US Food and Drug Administration From 2015 to 2018.

Background. Total ankle arthroplasty (TAA) use has increased with newer generation implants. Current reports in the literature regarding complications use data extracted from high-volume centers. The types of complications experienced by lower-volume centers may not be reflected in these reports. The purpose of this study was to determine a comprehensive TAA adverse event profile from a mandatory-reporting regulatory database. Methods. The US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2015 to 2018 to determine reported adverse events for approved implants. Results. Among 408 unique TAA device failures, the most common modes of failure were component loosening (17.9%), intraoperative guide or jig error (15.4%), infection (13.7%), and cyst formation (12.7%). In addition, the percentage distribution of adverse event failure types differed among implants. Conclusion. The MAUDE database is a publicly available method that requires mandatory reporting of approved device adverse events. Using this report, we found general agreement in types of complications reported in the literature, although there were some differences, as well as differences between implants. These data may more accurately reflect a comprehensive profile of TAA complications as data were taken from a database of all device users rather than only high-volume centers.Levels of Evidence: NA.

Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery.

BACKGROUND: We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). METHODS: We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. RESULTS: The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001). CONCLUSION: While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Total Ankle Total Talus Replacement Using a 3D Printed Talus Component: A Case Report.

The 3D custom total talus replacement is a novel treatment for avascular necrosis of the talus. However, patients who require a total talus replacement often have concomitant degenerative changes to the tibiotalar, subtalar, or talonavicular joints. The combined 3D custom total ankle-total talus replacement (TATTR) is used for patients with an unreconstructable talus and adjacent tibial plafond involvement. The goal of performing a TATTR is to provide pain relief, retain motion at the tibiotalar joint, maintain or improve the patient's functional status, and minimize limb shortening. TATTR is made possible by 3D printing. The advent of 3D printing has allowed for the accurate recreation of the native talar anatomy with a talar dome that can be matched to a total ankle replacement polyethylene bearing. In this article, we will discuss a case of talar avascular necrosis treated with a combined TATTR and review the current literature for TATTR.

3D Printed Total Talus Replacement for Avascular Necrosis of the Talus.

BACKGROUND: Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend on disease severity and functional goals. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study was to evaluate outcomes following TTR with a custom 3D printed metal implant. METHODS: Patients who underwent TTR were retrospectively reviewed over a 3-year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog scale (VAS) scores, Foot and Ankle Outcome Scores (FAOSs), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre- and postoperatively. Twenty-seven patients underwent TTR for talar AVN with a mean follow-up of 22.2 months. RESULTS: Ankle range of motion remained unchanged postoperatively. VAS pain scores improved postoperatively from 7.1 to 3.9 (P < .001). FAOSs improved postoperatively with regard to pain (P < .001), symptoms (P = .001), quality of life (P < .001), and activities of daily living (P < .001). There were 3 complications requiring reoperation in this cohort. CONCLUSION: 3D printed TTRs represent a unique surgical option for patients with severe talar AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and AVN. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical Safety and Efficacy of a Novel Ultrasound-Assisted Bioabsorbable Suture Anchor in Foot and Ankle Surgeries.

BACKGROUND: Suture anchors have been used for soft tissue repair in orthopedic surgery for decades. Recently, bioabsorbable suture anchors have increased in popularity and have spurred the introduction of ultrasound-assisted systems. The purpose of our study was to determine the clinical safety and efficacy of a new ultrasound-assisted suture anchor system for foot and ankle procedures. METHODS: We retrospectively reviewed 50 cases using the ultrasound-assisted suture anchor with at least 24 months of follow-up. We reviewed demographic data including comorbidities, type of procedure, adverse events, and clinical outcomes using the Foot and Ankle Outcome Score (FAOS) and visual analog scale (VAS) score. We divided complications into minor and major, with major complications requiring revision surgery or leading to long-term morbidity. Our primary outcome was complication rates and our secondary outcome was improvement in clinical scores. RESULTS: The most frequent cases using the anchor included lateral ankle ligament reconstruction (n = 19), insertional Achilles repair (n = 15), lateral ligament reconstruction in conjunction with a total ankle arthroplasty (n = 6), and plantar plate repair (n = 3). There were 5 superficial wound infections that resolved with wound care and/or oral antibiotics. There were 3 major complications (6%): a deep wound infection that required an irrigation and debridement, a deep venous thrombosis, and a recurrence of varus deformity in a patient who underwent a total ankle arthroplasty with lateral ligament reconstruction. Only the varus deformity recurrence case could possibly be directly linked to the suture anchor (2% of all cases). VAS scores improved from 6.0 to 1.2 (P < .001) and FAOS improved from 54.7 to 94.2 (P < .001). CONCLUSION: This bioabsorbable anchor was a safe device with low failure rates, and it was used for soft tissue repair cases in the foot and ankle with successful clinical outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Biomechanical Effect on Joint Stability of Including Deltoid Ligament Repair in an Ankle Fracture Soft Tissue Injury Model With Deltoid and Syndesmotic Disruption.

BACKGROUND: The current operative standard of treatment for bimalleolar equivalent ankle fracture is open reduction and internal fixation (ORIF) of the lateral malleolus followed by syndesmotic stabilization if indicated. There is controversy surrounding the indication and need for deltoid ligament repair in this setting. The purpose of this study was to quantify the biomechanical effect of deltoid ligament repair in an ankle fracture soft tissue injury model. METHODS: Nine fresh-frozen cadaveric specimens were included in this study. Each leg was tested under 5 conditions: intact, syndesmosis and deltoid ligament sectioned, syndesmosis fixed, deltoid repaired, and both the syndesmosis and deltoid ligament repaired. Anterior, posterior, lateral, and medial drawer and rotational stresses were applied to the foot, and the resulting talus displacement was documented. RESULTS: Isolated deltoid repair significantly reduced anterior displacement to normal levels. Displacement with lateral drawer testing was not significantly corrected until both structures were repaired. Deltoid repair and syndesmosis fixation each reduced internal rotation significantly with further reduction to normal levels when both were repaired. External rotation remained elevated relative to the intact condition regardless of which structures were repaired. CONCLUSION: There is existing controversy regarding the importance of deltoid ligament repair in the setting of ankle fractures. The findings of this biomechanical study indicate that deltoid ligament repair enhances ankle stability in ankle fractures with both syndesmotic and deltoid disruption. CLINICAL RELEVANCE: Concomitant deltoid ligament repair in addition to stabilization of fracture and syndesmosis may improve long-term functioning of the ankle joint and clinical outcomes.

Minimally Invasive and Endoscopic Approach for the Treatment of Noninsertional Achilles Tendinopathy.

Minimally invasive treatment can offer an earlier recovery with less pain and scarring compared with traditional open surgeries. The goals of minimally invasive surgery are to debride degenerative tendon, stimulate healing, and, when appropriate, repair damaged tendon. Sclerotherapy and prolotherapy have been shown to reduce neovascularization and pain. Percutaneous stripping and endoscopic debridement are better options for diffuse tendinopathy. Plantaris release can be useful in diffuse disease in patients with primarily medial-sided Achilles pain. Overall, minimally invasive surgery provides similar benefits as open procedures with reduced complications and morbidity.

Radiographic Enchondroma Surveillance: Assessing Clinical Outcomes and Costs Effectiveness.

Background: Enchondromas are a common long bone benign tumor often discovered incidentally on imaging for adjacent pathology. These benign cartilaginous tumors can be difficult to differentiate from low-grade chondrosarcomas on imaging and histology. Multiple advanced imaging studies and clinic visits are required to confirm stability. Surveillance for these lesions can lead to significant patient costs without a clear oncologic or functional benefit. There is a lack of evidence-based consensus guidelines for the surveillance of enchondromas. The purposes of our study are: 1) to determine the number and proportion of low-grade cartilaginous tumors that demonstrate growth or require treatment and 2) to optimize the efficacy and cost-effectiveness of surveillance strategies for detecting biologically active lesions. Methods: A retrospective single-institution study was performed on 55 subjects, 18 years or older, with long bone enchondromas without concerning radiographic characteristics that were referred to our institution's orthopaedic oncology clinic from July 1, 2009 to November 30, 2016. All subjects had at least 12 months of radiographic follow-up. We performed a chart and imaging review to assess for growth of the lesion over time. The number of pre-referral imaging and the number of follow-up imaging studies were recorded. The costs of plain radiographs and advanced imaging were estimated using our institution's global charge list in 2016. Results: For stable enchondromas, 35 out of 52 lesions (67.3%) presented in the lower extremities compared to three out of three (100%) growing cartilaginous tumors. Three out of 55 (5.45%) long bone cartilaginous lesions exhibited growth at a median of 23 (range 21-25 months) follow-up. There was no apparent difference in median presenting age for stable versus growing lesions (58.5 versus 55.0 years old, p =0.5673) or median lesion size at presentation (4.1 cm versus 3.6 cm, p = 0.2923). None of these lesions presented with pain attributable to the lesion. One out of seven biopsied cartilaginous lesions (four stable and three growing) had a histology diagnosis of grade 1 chondrosarcoma. There was no significant difference in the median number of total clinical visits for stable (four) and growing (five) enchondromas (p = 0.0807). The median pre-referral costs per patient were: plain radiographs ($383.00), CT scans ($0.00), and MRI imaging ($3,969.00). The median post-referral costs for plain radiographs and MRI per patient were $1,326.00 and $4,668.00, respectively. The annual median costs for plain radiographs and MRI were $609.23 and $2,240.64, respectively. Discussion: In conclusion, enchondroma growth was a rare event and typically occurred at two years follow-up in our series. Given the low risk for malignant transformation, we propose surveillance with plain radiographic follow-up for stable enchondromas every 3-6 months for the first year and then annually for at least three years of total follow-up. The most significant costs savings can be made by limiting MRI imaging in the absence of clinical or radiographic concern. Additional studies are needed to determine the long-term risk of growth or declaration of chondrosarcoma.Level of Evidence: IV.

Clinical Examination and Radiographic Assessment of the Cavus Foot.

The purpose of the clinical examination is to detect subtle cavus or cavovarus deformity, assess the severity and type of deformity, differentiate between idiopathic versus secondary etiologies of cavus foot deformity, and evaluate for other associated abnormalities. The clinical examination should begin with a gait analysis. The neurologic examination reveals peripheral neuropathy or central nervous system etiology for the foot deformity. On plain radiographs, forefoot-driven deformity can be assessed using the Meary angle, and hindfoot-driven deformity can be measured by the calcaneal pitch. Computed tomography and MRI scans can assess for tarsal coalitions and soft tissue pathologies, respectively.