Epidemiology of Lower Leg Soft Tissue Injuries in High School Athletes

Background Annually there are an estimated 4.5 million sports- and recreation-related injuries among children and young adults in the United States. The most common sports-related injuries are to the lower extremities, with two-thirds occurring among children and young adults (age range 5-24 years). The objective is to describe the epidemiology of lower leg injuries across 27 high school (HS) sports over a 3-year period. Methods The Datalys Center for Sports Injury Research and Prevention provided lower leg injury data for 27 sports in 147 high schools for 2011-2012 through 2013-2014 academic years from National Athletic Treatment, Injury and Outcomes Network (NATION) HS Surveillance Program. Results The overall rate of lower leg injuries over this 3-year period was 1.70 per 10 000 acute events (AEs) (95% CI, 1.59-1.82). In men, the highest number of lower leg injuries was in football (n=181), but indoor track had the highest rate of injury at 2.80 per 10 000 AEs (95% CI, 2.14-3.58). In women, the highest number of lower leg injuries and the highest rate of injury were in cross-country (n=76) at 3.85 per 10 000 AEs (95% CI, 3.03-4.81). The practice injury rate was 0.91 times the competition injury rate (95% CI, 0.78-1.07). Conclusion An improved understanding of the most common sports in which lower leg injuries are seen may help direct appropriate resource utilization. Our data would suggest efforts toward prevention of these overuse injuries, especially in football, track, and cross-country may have the greatest impact on the health of student athletes. Level of Evidence: Level IV, case series.

Knotless Reconstruction of Chronic Achilles Tendon Ruptures With <3-cm Defects: Technique Tip

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation. Level of Evidence: Level V, Expert Opinion.

Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair

Background: There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. Methods: A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution’s registry. Demographics and complications were recorded. Results: PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). Conclusion: Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. Level of Evidence: Level III, retrospective cohort study.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty

Background: Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA. Methods: This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results. Results: In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA. Conclusions: The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA. Level of Evidence: Level IV, case series.

Accuracy of Weightbearing CT Scans for Patient-Specific Instrumentation in Total Ankle Arthroplasty

Background: Total ankle arthroplasty (TAA) is a popular and viable option for end-stage ankle arthritis. Posttraumatic arthritis is the most common etiology of ankle arthritis, which creates the additional challenge of osseus deformity. Accuracy and reproducibility in placing the implant on the mechanical axis has been shown to be paramount in all joint arthroplasty including total ankle replacement. Patient-specific preoperative navigation is a relatively new technology for TAA, and up until this past year has been based off of nonweightbearing (NWBCT) or simulated weightbearing computed tomography (WBCT). Our institution has created a protocol to use WBCT in the preoperative patient-specific navigation for TAA using the Prophecy system. The purpose of our study was to compare the accuracy and reproducibility of implant alignment and size using WBCT vs prior studies using NWBCT for the Prophecy reports. Methods: All patients from July 2019 through October 2020 who underwent TAA were evaluated. Inclusion criteria consisted of primary TAA using patient-specific preoperative navigation who had postoperative radiographs in the 4-6-week time frame. Prophecy predictions and measurements were then compared to actual implant placement and size. Results: Ten patients met our inclusion criteria of WBCT Prophecy preoperative planning using 2 different implant systems. Preoperative deformities in this cohort were small. The average postoperative coronal alignment was 0.84 degrees, range 0.19 to 2.4 degrees. Average postoperative sagittal plane deformity was 1.9 degrees, range 0.33 to 5.05 degrees. Tibial component size was properly predicted in all patients, talar component in 9 of 10. Conclusion: This initial report supports accuracy and reproducibility in preoperative patient-specific navigation when using WBCT for TAA with these implants. All TAAs were within the intended target of less than 5 degrees varus or valgus. Level of Evidence: Level III, retrospective comparative analysis.

Factors used in Applicant Ranking of Orthopedic Foot and Ankle Fellowships and the Availability of Online Information

Background: The Internet is often the first resource used by applicants to evaluate fellowship programs. However, information on these websites can be often incomplete, inaccessible, and/or inaccurate. The primary objective of this study was to examine key factors that orthopedic foot and ankle fellowship applicants use to rank programs. The secondary objective was to assess both the accessibility and availability of the information on orthopedic foot and ankle fellowship program websites. Methods: A Qualtrics survey was distributed via e-mail to those who matched into an orthopedic foot and ankle fellowship position from years 2008-2020. A comprehensive list of orthopedic foot and ankle fellowship programs was created. Program websites were evaluated for accessibility as well as the quality of recruitment and educational content. Results: There were a total of 114 survey responses out of 644 invites (17.7%). The most important factors for establishing a rank list were operative experience, current faculty, and program reputation. Eighty-five percent (41/48) of orthopedic foot and ankle fellowship websites were directly accessible using Google. On average, accessible orthopedic foot and ankle fellowship websites contained only 57% (11.5/20) of the content deemed desirable. Conclusion: Orthopedic foot and ankle websites are widely accessible and have higher recruitment and educational quality content scores compared with previously published data. The most important factors for establishing a rank list are consistent with previous literature. Those who ranked operative experience as one of the most important factors when establishing a rank list did not complete more operative cases than those who did not. Level of Evidence: Level IV.

Primary Rosai-Dorfman Disease in 39-Year-Old Woman With Osseous Tibial Lesion Manifestion: A Case Report and Literature Review

Rosai-Dorfman disease (RDD), otherwise known as sinus histiocytosis with massive lymphadenopathy (SHML), is a very rare and typically benign disorder of unknown etiology with <10% bone involvement. The report is of a case seen at the authors’ hospital of a patient presenting with several months’ onset unspecified nontraumatic ankle pain. There was no physical mass or lymphadenopathy appreciated on examination. Plain radiographs and magnetic resonance images demonstrated an osteolytic lesion at the medial malleolus. Biopsy revealed the diagnosis of intraosseous manifestation of Rosai-Dorfman disease.

Comparison of Outcomes Between Suture Button Technique and Screw Fixation Technique in Patients With Acute Syndesmotic Diastasis: A Meta-analysis of Randomized Controlled Trials

Background: Our aim was to compare the outcome between suture button (SB) stabilization and syndesmotic screw fixation (SF) in patients with acute syndesmotic diastasis. Methods: A systematic literature search up to June 30, 2021, was performed to identify randomized controlled trials (RCTs) comparing outcomes of SB with SF techniques in patients with acute syndesmotic diastasis. We calculated mean differences for continuous outcomes, using the Hartung-Knapp-Sidik-Jonkman method, and odds ratio for dichotomous outcomes, using the Mantel-Haenszel method. Results: Eight RCTs involving 569 patients met the inclusion criteria, 1 RCT with level I evidence, and 7 RCTs with level II evidence. The meta-analysis showed that the SB technique had a higher AOFAS score <6 months and 12 months postoperatively (MD = 4.74, 95% CI 1.68-7.80, P = .01; and MD = 5.42, 95% CI 1.50-9.33, P = .02) and reduced the risk of implant irritation (OR = 0.31, 95% CI 0.11-0.89, P = .03), implant failure (OR = 0.06, 95% CI 0.02-0.23, P < .01), and reoperation (OR = 0.43, 95% CI 0.22-0.83, P = .01). The 2 approaches did not differ in further functional outcomes or postoperative complications. Conclusion: Because functional outcomes showed no relevant difference between both SB and SF, the advantage of SB appears to be in the lower risk for postoperative complications. The SB technique led to fewer cases of implant irritation, implant failure, and reoperation compared with SF. Level of Evidence: Level I, meta-analysis of RCTs.

Biomechanical Analysis of Single Interference Screw vs Interference Screw With Cortical Button for Flexor Hallucis Longus Transfer

Background: Flexor hallucis longus tendon transfer (FHL) with a cortical button tension slide is an innovative addition that has not been measured against traditional methods. Methods: 12 pairs (n=24) of fresh-frozen cadaveric tibia-to-toe samples were used and randomized to receive one of the operative FHL techniques. Specimens underwent bone density analysis. Biomechanical loading was applied between 20 and 60 N at 1 Hz for 100 cycles. Post–cyclic load to failure occurred at 1.25 mm/s. Cyclic displacement, structural stiffness, and ultimate load were derived from load-displacement curves. Student t tests evaluated significant effects between both FHL techniques. Linear regression analysis assessed interactions between bone density and strength of FHL technique. Results: Average tendon diameter was 5.44±0.46 mm. Average bone density was 1.06±0.08 g/cm2. Addition of a cortical button to FHL transfer did not significantly affect cyclic displacement (0.78±0.52 mm vs 0.87±0.80 mm) or structural stiffness (162.11±43.34 N/mm vs 167.57±49.19 N/mm). Cortical button addition to FHL transfer resulted in significantly increased ultimate load (343.72±68.93 N) compared with interference screw alone (255.62±77.17 N) ( P = .0002). Linear regression analyses did not reveal any significant interactions between bone density and FHL tendon transfer technique. Conclusion: Enhanced strength can be achieved with FHL tendon transfer to calcaneus using an interference screw and cortical button tension slide technique as compared to an interference screw alone. Cortical buttons in the setting of FHL tendon transfer to the calcaneus offers an additional level of support. Clinical Relevance: Operative cases presenting with poor bone quality due to osteoporosis or osteopenia could benefit from cortical button fixation during FHL transfer. Clinical studies are needed to determine if the increased construct stability conferred from the additional use of a flip button results in fewer FHL transfer failures or better clinical outcomes. Level of Evidence: Level V, Controlled Laboratory Study.