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Background: Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Repetitive stresses endured by the fifth metatarsal can lead to stress fracture, delayed union, and refracture, making optimal treatment challenging. A radiographic analysis of fifth metatarsal morphology and foot type in National Football League (NFL) players was performed to investigate morphologic risk factors for these injuries. Methods: This was a case-control study that looked at NFL players treated between 1992 and 2012, as well as participants at the NFL Combine. Ninety-six feet (51 athletes) were included. Fractures were present in 15 feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior, lateral, and oblique radiographs. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined. Results: On anteroposterior radiographs, significant differences in apex medullary canal width, 4-5 intermetatarsal angle, fifth metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet (P = .001, .003, .004, .008, respectively). On lateral radiographs, significant differences in the fifth metatarsal length, distance to apex, apex height, fifth metatarsal angle, and talocalcaneal angle were observed between fractured and nonfractured feet (P = .04, .01, .02, .01, .01, respectively). On oblique radiographs, a significant difference was observed in apex height between fractured and nonfractured feet (P = .002). Conclusion: Individuals with long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures. With this insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at risk. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Stenosing peroneal tenosynovitis (SPT) is an uncommon entity that is equally difficult to diagnose. We evaluated our outcomes with a local anesthetic diagnostic injection followed by surgical release of the sheath and calcaneal exostectomy. Methods: Eleven patients diagnosed with SPT underwent surgery between 2006 and 2014. Upon initial presentation, all patients reported a persistent history of pain along the ankle. Ultrasound-guided injections of anesthetics were administered into the peroneal tendon sheath to confirm the diagnosis. In patients with a confirmed diagnosis of SPT, we proceeded with surgical intervention with release of the peroneal tendon sheath and debridement of the calcaneal exostosis. Retrospective chart review was performed, and functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS). FAOS results were collected pre- and postoperatively and were successfully obtained at 1 year or greater. Results: Of these patients, all showed significant improvements (P < .05) in 4 of 5 categories of the FAOS (pain, daily activities, sports activities, and quality of life). Conclusion: We present a case series in which the peroneal tendon sheath was diagnostically injected with anesthetic to confirm a diagnosis of SPT. In each of these cases, symptomatic improvement was obtained following the injection. With the fact that many of these patients had advanced imaging denoting no significant tears, we believe that this diagnostic injection is paramount for the success of surgical outcome. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement. Conclusions: The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle. [ABSTRACT FROM AUTHOR]

Background: External rotation, lateral, and sagittal stress tests are commonly used to diagnose syndesmotic injuries, but their efficacy remains unclear. The purpose of this study was to characterize applied stresses with fibular motion throughout the syndesmotic injury spectrum. We hypothesized that sagittal fibular motion would have greater fidelity in detecting changes in syndesmotic status compared to mortise imaging. Methods: Syndesmotic instability was characterized using motion analysis during external rotation, lateral, and sagittal stress tests on cadaveric specimens (n = 9). A progressive syndesmotic injury was created by sectioning the tibiofibular and deltoid ligaments. Applied loads and fibular motion were synchronously measured using a force transducer and motion capture, respectively, while mortise and lateral radiographs were acquired to quantify clinical measurements. Fibular motion in response to these 3 stress tests was compared between the intact, complete lateral syndesmotic injury and lateral injury plus a completely sectioned deltoid condition. Results: Stress tests performed under lateral imaging detected syndesmotic injuries with greater sensitivity than the clinical-standard mortise view. Lateral imaging was twice as sensitive to applied loads as mortise view imaging. Specifically, half as much linear force generated 2 mm of detectable syndesmotic motion. In addition, fibular motion increased linearly in response to sagittal stresses (Pearson’s r [ρ] = 0.91 ± 0.1) but not lateral stresses (ρ = 0.29 ± 0.66). Conclusion: Stress tests using lateral imaging detected syndesmotic injuries with greater sensitivity than a typical mortise view. In addition to greater diagnostic sensitivity, reduced loads were required to detect injuries. Clinical Relevance: Syndesmotic injuries may be better diagnosed using stress tests that are assessed using lateral imaging than standard mortise view imaging. [ABSTRACT FROM AUTHOR]

Background: The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia. Methods: Eighty-four patients underwent outpatient foot and ankle surgeries under spinal blockade and long-acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3-day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids. Results: Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication. Conclusions: Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population. [ABSTRACT FROM AUTHOR]

Background: Hamstring tendon autografts may be used for foot and ankle surgeries, although reports on their effectiveness and morbidity in the foot and ankle literature are limited. We studied a cohort of patients who underwent hamstring harvest for foot and ankle applications, hypothesizing that morbidity to the knee would be limited. Methods: We studied a cohort of patients who underwent hamstring autograft for foot or ankle applications by a fellowship-trained sports and foot and ankle surgeon since 2011. Thirty-seven patients underwent isokinetic strength testing using a dynamometer an average of 38 months postoperatively. The average patient age was 45 ± 16 (range, 18-78) years, and 54% were women. Peak flexion and extension torque as well as flexion and extension torque at 30, 70, and 90 degrees of flexion were collected at 2 different testing speeds, 180 and 300 degrees/s. t tests were used for all comparisons. Results: At follow-up, 32 patients (86%) reported no pain at the harvest site; the remaining 5 patients reported mild to moderate symptoms. No patients were dissatisfied, and all would recommend the surgery to someone else. Flexion strength at higher degrees of flexion was significantly lower compared with extension strength as well as compared with flexion strength at lower degrees of flexion, when testing was performed at lower speed (P < 0.05). Conclusions: When used for foot and ankle surgery, hamstring autografts resulted in high patient satisfaction with minimal donor site morbidity. While knee flexion strength was decreased at higher degrees of flexion, this finding did not appear to be clinically significant. [ABSTRACT FROM AUTHOR]

Background: Research regarding outcomes in sports and physical activities after primary partial arthrodesis for Lisfranc injuries has been sparse. The purposes of this study were to assess various sports and physical activities in young patients following primary partial arthrodesis for Lisfranc injuries and to compare these with clinical outcomes. Methods: Patients who underwent primary partial arthrodesis for a Lisfranc injury were identified by a retrospective registry review. Thirty-eight of 46 eligible patients (83%) responded for follow-up at a mean of 5.2 (range, 1.0 to 9.3) years with a mean age at surgery of 31.8 (range, 16.8 to 50.3) years. Physical activity participation was assessed with a new sports-specific, patient-administered questionnaire. Clinical outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: Patients participated in 29 different and 155 total physical activities preoperatively, and 27 different and 145 total physical activities postoperatively. Preoperatively, 47.1% were high impact, and postoperatively, 44.8% were high impact. The most common activities were walking, bicycling, running, and weightlifting. Compared to preoperatively, difficulty was the same in 66% and increased in 34% of physical activities. Participation levels were improved in 11%, the same in 64%, and impaired in 25% of physical activities. Patients spent on average 4.2 (range, 0.0 to 19.8) hours per week exercising postoperatively. In regard to return to physical activity, 97% of respondents were satisfied with their operative outcome. Mean postoperative FAOS subscores were significantly worse for patients who had increased physical activity difficulty. Conclusion: Most patients were able to return to their previous physical activities following primary partial arthrodesis for a Lisfranc injury, many of which were high-impact. However, the decreased participation or increase in difficulty of some activities suggests that some patients experienced postoperative limitations in exercise. Future studies could compare sports outcomes between primary partial arthrodesis and open reduction internal fixation for Lisfranc injuries. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Achilles tendon repairs and reconstructions have historically been associated with high wound infection rates due to poor vascularity in this region. The risk of postoperative infection, a potentially devastating complication, has led surgeons to pursue non-operative treatment when possible for a range of Achilles tendon pathology. However, new surgical techniques have allowed for smaller incisions and modern, aggressive infection control strategies have limited the morbidity associated with these complications. The present study will review a large case series of Achilles infections, evaluating treatment strategies and outcomes for patients who developed a postoperative infection following treatment for Achilles pathology. Methods: This is a retrospective case series including all patients who experienced a postoperative Achilles tendon infection at a single hospital. Cases from 11 surgeons performed between 2011 and 2020 were reviewed for infection requiring a return to the operating room for irrigation, debridement, and any other necessary interventions. Cases that presented to our institution with an existing infection were also included. Thorough chart review was performed for all patients to determine pathology and initial treatment method, infection management, and clinical outcomes. For patients undergoing Achilles reconstruction with a graft, operative notes were reviewed to determine whether the graft was infected and thus removed during debridement. Clinical follow-up was performed and Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were sent to all patients who were over 1 year out from surgery. Results: 33 patients experienced a postoperative Achilles infection, including 10 who developed infection after surgery at an outside hospital. For patients treated initially at our institution, 8 presented with an acute rupture and 15 with chronic pathology. 12 of 15 chronic cases underwent reconstruction with a graft. For 3 reconstructions and 1 acute repair (12%) the entire Achilles was infected and removed. The graft was partially removed in 2 reconstruction cases (6%) and remained fully intact in the remaining 27 cases (82%). In 2/4 cases in which the Achilles was removed, it ultimately reconstituted as confirmed on MRI. A skin graft or flap was required in 5 of 33 cases (15%) for adequate soft-tissue coverage. In 14 cases (42%), the infection was controlled after a single debridement, 17 cases (52%) required a second debridement, and 2 cases (6%) a third. Postoperative PROMIS scores were available for 17 patients (Table 1). Conclusion: To our knowledge, this case series represents the largest number of postoperative infections analyzed following Achilles tendon surgery. Relatively high postoperative PROMIS scores indicate that infected patients can ultimately reach high levels of physical function with minimal pain when managed appropriately. In many cases the Achilles or graft could be salvaged and in those where it was not, the tendon did at times reconstitute. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Post-operative infections can be a devastating complication after Achilles tendon surgery. While Achilles infection rates have decreased with the development of less invasive surgical techniques, these infections remain a challenging complication for patients and clinicians due to the relative lack of vasculature in the Achilles tendon region. This study aimed to analyze rates of postoperative Achilles tendon infection based on the type of Achilles pathology and surgical approach. We hypothesized that procedures with smaller incisions that avoided the critical zone would be associated with lower infection rates than those that require larger incisions, such as reconstructions. Methods: All patients undergoing Achilles tendon surgery at a single, multi-surgeon center between 2011 and 2020 were identified. Charts were reviewed for infection, pathology, surgical approach, incision size, and risk factors such as body mass index (BMI), smoking status, and diabetes. Rates of infection were compared between groups based on pathology and operative technique. These groups included acute rupture treated immediately, chronic pathology treated with debridement and repair, and chronic pathology treated with graft reconstruction. For patients treated for an acute rupture, minimally invasive and open approach sub-groups were compared. Further, prevalence of risk factors was compared between patients with and without postoperative infections. Statistical comparisons were performed between groups using a student's t-test or Fisher's exact test. Results: A total of 1,148 cases were identified, 23 of which involved a post-operative infection requiring a return to the operating room for irrigation and debridement. The overall infection rate was 2.00%. Cases involving chronic pathology treated with graft reconstruction were associated with an infection rate of 8.96%. Acute repairs had an infection rate of 1.32% and other chronic pathologies treated without graft reconstruction had an infection rate of 0.73%. Statistical comparisons of infection rates for these sub-groups are displayed in Table 1 alongside comparisons of risk factor prevalence between the infection and non-infection groups. The comparison of risk factors between groups did not identify any significant differences. No infections were observed following the use of a distal lateral incision to treat chronic tendon pathology (179 cases) or the use of a windows incision technique for reconstructions (8 cases). Conclusion: Analysis of infection rates indicated that treatment options requiring large incisions, such as reconstruction with a graft, pose a significantly greater risk of post-operative Achilles infection. Both minimally invasive treatments and measured open incisions were associated with similarly low infection rates for primary repair of acute ruptures. Comparison of risk factors between patients with and without infection did not reveal any significant differences. Given low infection rates for chronic pathology treated with distal lateral incisions and windows-type incisions, we recommend these whenever possible. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Blood flow restriction (BFR) therapy involves the use of a tourniquet to partially occlude blood flow to the affected limb, creating an anaerobic environment during exercise. This is thought to stimulate growth and recovery by increasing the body's anabolic response. BFR therapy can be initiated shortly after surgery since it allows for significant muscle activation with limited load bearing. To date, no existing study has evaluated the effect of using BFR therapy for recovery following Achilles tendon rupture and repair, after which patients often experience significant losses in calf strength and girth. This is a randomized controlled trial designed to study whether BFR can minimize loss of calf strength and muscle volume after Achilles rupture compared to a conventional physical therapy protocol. Methods: Patients presenting with an acute Achilles tendon rupture were randomized into the BFR or control group. Patients in the control group performed at-home exercises and began in-person physical therapy at 6 weeks postoperatively, as is the standard of care in our practice. The exercises were standardized across groups with BFR the isolated variable. The primary outcome studied was ankle plantarflexion strength as measured during isokinetic strength testing 3 months after surgical repair. We also tested knee strength during flexion and extension. All strength tests were performed at two rotational speeds. Calf atrophy was assessed by measuring the circumference of both calves 15 cm below the joint line at the time of operation and at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Finally, Patient-Reported Outcome Measurement Information System (PROMIS) scores were collected pre- and postoperatively. Results: The study enrolled 43 patients, 24 of whom were assigned to the BFR group. 30 patients completed strength testing at 3 months and 26 at 6 months. Calf measurements through 3 months were completed for 39 patients and 6 month measurements were completed for 32 patients. Results for ankle plantarflexion strength at 3 months are displayed in Table 1, showing that patients in the BFR group demonstrated greater absolute strength in the operative calf compared to the control group, but no significant advantage in strength relative to the uninvolved calf. We failed to detect a significant difference in strength between groups for ankle dorsiflexion, knee extension, or knee flexion. Our model of calf circumference over time showed that BFR had a positive but insignificant correlation to calf circumference (p = 0.59). The only factors that demonstrated a significant (p<0.05) positive relationship to calf circumference were male sex and BMI. Conclusion: We have observed significant advantages in the BFR group when analyzing absolute calf strength metrics when compared to a randomized control group. This indicates that, when used during rehabilitation following Achilles rupture, BFR therapy may increase the strength of the operative leg and may facilitate recovery and outcome. [ABSTRACT FROM AUTHOR]