Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature.

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL Reconstruction: A Matched-Cohort Analysis.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous fixation. Given the disadvantages of BTB, an alternative is a bone-tendon autograft (BTA) procedure that has been developed at our institution. BTA is a patellar tendon autograft with the single bone plug taken from the tibia. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the short-term outcomes of BTA ACLR. We hypothesized that this procedure will provide noninferior failure rates and clinical outcomes when compared with a BTB autograft, as well as a lower incidence of anterior knee pain, pain with kneeling, and patellar fracture. METHODS: A consecutive series of 52 patients treated with BTA ACLR were retrospectively identified and compared with 50 age-matched patients who underwent BTB ACLR. The primary outcome was ACL graft failure, while secondary outcomes included subjective instability, anterior knee pain, kneeling pain, and functional outcome scores (Single Assessment Numeric Evaluation, Lysholm, and International Knee Documentation Committee subjective knee form). RESULTS: At a mean follow-up of 29.3 months after surgery, there were 2 reruptures in the BTA cohort (4.0%) and 2 in the BTB cohort (4.0%). In the BTA group, 18% of patients reported anterior knee pain versus 36% of the BTB group (P = .04). A total of 22% of patients noted pain or pressure with kneeling in the BTA cohort, as opposed to 48% in the BTB cohort (P = .006). There were no differences in functional scores. In the BTA group, 94.2% of patients reported that their knees subjectively felt stable, as compared with 86% in the BTB group (P = .18). CONCLUSION: This study demonstrated that the BTA ACLR leads to similarly low rates of ACL graft failure requiring revision surgery, with significantly decreased anterior knee pain and kneeling pain when compared with a BTB. Additionally, the potential complications of graft-tunnel mismatch and patellar fracture are eliminated with the BTA ACLR technique.

Syndesmosis Injury From Diagnosis to Repair: Physical Examination, Diagnosis, and Arthroscopic-assisted Reduction.

Injuries to the tibio-fibular syndesmotic ligaments are different than ankle collateral ligament injuries and occur in isolation or combination with malleolar fractures. Syndesmotic ligament injury can lead to prolonged functional limitations and ultimately long-term ankle dysfunction if not identified and treated appropriately. The syndesmosis complex is a relatively simple construct of well-documented ligaments, but the dynamic kinematics and the effects of disruption have been a point of contention in diagnosis and treatment. Syndesmotic ligament injuries are sometimes referred to as "high ankle sprains" because the syndesmotic ligaments are more proximal than the collateral ligaments of the ankle joint. Rotational injuries to the ankle often result in malleolar fractures, which can be combined with ankle joint or syndesmotic ligament injuries. Most of the orthopaedic literature to this point has addressed syndesmosis ligament injuries in combination with fractures and not isolated syndesmotic ligament injuries. Thus, we propose a simplified general video guide to do the diagnostic examinations and arthroscopic-assisted reduction based on current evidence-based medicine.

Ultrasound Evaluation of the Peroneal Tendons in an Asymptomatic Elite Military Population: A Prospective Cohort Study.

INTRODUCTION: The purpose of this study was to identify the location of the peroneal tendons in relationship to the fibular groove in an asymptomatic population of elite U.S. Military Service members. MATERIALS AND METHODS: The peroneal tendons of 41 active duty U.S. Army Rangers were examined. Subjects were placed in a lateral recumbent position with the ankle in a resting neutral position to visualize the tendon in a retromalleolar short-axis view. Maximum active ankle eversion followed by gravity inversion was facilitated while the ultrasound probe was maintained in its original position. Distance from the fibrous lateral ridge of the retromalleolar groove to the anterior aspect of the peroneal brevis was measured in the short axis in neutral, eversion, and inversion. RESULTS: The mean sagittal distance and standard deviation was 0.48 ± 0.9 mm. No subjects demonstrated greater than 1 mm difference between positions, and no dislocations were identified. Side-to-side difference and dominant vs nondominant differences were not statistically significant. CONCLUSION: The study demonstrates that the distance between the peroneal brevis and the lateral fibular ridge is consistent throughout extremes of motion. These results further the understanding of peroneal tendon function under dynamic examination. Our findings also establish side-to-side consistency prompting a bilateral examination to help identify abnormal pathology.

Comparison of Visual Analog Pain Score Reported to Physician vs Nurse in Nonoperatively Treated Foot and Ankle Patients.

BACKGROUND:: Patient-reported outcome measures (PROMs) are taking a more prominent role in orthopedics as health care seeks to define treatment outcomes. The visual analog scale (VAS) is considered a reliable measure of acute pain. A previous study found that operative candidates' VAS pain score was significantly higher when reported to the surgeon compared to the nurse. This study's aim is to examine whether this phenomenon occurs in patients that do not undergo an operative procedure. We hypothesized that patients' VAS pain scores reported to the surgeon vs the nurse would be the same. METHODS:: This study is a retrospective cohort of 201 consecutive nonoperative foot and ankle patients treated by a single surgeon. Patients were asked to rate pain intensity by a nurse followed by the surgeon using a horizontal VAS, 0 "no pain" to 10 "worst pain." Differences in reported pain levels were compared with data from the previous cohort of 201 consecutive operative foot and ankle patients. RESULTS:: The mean VAS score reported to the nurse was 3.2 whereas the mean VAS score reported to the surgeon was 4.2 ( P < .001). The mean difference in VAS scores reported for operative patients was 2.9, whereas the mean difference for nonoperative patients was 1.0 ( P < .001). CONCLUSION:: This study found statistically significant differences between VAS pain scores reported to the surgeon vs the nurse in nonoperative patients. These results support the trend found in our previous study, where operative patients reported significantly higher pain scores to the surgeon vs the nurse. The mean difference between reported pain scores was significantly higher for operative patients compared to nonoperative patients. LEVEL OF EVIDENCE:: Level III, comparative study.

Optimizing Tactical Medical Performance: The Effect of Light Hue on Vision Testing.

BACKGROUND: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings. METHODS: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights. RESULTS: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white. CONCLUSION: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing.

Cross-sectional Area of the Achilles Tendon in a Cohort of Elite Military Warriors Using Standard Ultrasound Techniques.

Background: The prevalence of Achilles tendon (AT) pathology is common and can result in disability. Understanding normal AT properties can improve our ability to prevent AT injuries. We examined the cross-sectional area of the AT at multiple levels in an asymptomatic population of Army Rangers. Methods: This is a prospective cohort study composed of 41 voluntarily recruited United States Army Rangers deployed in a combat theater. All subjects were members of the Ranger Regiment participating in more than 20 h of intense bipedal non-sport weekly training with no history of AT pathology. While standing, each subject had bilateral AT calcaneal tuberosity insertions (0 cm) marked, along with skin markings made at 2 cm, 4 cm, and 6 cm superior to the AT insertion. AT diameter was measured at each level in the coronal and sagittal planes using ultrasound. Results: Mean sagittal diameter of the AT was 4.4 mm, 4.3 mm, 4.2 mm, and 3.9 mm at 0 cm, 2 cm, 4 cm, and 6 cm, respectively. Mean coronal diameter of the AT was 19.3 mm, 14.7 mm, 13.8 mm, and 14.5 mm at 0 cm, 2 cm, 4 cm, and 6 cm, respectively. The cross-sectional area was calculated as 0.66 cm2, 0.5 cm2, 0.46 cm2, and 0.44 cm2 at 0 cm, 2 cm, 4 cm, and 6 cm, respectively. Conclusion: Our data suggest that increased non-sport activity may not increase the cross-sectional area of the AT. Identifying the normal diameter at multiple levels throughout the most commonly injured area may improve the provider's ability to identify early disease processes and apply targeted interventions to help slow or prevent progression and possible rupture. Level of Evidence: Level III-V.

Comparison of Visual Analog Pain Score Reported to Physician vs Nurse.

BACKGROUND: The visual analog scale (VAS) is considered a reliable and validated measure of patient-reported acute pain. Patient-reported outcome measures are becoming the standard of care throughout the orthopedic community, but interpretation and clinical applications are still under investigation. The aim of the current study was to compare preoperative patient-reported VAS scores reported at the same visit to nursing staff and the treating surgeon. Our hypothesis was that there would be no difference in the scores reported. METHODS: This study is a retrospective cohort of 201 consecutive foot and ankle patients treated by a single surgeon. The patients were asked to rate their pain intensity by the nursing staff and then by the surgeon using a standard horizontal VAS 0 to 10, from "no pain" to the "worst pain." Differences in reported pain values were analyzed. RESULTS: The results demonstrate that patients reported higher pain scores to the surgeon in 81% of the encounters, nursing staff 8%, and equal 11%. On average, the VAS score reported to the surgeon was significantly ( P < .05) higher than that reported to the nursing staff. CONCLUSION: The current study found a statistically significant higher patient-reported pain score to the treating surgeon compared to the nursing staff. While the exact cause is unclear, the discrepant pain scores call into question the validity of the VAS, considered a fifth vital sign and standard outcome measure in an outpatient clinic setting. LEVEL OF EVIDENCE: Level III, comparative study.

Posterior Tibial Tendon Endoscopic Debridement for Stage I and II Posterior Tibial Tendon Dysfunction.

Adult acquired flatfoot deformity (AAFD), formerly known as posterior tibial tendon (PTT) dysfunction, is one of the most common problems of the foot and ankle. It was first described as tendon failure but has since been revealed as ligamentous failure in addition. AAFD is a spectrum of deformities that ranges from tenosynovitis (stage I) to AAFD (stages II-IV). Regarding mild stage I and stage II disease, it was once standard to perform an open synovectomy completely removing the inflamed synovium; this procedure required a large 6-cm medial ankle incision. Postoperative management included plaster cast immobilization for 3 weeks, followed by a boot with controlled ankle movement for another 3 weeks. Now, the standard is shifting to PTT endoscopy, which has proved to be an efficient way to treat tenosynovitis in stage I and II AAFD with a shorter postoperative period. Using this technique, we can achieve 360° visualization of the PTT within the tendon sheath, allowing for a complete exploration and debridement. We hope that by using this video description, practitioners could avoid the increased morbidity associated with open procedures, as well as help patients return to activity sooner after surgery.