Stimulation of human bone marrow mesenchymal stem cells by electromagnetic transduction therapy - EMTT.

Many different pulsed electromagnetic field (PEMF) devises have been clinically used to stimulate healing processes, but many procedures are still without supporting basic research data. The aim of this study was to investigate a new modified pulsed electromagnetic field therapy: electromagnetic transduction therapy (EMTT). EMTT is technically based on high-intensive PEMFs with a magnetic field strength between 80 and 150 mT. The effect of EMTT for a 10-min session three times a week on human bone marrow mesenchymal stem cells (MSCs) was evaluated by assessing cell viability, gene expression of bone regenerative factors and VEGF-A (vascular endothelial growth factor) secretion after 7 and 14 days of treatment. No negative or toxic effects of EMTT on MSCs in vitro were observed in the applied test frame. The VEGF-ELISA at day 7 of EMTT treatment with 80 mT showed a significant higher VEGF concentration compared to untreated control group. In conclusion, high-intensive electromagnetic impulses showed no harmful effects on MSC cultures in our study. The enhancement of the proangiogenic factor VEGF in MSCs on day 7 indicates a substantial role in cell-stimulating effect of EMTT. Further in vitro and in vivo studies should differentiate specific stimulating and regenerating effects of EMTT impulses in soft tissue engineering. Specific electromagnetic characteristics have to be determined to optimize electromagnetic treatment options in orthopedic surgery and traumatology and soft tissue treatment options.

Sesamoidectomy in Athletes: Outcomes From 2-Centers.

Sesamoid pain can arise from avascular necrosis, fracture, osteochondrosis, and advanced degeneration. Disorders of the sesamoids in athletes can be debilitating. Total sesamoidectomy of the involved sesamoid is considered an effective surgical treatment when conservative measures have failed. There is limited literature evaluating the outcome of sesamoidectomy in athletically active patients. Our 2-center study reports on 68 patients (70 procedures; 2 male patients were operated on both feet in separate procedures approximately 3 years apart; 41 (58.6%) tibial and 29 (41.4%) fibular sesamoidectomies; 24 males and 44 females, average age 28.4 ± 12.2 years) who underwent total sesamoidectomy from 01/2001 to 12/2019. In our cohort, the average time to return to activity (RTA) was 11.1 ± 5.1 weeks, with no statistically significant difference between gender and age, or between fibular and tibial sesamoidectomy in relation to RTA. There was a minimum follow-up of 1 year, with an average of 106.6 ± 66.6 months. The total incidence of complication rate was 5.7%. In athletes in whom conservative management has failed, sesamoidectomy is safe, and allows predictable return to their chosen sport. To our knowledge, none of the patients subsequently developed pathology to the remaining sesamoid.

Outcomes of Talar Osteochondral and Transchondral Lesions Using an Algorithmic Approach Based on Size, Location, and Subchondral Plate Integrity: A 10-Year Study on 204 Lesions.

The management of transchondral and osteochondral talar lesions has evolved, with microfracturing originally considered the best initial treatment. Despite talar lesions being a tri-dimensional defect, most studies use 2-dimensional parameters to grade them. We propose in this study that tri-dimensional sizing may be more appropriate in evaluation for treatment. The present study evaluated the outcomes of treatment of talar lesions performed by a single surgeon, creating and using an algorithm based on volume, location, and integrity of the subchondral plate. The lesions were classified as "small" (up to 125 mm3), "medium" (125 mm3-1500 mm3), and "large" (>1500 mm3) based upon evaluation of the preoperative magnetic resonance imagining. Location of the lesion was also noted on a 9-region grid pattern of the talar dome. These 3 parameters dictated whether a lesion required microfracturing or retrograde drilling, autogenous or allogenous bone graft, and whether an open versus an arthroscopic approach was required. Over a 10-year period, surgery was performed on 204 lesions. Overall, the average time to return to activity was 7.93 ± 5.00 (range 2-36) months. The average preoperative American Orthopaedic Foot and Ankle score was 76.44 ± 10.98 (range 52-86), and the average postoperative American Orthopaedic Foot and Ankle score was 96.12 ± 3.46 (range 81-100), p = .0001. By using the proposed algorithm, the outcome and return to activity for most patients can be better predicted, regardless of the size or location of the osteochondral lesion. The treatment algorithm implemented in the present investigation yielded overall acceptable results, with only 7 of the 204 lesions needing additional surgery.

Arthrodesis in Acute and Chronic Lisfranc's Patients: A Retrospective Cohort Study.

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.

Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group.

Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.

The double posteromedial portals endoscopy for posterior ankle impingement syndrome in athletes.

BACKGROUND: Posterior ankle impingement syndrome (PAIS) may result from flexor hallucis longus tendinopathy, compression of the posterior process of the talus from the presence of an os trigonum, soft-tissue impingement, or a combination of these. Posterior extra-articular endoscopy performed with the patient supine through the double posteromedial portals, with excision of adhesions, excision of the posterior process of the talus or an os trigonum, and decompression of the tendon of the flexor hallucis longus (FHL), can be used in athletes with PAIS. METHODS: Thirty-four athletes with PAIS in whom conservative management had failed underwent posterior ankle endoscopy in the supine position using the double posteromedial portals. The patients were assessed pre- and postoperatively using the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner scale, and the simple visual analogue scale. Time of surgery, return to sports, patient satisfaction, and complications were recorded and analysed. The average length of postoperative follow-up was 26.7 ± 12.6 (range 24 to 72) months. RESULTS: The mean Tegner activity scale score improved to 9 ± 0.2 postoperatively (p < 0.05), while the mean American Orthopaedic Foot and Ankle Society scale score improved to 96 ± 5.1 (range 87 to 100) postoperatively, with 29 of 34 patients (85.3%) achieving a perfect score of 100 (p < 0.05). The mean time to return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. The complication rate was low, with no superficial wound infections or venous thromboembolism events; only two patients (5.9%) reported pain and tenderness by 3 months after the index procedure. CONCLUSION: Posterior ankle endoscopy for the resection of a posterior process of the talus or an os trigonum and decompression of the tendon of FHL is safe and allows excellent outcomes with low morbidity in athletes with PAIS.

A Novel Technique to Treat Hallux Rigidus in Athletic Patients With Central Osteochondral Defects: Preliminary Report on 12 Cases.

Osteochondral defects, often caused by traumatic injuries, are focal areas of articular damage resulting in joint pain and stiffness ultimately leading to degenerative joint disease. This has not been well studied in the first metatarsal head, but is an often encountered problem in the active population in other joints. In this study, we prospectively evaluated the results of 12 patients who received autogenous bone grafting for repair of osteochondral defects of the first metatarsal head. Clinical outcomes were evaluated by the visual analog scale for pain and the Roles and Maudsley (RM) score. Between the years of 2009 and 2016, 12 patients received treatment for this particular surgical intervention and their outcomes were measured. The patients' average age was 43.5 ± 10.6 years and were followed from 52.3 ± 26.7 months postoperatively. Average return to activity was 4.7 ± 1.1 months. The average preoperative RM score was 4.0 ± 0.0 and postoperative RM score was 1.4 ± 0.7 (p = .0001). The encouraging outcomes of this study suggest that autogenous bone grafting for osteochondral defects of the first metatarsal head is an effective treatment to help restore the function of the first metatarsophalangeal joint.

Insertional Achilles Tendinopathy: Analysis of 166 Procedures and Return to Activity.

The surgical procedure for Insertional Achilles tendinopathy (IAT) varies widely with no consensus as to approach and documenting return to activity (RTA). This study presents outcomes of surgery for IAT by a single surgeon, documenting activity level and return to activity. From January 2001 through January 2018, 166 procedures were reviewed. Surgery included debridement of the Achilles insertion, resection of the superior calcaneus and bursa, and re-attachment with suture anchors. There were 110 males and 56 females. The majority of patients in the entire cohort were runners (n = 54). The average age of the cohort was 50.3 ± 12.1 years (range 20-80). Average follow-up was 114.0 ± 63.5 months (range 6-222 months). Average RTA for males and females were 6.43 months and 7.22 months, (p = .2), respectively. There was no difference in RTA between patients who had calcific tendinosis (n = 84) and noncalcific tendinosis (n = 82). Complications were 2 infections, 2 DVTs, and 17 deep suture reactions with a total complication rate of 12.6%; there were no re-ruptures postoperatively. There was no significant difference in number of complications between absorbable and nonabsorbable suture in the anchors (p = .41). The average RM score was 1.5 ± 0.7. The RM scores were better for males (p = .002), but there were no differences in RTA or complications between sexes. Overall, 95.8% of the procedures resulted in improved outcome and ability to return to activity including sports. This retrospective investigation shows surgical intervention for IAT yields good results with an average return to activity including sports in approximately 7 months.

Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons.

We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).

Hallux Valgus Surgery in the Athlete: Current Evidence.

Hallux valgus is a common disorder characterized by a medial deviation of the 1st metatarsal, eventually leading to subluxation and pain of the 1st metatarsophalangeal joint. This can inhibit sports activity. Despite being a common forefoot pathology, debate exists regarding the appropriate surgical approach in the athletic population. Paucity in literature exists with reporting of outcomes of 1st metatarsal procedures leading to best outcomes. This review was able to identify 5 studies of surgical correction of hallux valgus in athletes published to date. The aim is to guide the physician in treating athletes with hallux valgus deformity. Currently, the literature supports distal 1st metatarsal osteotomy (Chevron) with a return to activity of approximately 3 months for mild to moderate deformity, and the Ludloff osteotomy for moderate to severe deformity at a slightly slower time frame of return to sports. At best, the Lapidus procedure allows approximately 80% of patients to return to activity. Studies need to document activity level and return to sport in order to help guide treatment.

Modified Valenti Arthroplasty in Running and Jumping Athletes With Hallux Limitus/Rigidus: Analysis of One Hundred Procedures.

Despite hallux limitus/rigidus being a common condition, results of surgical procedures specifically pertaining to athletes are scarce. The results of 100 modified Valenti procedures, prospectively studied from January 2000 to June 2016 with an average 49.17 months of follow-up, are presented evaluating demographics, sport, time and ability to return to activity (RTA), decreased desired activity level, and need for additional surgery. Inclusion criteria included athletes who have exhausted conservative care without relief of daily pain, dorsiflexion <20°, and grade ≥2. Seventeen had grade 2, 79 had grade 3, and 4 had grade 4 disease. RTA for the 89 procedures where exact time could be determined was 9.25 weeks; however, 100% were confirmed to RTA to some degree. The RTA of dancers and runners (the largest portion of the cohort at 76) was around 8 weeks, whereas soccer players were the slowest at >16 weeks, which was significant. There was no other significant difference in RTA between sport, sex, or grade of hallux limitus/rigidus except for between runners and soccer players. Six patients (6%) stated a decreased desire to activity, although this was not a significant finding. The modified Valenti procedure is a safe and highly effective treatment for running and jumping athletes limited by hallux limitus/rigidus because 94% of patients were able to return to their desired level of activity.

Triple Achilles Tendon Rupture: Case Report.

We present a case report with 1-year follow-up data of a 57-year-old male soccer referee who had sustained an acute triple Achilles tendon rupture injury during a game. His triple Achilles tendon rupture consisted of a rupture of the proximal watershed region, a rupture of the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient was treated surgically with primary repair of the tendon, including tenodesis with anchors. Postoperative treatment included non-weightbearing for 4 weeks and protected weightbearing until 10 weeks postoperative, followed by formal physical therapy, which incorporated an "antigravity" treadmill. The patient was able to return to full activity after 26 weeks, including running and refereeing, without limitations.

Stabilization of the Fourth Metatarsal-Cuboid Lateral Lisfranc Injury: Early Results of an Innovative Technique Using Suture Anchors.

This report presents an innovative surgical technique for the correction of cuboid-metatarsal subluxation at the level of the lateral Lisfranc joint. This stabilization technique reinforces the dorsal fourth tarsometatarsal ligament by incorporating sutures and anchors, establishing a more stable joint. The data from 5 female patients undergoing stabilization using a suture anchor construct were reviewed. All 5 patients were able to resume their activities, including the adolescent athletes. Anatomic reconstruction of the dorsal fourth tarsometatarsal ligament complex can lead to full mechanical and functional stability, which ultimately allows for a return to activity, even in highly demanding sports and athletes.

Percutaneous Plating of Weber B Fibular Fractures.

The purpose of the present study was to describe a minimally invasive percutaneous technique for plating Weber B distal fibular fractures and to evaluate its efficacy by measuring patient outcomes and hardware removal rates. The data from 17 patients undergoing percutaneous plating of a distal fibular (Weber B) fracture were prospectively studied. A 4- to 6-hole semitubular plate with 3 screws was used for percutaneously plating. The Roles and Maudsley score was used to assess the patients' activity level. All fibular fractures had healed clinically and radiographically by 8 weeks after surgery. The postoperative Roles and Maudsley scores had improved significantly. The time required to return to activity was 4.3 ± 2.0 months. Hardware removal was required in 3 patients during the study period, which had an average of almost 4 years postoperatively. The results of the present study have demonstrated that percutaneous plating is an effective surgical option for treating Weber B distal fibular fractures.

Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures.

Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.

Synovial Chondromatosis of the Ankle: Report of Two Cases With 23 and 126 Loose Bodies.

Synovial chondromatosis is rare joint disorder that has no clear etiology. Classification of the disorder was first reported by Milgram in 1977. One possible cause is a change in the level of fibroblast growth receptor factor receptor-3, which leads to a possible feedback loop that results in the formation of loose bodies. Genetics is another possible cause for the disorder. Synovial chondromatosis is considered benign but does the have the potential for malignant transformation. We report the case of 2 patients with 23 and 126 loose bodies of the ankle, respectively, who had successful outcomes without malignancy, after excision of the lesions. Also presented is a review of the published data for the possible causes of synovial chondromatosis and the symptoms leading up to the transformation from benign to malignant.

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.

Percutaneous Ultrasonic Tenotomy for Achilles Tendinopathy Is a Surgical Procedure With Similar Complications.

Percutaneous ultrasonic tenotomy is a relatively new treatment option for multiple types of tendinopathy. However, a paucity of high-level data is available on its use for chronic Achilles tendinosis. The present case series details the complications associated with the use of this technique. When considering percutaneous ultrasonic tenotomy, the surgeon should be cognizant that it is a surgical procedure with complications similar to those of other Achilles tendon surgeries.