Pregnancy and infertility in orthopedics: A review of the current state.

BACKGROUND: Orthopedic surgery continues to have one of the lowest rates of female trainees among all medical specialties in the United States. Barriers to pursuing a surgical residency include the challenges of family planning and work-life balance during training. METHODS: A systematic literature search of articles published between June 2012 and December 2022 in the MEDLINE, EMBASE, and Cochrane databases was performed in January 2023 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). Studies were included if they evaluated pregnancy and peripartum experience and/or outcomes amongst orthopedic surgeons or trainees. RESULTS: Eighteen studies were included. Up to 67.3% of female orthopedic surgeons and trainees and 38.7% of their male counterparts delayed childbearing during residency. The most reported reasons for this delay included career choice as an orthopedic surgeon, residency training, and reputational concerns among faculty or co-residents. Infertility ranged from 17.0% to 30.4% in female orthopedic surgeons and up to 31.2% suffered obstetric complications. Assisted Reproductive Technology (ART) resulted in 12.4%-56.3% of successful pregnancies. Maternity and paternity leaves ranged from 1 to 11 weeks for trainees with more negative attitudes associated with maternal leave. CONCLUSIONS: Female orthopedic trainees and attending delay childbearing, experience higher rates of obstetric complications, and more stigma associated with pregnancy compared to their male colleagues. Program and institutional policies regarding maternity and paternity leave are variable across programs, and therefore, attention should be directed toward standardizing policies.

Sex-specific analysis in patients undergoing Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large osteochondral lesions of the talus.

PURPOSE: The purpose of the present study is to assess the gender-specific differences in the presentation and outcomes following Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) between male and female patients. METHODS: A prospective comparative analysis was performed comparing consecutive female and male patients having been treated by the press-fit TOPIC procedure. Clinical comparative assessment preoperatively and at 12 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) was also assessed. A computed tomography (CT) scan was performed for lesion size, morphology and localization determination preoperatively as well as 10-12 weeks postoperatively to assess the union of the osteotomy site and at 1 year postoperatively to assess consolidation of the graft as well as intra-graft cyst development. RESULTS: A total of 48 patients (30 women, 18 men) were eligible for inclusion. Both men and women demonstrated significant functional improvements postoperatively concerning the clinical outcomes with no significant differences between men and women (n.s.) except for a significantly greater improvement in postoperative FAOS pain scores in women. Men presented with OLTs significantly larger in both surface area (208 mm2 for males versus 155 mm2 for females, p < 0.05) as well as lesion volume (3.0 cm3 for males versus 1.8 cm3 for females, p < 0.05). At 1-year postoperatively, all patients showed graft consolidation. Cyst formation was present in 11 females (37% of the group) and 10 males (59% of the group), respectively (n.s.). CONCLUSION: Both males and females showed clinically relevant improvements in the clinical outcomes after undergoing the TOPIC procedure with significant differences in preoperative lesion size. The TOPIC procedure is a good treatment strategy for large OLTs in both men and women. LEVEL OF EVIDENCE: Level III, comparative prospective clinical cohort.

Gender Differences in Achilles Tendon Ruptures-A Retrospective Study and a Review of the Literature.

Achilles tendon ruptures are common injuries typically sustained during sport with higher incidence in men, though little is understood regarding sex-specific risk factors or outcomes following injury management. This cross-sectional clinical study and systematic review aimed to examine sex-specific Achilles tendon rupture incidence and outcomes following intervention. This study included patients who sustained a rupture between 2011-2021, were ≥18 years old, and who had a minimum follow-up of at least six months, and evaluated age, sex, sport involvement, mechanism of injury, and postoperative complications and revision. Separately, a systematic literature review in the PubMed, EMBASE, and Cochrane databases was performed. A total of 705 male and 158 female patients were included in this retrospective study. 71.1% of men and 52.5% of women sustained a sports-related rupture (p < .001), with sport involvement demonstrating a positive correlation with revision rate (coefficient = 0.09, p = .02). A total of 21 studies with 250,907 patients (87,514 male, 35,792 female) were included in the systematic review. All studies revealed an increased incidence of ATR in men. Functional outcomes were worse in women, and female sex was an independent risk factor for postoperative complications and need for revision surgery. This study demonstrated a higher incidence of sports-related ATR in men than women, likely related to their higher ball sport participation. Although the retrospective analysis did not find a significant difference in complication or revision rates, the systematic review demonstrates poorer functional outcomes, with increased likelihood for postoperative complication and revision surgery in women as compared to men.

Platelet rich plasma therapy versus other modalities for treatment of plantar fasciitis: A systematic review and meta-analysis.

INTRODUCTION: Plantar fasciitis (PF) is the most common cause of heel pain in adults. There are numerous non-operative treatments available including platelet rich plasma (PRP) injections. PPR has demonstrated effectiveness for a range of musculoskeletal conditions including plantar fasciitis. PURPOSE/OBJECTIVE: To compare the effectiveness of PRP to other conservative treatment options for the management of PF. METHODS: A systematic search of PubMed and Google Scholar was performed for randomized control trials (RCT) comparing PRP to other treatment modalities. Studies met inclusion criteria if mean and standard deviations for visual analog scale (VAS) pain scores, plantar fascia thickness (PFT), Foot Function Index (FFI), or American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were reported. Mean differences (MD) were used to compare VAS pain, PFT, FFI, and AOFAS between PRP and other treatments. RESULTS: Twenty-one RCTs which altogether included 1356 patients were included in the meta-analysis. PRP demonstrated significantly greater improvements in VAS pain scores compared to extracorporeal shock wave therapy (ESWT) (SMD: 0.86; CI: [0.30, 1.41]; p = 0.002), corticosteroid injections (CSI) (SMD: 1.08; CI: [0.05, 2.11]; p = 0.04), and placebo (SMD: 3.42; CI: [2.53, 4.31]; p < 0.00001). In terms of FFI, no significant differences existed among PRP, ESWT, CSI, dextrose prolotherapy (DPT), and meridian trigger points (MTP) in enhancing foot functionality. However, PRP demonstrated a marked advantage over phonophoresis, showing a substantial improvement in FFI scores (SMD: 3.07, 95% CI: 2.34-3.81). PRP did not demonstrate superiority over ESWT, CSI, or MTP for improving PFT, but it was notably more effective than phonophoresis (SMD: 3.18, 95% CI: 2.43-3.94). PRP demonstrated significantly greater improvements in AOFAS scores over CSI (SMD: 3.31, CI: [1.35, 5.27], p = 0.0009) and placebo (SMD: 3.75; CI: [2.81, 4.70]; p < 0.00001). CONCLUSION: PRP is more effective than CSI, ESWT, and placebo in reducing VAS and more effective than CSI and placebo in improving AOFAS. PRP did not demonstrate a consistent advantage across all outcome measures, such as PFT and FFI. These findings underscore the complexity of PF treatment and call for a more standardized approach to PRP preparation and outcome measurement. LEVEL OF EVIDENCE: Level I Meta-Analysis.

Gender Differences May Exist in the Presentation, Mechanism of Injury and Outcomes Following Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

Bone marrow stimulation (BMS) is indicated for patients who have symptomatic osteochondral lesions of the talus (OLT). Despite differences in ankle biomechanics and cartilage morphology between men and women, there is scant evidence examining whether these differences affect surgical outcomes. The purpose of this study was to compare the outcomes in men and women following BMS for OLTs. A retrospective analysis comparing female and male patients treated with BMS for OLT between 2007 and 2015 was performed. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12). Magnetic resonance imaging at final follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue score. Thirty-one females and 38 males were included. In female patients, the mean FAOS pain score improved from 60 ± 16 preoperatively to 84 ± 8.9 at 1- to 2-year follow-up (p < .01), and then decreased to 80±13 at final follow-up at 3-4 years. In male patients, the mean FAOS pain score improved from 65±17 preoperatively to 83±9.2 at 1-2 year follow-up (p < .01), and then decreased to 76±14.6 at final follow-up at 3-4 years. Lateral lesions were more common in male patients. Medial lesions were more common in female patients. The outcomes following BMS in both female and male patients were good with no significant differences at short-term follow-up. FAOS scores in male patients were more likely to decrease after 1 to 2 years postsurgery, implying a possibly faster decline than in female patients.

Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus-Does Sex Play a Role?

Autologous osteochondral transplantation (AOT) is used in the treatment of osteochondral lesions (OCL) of the talus. The purpose of this study was to compare the differences in the presentation of talar OCLs and outcomes following AOT between male and female patients. Eighty-seven consecutive patients, ages 16 to 65 years, who underwent AOT were retrospectively reviewed. Patients were divided into 2 groups based on sex. Demographic data and OCL defect characteristic data were recorded. Functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. Fifty-six (64%) males and 31 (36%) females with mean clinical follow-up of 47.2 months were included in this study. OCL defect size was significantly larger in male patients (112.8 mm2) when compared with female patients (88.7 mm2) (p < .001). Male patients presented with a lesion associated with a recognized trauma (p < .006) when compared with female patients who typically presented with associated chronic ankle instability. Mean FAOS improved pre- to postoperatively from 50 to 81 (p < .001) with a statistically significant increase found in male patients (p < .001). The mean MOCART score was 82.1 in male and 86.7 female patients (p < .001). Our study demonstrates potential gender-related differences in the presentation and mechanism of injury in the development of OCLs. It is also not unreasonable to suggest that there may also be differences in treatment and rehabilitation strategies to reduce the risk of developing OCLs in men and women.

Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review.

BACKGROUND: The negative effects of bullying, discrimination, harassment, and sexual harassment (BDHS) on well-being and productivity of surgical residents in training have been well documented. Despite this, little has changed over the past decade and these behaviors continue. The purpose of this study was to determine the prevalence of each abusive behavior experienced by residents, identify the perpetrators, and examine the reporting tendency. METHODS: A systematic review of articles published between 2010 and 2020 in the MEDLINE, EMBASE, and Cochrane databases was performed following PRISMA guidelines. The following search terms were used: bullying, harassment, sexual harassment, discrimination, abuse, residency, surgery, orthopedic surgery, general surgery, otolaryngology, obstetrics, gynecology, urology, plastic surgery, and training. RESULTS: Twenty-five studies with 29,980 surgical residents were included. Sixty-three percent, 43, 29, and 27% of surgical residents experienced BDHS, respectively. Female residents reported experiencing all BDHS behaviors more often. Thirty-seven percent of resident respondents reported burnout, and 33% reported anxiety/depression. Attending surgeons, followed by senior co-residents, were the most common perpetrators. Seventy-one percent did not report the behavior to their institution. Fifty-one percent stated this was due to fear of retaliation. Of those who reported their experiences, 56% stated they had a negative experience reporting. CONCLUSION: Our review demonstrates high prevalence rates of BDHS experienced by residents during surgical training, which have been associated with burnout, anxiety, and depression. The majority of residents did not report BDHS due to fear of retaliation. Residency programs need to devise methods to have a platform for residents to safely voice their complaints.

The Pregnant Patient - Why Do My Feet Hurt?

Although hormonal and anatomical changes that occur during pregnancy have been well documented, how these changes affect foot and ankle function are less understood. Changes during pregnancy in body mass, body-mass distribution, joint laxity, and muscle strength can all contribute to alterations in gait pattern that can lead to pain or injury to the foot and ankle. This review provides an overview of the various foot and ankle anatomic, biomechanic, and kinematic changes that occur during pregnancy. In addition, this article presents the most common causes of foot and ankle symptoms expressed by the pregnant patient population and discuss the management and treatment of each condition.

Interpositional Arthroplasty in the Treatment of Hallux Rigidus: A Systematic Review.

Hallux rigidus is the most common arthritic condition of the foot. Interpositional arthroplasty (IPA) is indicated for advanced-stage hallux rigidus and attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, the data evaluating the effectiveness of IPA are limited. The purpose of this study was to systematically review the outcomes of IPA in the treatment of hallux rigidus. MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed based on the preferred reporting items for systematic reviews and meta-analyses guidelines. Outcomes collected and analyzed included: American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (HMI) score, visual analogue scale score, short-form 36 score, range of motion (ROM), radiographic parameters, and postoperative complications. The level and quality of clinical evidence were recorded and assessed. Sixteen studies with a total of 428 patients met inclusion/exclusion criteria. The mean AOFAS-HMI score improved from 51.6 ± 10.1 (range 35.0-64.2) preoperatively to 86.0 ± 7.7 (range 71.6-95.4) postoperatively (p ≤ .001) at weighted mean follow-up of 58.0 ± 34.5 (range 16.5-135.6) months. The preoperative weighted mean total ROM was 39.3° ± 9.6° (range 24.2-49.9) and the postoperative weighted mean total ROM was 61.5° ± 4.8° (range 54.0-66.5) (p ≤ .001). The complication rate was 21.5% with metatarsalgia as the most commonly reported complication. One study was level 3 and 15 studies were level 4 clinical evidence. This systematic review demonstrates improvement in functional and ROM outcomes following IPA procedure at mid-term follow-up. The procedure however has a moderate complication rate. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data.

Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population.

PURPOSE: (1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols. METHODS: A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated. RESULTS: Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm2. The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R2 = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R2 = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks. CONCLUSIONS: This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence. LEVEL OF EVIDENCE: Level IV.

Clinical Outcomes of Peroneal Tendon Tears: A Systematic Review.

The purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane. Criteria for inclusion were clinical studies reporting outcomes after treatment for peroneal tendon tear within the last 10 years. Nine studies evaluating 336 patients (146 males/190 females) and 336 ankles were included in this review. The mean age of included patients was 46.3 years (range, 46-56.9 years). The weighted mean follow-up was 23.82 months (range 9.2-78 months. Five surgical interventions were reported: primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction. Four studies recorded the AOFAS score, with a weighted mean preoperative score of 69.58 and a weighted mean postoperative score of 88.82. Six studies measured the VAS score showing an improvement from a mean weighted preoperative score of 4.68 to a mean weighted postoperative score of 1.2. FAAM score was measured in 3 studies, which showed an improvement from 41.1 preoperatively to 84.4 postoperatively. The average overall complication rate was 38.7% (130/336) with the most commonly reported minor complication being ankle pain, which made up 46.2% of all minor complications (56/121). Primary repair without tenodesis was associated with a higher complication rate compared to any other surgical intervention (p=.001176). The current systematic review showed that overall clinical outcomes were positive in lieu of the different modalities of surgical intervention for peroneal tendon tears.

Combination Lower Extremity Nerve Blocks and Their Effect on Postoperative Pain and Opioid Consumption: A Systematic Review.

The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve blocks (PNBs), including (1) sciatic and femoral nerve, (2) popliteal and saphenous nerve, and (3) popliteal and ankle nerve, during elective foot and ankle surgery. We hypothesized that combination blocks would decrease postoperative narcotic consumption and afford more effective postoperative pain control as compared to general anesthesia, spinal anesthesia, or single site PNBs. A review of the literature was performed according to the PRISMA guidelines. Medline, EMBASE, and the Cochrane Library were searched from January 2009 to October 2019. We identified studies by using synonyms for "foot," "ankle" "pain management," "opioid," and "nerve block." Included articles explicitly focused on elective foot and ankle procedures performed under general anesthesia, spinal anesthesia, PNB, or with some combination of these techniques. PNB techniques included femoral, adductor canal, sciatic, popliteal, saphenous, and ankle blocks, as well as blocks that combined multiple anatomic sites. Outcomes measured included postoperative narcotic consumption as well as patient-reported efficacy of pain control. Twenty-eight studies encompassing 6703 patients were included. Of the included studies, 57% were randomized controlled trials, 18% were prospective comparison studies, and 25% were retrospective comparison studies. Postoperative opioid consumption and postoperative pain levels were reduced over the first 24 to 48 hours with the use of combined PNBs when compared with single site PNBs, both when used as primary anesthesia or when used in concert with general anesthesia either alone or combined with systemic/local anesthesia in the first 24 to 48 hours following surgery. Studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined PNB. Nine of 14 (64%) studies reported no neurologic related complications with an overall reported rate among all studies ranging from 0% to 41%. Our study identified substantial improvement in postoperative pain levels, postoperative opioid consumption, and patient satisfaction in patients receiving PNB when compared with patients who did not receive PNB. Published data also demonstrated that combination PNB are more effective than single-site PNB for all data points. Notably, the addition of a femoral nerve block to a popliteal nerve block during use of a thigh tourniquet, as well as addition of either saphenous or ankle blockade to popliteal nerve block during use of calf tourniquet, may increase overall block effectiveness. Serious complications including neurologic damage following PNB administration are rare but do exist.

Sex- and Gender-specific Analysis in Orthopaedic Studies.

BACKGROUND: Orthopaedic studies have reported the prevalence of injuries and outcomes after treatment in men and women patients, and although these differences have been recognized, few studies have evaluated for gender-specific injury patterns, disease progression, and treatment outcomes. A thorough understanding of gender-related differences is important to better individualize treatment and improve outcomes. QUESTIONS/PURPOSES: In this study, we sought (1) to determine the proportion of studies published in six orthopaedic journals that provided sex- or gender-specific analyses in 2016 and whether a difference was found in outcomes between men and women and (2) to evaluate whether this proportion varied across several orthopaedic subspecialty journals or between general orthopaedic journals and subspecialty journals. METHODS: Six leading orthopaedic surgery journals were selected for review, including two general orthopaedic journals (Journal of Bone and Joint Surgery and Clinical Orthopaedics and Related Research®) and four subspecialty journals (American Journal of Sports Medicine, Journal of Arthroplasty, Journal of Shoulder and Elbow Surgery, and Spine). Journal issues published in the even-numbered months of 2016 were reviewed for clinical randomized controlled, cohort, and case-control studies in which women were a part of the study population. A total of 712 studies evaluating 24,607,597 patients met the criteria and were included in our review of publications from 2016. The selected studies were stratified based on whether gender was a variable in a multifactorial statistical model. Outcomes of interest included the proportion of patients who were women and the presence or absence of a gender-specific analysis. These endpoints were compared between journals. RESULTS: Overall, 55% (13,565,773 of 24,607,597) of patients analyzed in these studies were women. Only 34% (241 of 712) of the studies published in 2016 included gender as variable in a multifactorial statistical model. Of these, 39% (93 of 241) demonstrated a difference in the outcomes between patients who were men and women. The Journal of Arthroplasty had the greatest percentage of patients who were women (60%, 9,251,068 of 15,557,187) and the American Journal of Sports Medicine had the lowest (44%, 1,027,857 of 2,357,139; p < 0.001). Orthopaedic subspecialty journals tended to include a greater percentage of women (54%) than did general orthopaedic journals (50%; p = 0.04). CONCLUSION: Currently, it is unclear what percentage of published orthopaedic studies should include a gender-specific analysis. In the current study, more than one-third of publications that performed a gender-specific analysis demonstrated a difference in outcomes between men and women, thereby emphasizing the need to determine when such an analysis is warranted. CLINICAL RELEVANCE: Future studies should aim to determine when a gender-specific analysis is necessary to improve the management of orthopaedic injuries in men and women. It is important for investigators at the individual-study level to look for every opportunity to ensure that both men's and women's health needs are met by performing appropriate by-sex and by-gender analyses, but not to perform them when they are unnecessary or inappropriate.

Postoperative Reoperations and Complications in 32,307 Ankle Fractures With and Without Concurrent Ankle Arthroscopic Procedures in a 5-Year Period Based on a Large U.S. Healthcare Database.

Residual symptoms often persist even after successful operative reduction and internal fixation (ORIF) of ankle fractures. Concurrent ankle arthroscopic procedures (CAAPs) have been proposed to improve clinical outcomes; however, a dearth of evidence is available supporting this practice. The purpose of the present study was to investigate the reoperation and complication rates after ORIF of ankle fractures with and without CAAPs. Reoperations and complications after ORIF of ankle fractures were identified using the PearlDiver database from January 2007 to December 2011. The CAAPs included bone marrow stimulation, debridement, synovectomy, and unspecified cartilage procedures. Reoperation procedures consisted of ankle fracture repeat fixation, arthroscopic procedures, osteochondral autograft transfers, and ankle arthrodesis. Of the 32,307 patients who underwent ankle fracture fixation, 248 received CAAP and 32,059 did not. No significant difference was found in the reoperation rate between the 2 groups (7.7% versus 8.6%; odds ratio 0.89; 95% confidence interval 0.55 to 1.42; p = .61). Of the 248 patients in the CAAP group, 19 (7.7%) underwent reoperation, of which 13 (68.4%) were arthroscopic debridement and 6 were either ankle refixation or osteochondral autograft transfer. For the non-CAAP group, 3021 reoperation procedures were performed, consisting of ankle refixation in 83.2%, arthroscopic procedures in 14.3%, and ankle arthrodesis in 2.5%. The complication rate in the non-CAAP group included wound dehiscence in 2.4%, wound surgery in 0.4%, deep vein thrombosis in 0.8%, and pulmonary embolism in 0.4%. No complications were detected in the CAAP group. Ankle fracture fixation with CAAPs did not increase the postoperative reoperation rate compared with ankle fracture fixation without CAAPs.

Limited evidence for adipose-derived stem cell therapy on the treatment of osteoarthritis.

PURPOSE: The purpose of this systematic review is to evaluate the effects of adipose derived mesenchymal stem cells (ADSCs) in the treatment of osteoarthritis (OA) in the clinical setting. METHODS: A literature search was performed in the MEDLINE, EMBASE, and The Cochrane Library Database up to January 2017 for inclusion and exclusion criteria. Criteria for inclusion were clinical studies demonstrating the effects of ADSCs on OA, and written in English. The following variables were analyzed: donor site, volume of adipose tissue, preparation of ADSCs, clinical outcomes, and complication rate. RESULTS: Sixteen studies (knee: 14 studies, multiple joints: 1 study, ankle: 1 study) were included in this systematic review. All of the studies prepared ADSCs in the form of the stromal vascular fraction (SVF). Inconsistencies between studies were found with regards to reported clinical variability, donor sites of SVF, and reported clinical outcomes. Nine studies used either platelet-rich plasma (PRP) (7/16) or fibrin (4/16) or both PRP and Fibrin (1/16), as an adjunct at time of SVF injection. All of the studies reported an improvement in clinical outcomes with the use of SVF. Five studies reported a 90% satisfaction rate, and no study reported any complications with liposuction. Five studies reported on complications, with a 5% incidence of swelling and pain. CONCLUSIONS: This systematic review demonstrated that ADSCs are currently used in the form of SVF. While SVF may produce favorable clinical outcomes with minimal risk of side effects on osteoarthritis, the variability in the data and the use of biological adjuvants have confounded the effectiveness of ADSCs. This study will help surgeons understand the limitations in the literature on ADSCs. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

The Effect of Different Bone Marrow Stimulation Techniques on Human Talar Subchondral Bone: A Micro-Computed Tomography Evaluation.

PURPOSE: To evaluate morphological alterations, microarchitectural disturbances, and the extent of bone marrow access to the subchondral bone marrow compartment using micro-computed tomography analysis in different bone marrow stimulation (BMS) techniques. METHODS: Nine zones in a 3 × 3 grid pattern were assigned to 5 cadaveric talar dome articular surfaces. A 1.00-mm microfracture awl (s.MFX), a 2.00-mm standard microfracture awl (l.MFX), or a 1.25-mm Kirschner wire (K-wire) drill hole was used to penetrate the subchondral bone in each grid zone. Subchondral bone holes and adjacent tissue areas were assessed by micro-computed tomography to analyze adjacent bone area destruction and communicating channels to the bone marrow. Grades 1 to 3 were assigned, where 1 = minimal compression/sclerosis; 2 = moderate compression/sclerosis; 3 = severe compression/sclerosis. Bone volume/total tissue volume, bone surface area/bone volume, trabecular thickness, and trabecular number were calculated in the region of interest. RESULTS: Visual assessment revealed that the s.MFX had significantly more grade 1 holes (P < .001) and that the l.MFX had significantly more poor/grade 3 holes (P = .002). Bone marrow channel assessment showed a statistically significant increase in the number of channels in the s.MFX when compared with both K-wire and l.MFX holes (P < .001). Bone volume fraction for the s.MFX was significantly less than that of the l.MFX (P = .029). CONCLUSIONS: BMS techniques using instruments with larger diameters resulted in increased trabecular compaction and sclerosis in areas adjacent to the defect. K-wire and l.MFX techniques resulted in less open communicating bone marrow channels, denoting a reduction in bone marrow access. The results of this study indicate that BMS using larger diameter devices results in greater microarchitecture disturbances. CLINICAL RELEVANCE: The current study suggests that the choice of a BMS technique should be carefully considered as the results indicate that smaller diameter hole sizes may diminish the amount of microarchitectural disturbances in the subchondral bone.

Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review.

PURPOSE: The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures. METHODS: A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included. RESULTS: Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5% at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022). CONCLUSIONS: Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

In-Office Needle Arthroscopy: Indications, Surgical Techniques, Tips, and Tricks.

In-office needle arthroscopy (IONA) has gained increased attention as a minimally invasive alternative to standard arthroscopy performed in the operating room (OR) setting. IONA uses instrumentation that is markedly smaller in size and diameter making arthroscopy less invasive. Less OR equipment and less OR staff are required resulting in procedures that may be more accessible and less expensive. IONA is typically performed using local intra-articular blocks, thereby reducing the need for regional anesthesia or general anesthesia along with its associated risks. Using a clinic setting rather than an OR reduces the cost and increases the efficiency of the procedure. This article will present the indications for IONA in upper and lower extremity injuries and will describe the best practice office setup. Technical pearls and pitfalls will also be discussed.

Analysis of Gender Diversity Within Foot and Ankle Surgery Fellowship Programs.

BACKGROUND: Women continue to be underrepresented in orthopaedic surgery. This study seeks to evaluate gender diversity of faculty and trainees at foot and ankle surgery fellowship programs. METHODS: In this cross-sectional analysis of 49 US foot and ankle fellowship programs, all publicly available data on program faculty (as of July 2023) were collected, as well as data on current and past fellows between 2018 and 2024. RESULTS: Of 49 programs with 195 foot and ankle surgery faculty, 26.5% (n = 13) had at least 1 female on faculty, with only 8.2% (n = 4) having female fellowship directors. Female faculty made up 9.7% (n = 19) of foot and ankle surgery faculty overall. Of 307 total fellows identified within the 6-year period, 19.5% (n = 60) were female. Geographic distribution of programs was as follows: 29% (n = 14) Northeast, 31% (n = 15) South, 19% (n = 9) Midwest, and 21% (n = 10) West. Northeast programs made up 62% of all programs with female faculty, whereas Midwest programs made up the least at 8% (P = .048). Programs with female faculty had more female fellows from 2018 to 2024 than programs without female faculty (33.7% vs 14%, P < .001). CONCLUSION: Our findings suggest that females remain underrepresented in foot and ankle surgery fellowship director positions, despite an increasing proportion of females entering orthopaedic surgery. Foot and ankle surgery fellowship programs with female faculty had a higher number of female trainees; as such, diversification of foot and ankle fellowship departments may be an important factor in ongoing efforts to promote gender diversity within the specialty. LEVEL OF EVIDENCE: Level IV, observational cross-sectional analysis.

Platelet-Rich Plasma vs Extracorporeal Shock Wave Therapy in the Treatment of Plantar Fasciitis at 3-6 Months: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Plantar fasciitis (PF) is a common foot disorder with variability in treatment strategy. Two effective management techniques include platelet-rich plasma (PRP) injections and extracorporeal shock wave therapy (ESWT). The purpose of this meta-analysis is to compare the effectiveness of PRP vs ESWT in the management of PF. METHODS: A systematic search was performed of PubMed, Cochrane, and Google Scholar for randomized controlled trials comparing PRP to ESWT. Studies met inclusion criteria if mean and SDs for visual analog scale (VAS) pain scores and plantar fascia thickness (PFT) were reported. Mean differences were used to compare VAS pain score and PFT between PRP and ESWT. RESULTS: Six randomized controlled trials, comparing a total of 214 subjects in the PRP group and 218 subjects in the ESWT group, were analyzed. A significantly greater statistical improvement was seen in the PRP group in VAS pain (mean difference = -0.67 [95% CI -1.16, -0.18], P = .007) and plantar fascia thickness (PFT) (mean difference = -0.56 [95% CI -0.77, -0.35], P < .001). CONCLUSION: PRP had a statistically higher pain reduction than ESWT, but the difference does not reach clinical significance in this meta-analysis.