Publications by authors named "Amol Saxena"

65 Publications

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

J Foot Ankle Surg 2021 Mar 31. Epub 2021 Mar 31.

Rosalind Franklin University, Scholl College, Chicago IL.

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).
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http://dx.doi.org/10.1053/j.jfas.2021.01.009DOI Listing
March 2021

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

J Foot Ankle Surg 2020 Dec 31. Epub 2020 Dec 31.

Podiatric Physician and Surgeon, Reconstructive Orthopedics, Sewell, NJ.

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.
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http://dx.doi.org/10.1053/j.jfas.2019.11.011DOI Listing
December 2020

An Unusual Case of a Fibular Sesamoid Phalangeal Ligament Tear Caused By Chronic Trauma.

J Am Podiatr Med Assoc 2019 Mar 12;109(2):162-165. Epub 2019 Jan 12.

Injuries involving the first metatarsophalangeal joint and its associated structures are common, especially in athletes. However, injuries to the hallucal sesamoid complex constituted only 3% of all podiatric sports medicine injuries reported by Agosta. This case study reports a female ballet dancer with an isolated fibular sesamoid retraction injury that presented with a history of chronic microtrauma secondary to overuse. When consulting epidemiologic studies of forefoot injuries involving the hallucal sesamoid complex, we were unable to find a single instance of an isolated retraction of the fibular sesamoid resulting from chronic use, demonstrating the unusual nature of this case.
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http://dx.doi.org/10.7547/18-052DOI Listing
March 2019

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

J Foot Ankle Surg 2019 Jul 13;58(4):609-616. Epub 2018 Dec 13.

Podiatrist, Podiatry Associates, PC Castle Pines, CO.

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.
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http://dx.doi.org/10.1053/j.jfas.2018.07.009DOI Listing
July 2019

Hallux Valgus Surgery in the Athlete: Current Evidence.

J Foot Ankle Surg 2019 Jul 15;58(4):641-643. Epub 2018 Nov 15.

Professor, Orthopedic Surgery, Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentistry, Salerno, Italy; Professor, Centre for Sports and Exercise Medicine, Bart's and London School of Medicine and Dentistry, Queen Mary School of Medicine, London, UK.

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.
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http://dx.doi.org/10.1053/j.jfas.2018.04.003DOI Listing
July 2019

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

J Foot Ankle Surg 2018 Mar - Apr;57(2):409-413. Epub 2017 Dec 2.

Fellow, Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2017.08.024DOI Listing
September 2018

Triple Achilles Tendon Rupture: Case Report.

J Foot Ankle Surg 2018 Mar - Apr;57(2):404-408. Epub 2017 Nov 16.

Fellow, Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2017.08.023DOI Listing
September 2018

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

J Foot Ankle Surg 2017 Sep - Oct;56(5):985-989

Orthopedist, Department of Orthopaedic Surgery and Traumatology, University Schleswig-Holstein, Campus Kiel, Kiel, Germany; Orthopedist, Department of Orthopaedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany.

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.
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http://dx.doi.org/10.1053/j.jfas.2017.06.013DOI Listing
June 2018

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

J Foot Ankle Surg 2017 Sep - Oct;56(5):982-984

Fellowship Director, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2017.06.015DOI Listing
June 2018

Electromagnetic Transduction Therapy for Achilles Tendinopathy: A Preliminary Report on a New Technology.

J Foot Ankle Surg 2017 Sep - Oct;56(5):964-967

Professor and Orthopedist, Department of Orthopaedic Surgery and Traumatology, University Schleswig Holstein, Campus Kiel, Kiel, Germany.

A parallel prospective feasibility study was performed on 53 patients with chronic mid-portion Achilles tendinopathy (age 44.7 ± 9.1 years). Of the 53 patients, 28 (active group) were treated using a new electromagnetic (pulsed electromagnetic field) transduction therapy device (Cellactor MT1) and heel cushions. The device produces an electromagnetic field of 80 milliTesla; a total of 8 treatments was performed within 4 weeks in an outpatient setting, without anesthesia, immobilization, or rest. A control group of 25 patients with a similar duration of symptoms was treated with heel cushions only. At the 12-week assessment point, the visual analog scale scores in both groups had significantly decreased, although the active group had significantly improved visual analog scale scores compared with those of the controls. The Role-Maudsley scores had also significantly improved in both the active and the control groups (p < .00001 and p = .0002, respectively). Electromagnetic transduction therapy could potentially be a useful modality for the treatment of Achilles tendinopathy. It should be compared with the current reference standard of extracorporeal shockwave therapy/radial soundwave therapy with similar level I, II, and III studies.
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http://dx.doi.org/10.1053/j.jfas.2017.06.014DOI Listing
June 2018

Treatment of Plantar Fasciitis With Radial Soundwave "Early" Is Better Than After 6 Months: A Pilot Study.

J Foot Ankle Surg 2017 Sep - Oct;56(5):950-953

Orthopedic Surgeon, Universitaet Schleswig Holstein, Kiel, Germany.

Extracorporeal shock wave therapy/radial soundwave therapy has been predominantly used for chronic or recalcitrant plantar fasciitis with strong scientific evidence of reliable outcomes. Most of the studies included patients with plantar fasciitis with symptoms >6 months in duration. Only 2 known studies have investigated acute plantar fasciitis, which is <6 weeks in duration. They both found suboptimal results for the use of extracorporeal shock wave therapy. To the best of our knowledge, no studies have investigated radial soundwave therapy for the subacute stage or early stage of plantar fasciitis. Data were prospectively collected from 28 eligible patients who underwent radial soundwave therapy (RSWT) during a 9-month period in 2014. Of the 28 subjects, 14 were enrolled in the "early group" with a symptom duration of <3 months and 14 in the "standard/control" group with a symptom duration of >6 months. The pretreatment and posttreatment visual analog scale scores, Roles-Maudlsey scores, and activity level were recorded and compared. The early implementation of RSWT yielded comparable outcomes when compared with the standard group. RSWT is a valid treatment modality that can be implemented soon after the initial treatment options or first-phase treatment options have failed. Early treatment is more likely to allow for maintenance of patients' activity level. Also, waiting 6 months to treat plantar fasciitis with RSWT results in delays and inferior results. Early treatment is better for active and athletic patients.
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http://dx.doi.org/10.1053/j.jfas.2017.06.020DOI Listing
June 2018

Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries.

J Foot Ankle Surg 2017 Sep - Oct;56(5):943-948

Adjunct Associate Professor, Department of Medicine, University of California at Los Angeles, Los Angeles, CA; Senior Scientist, PAMFRI, Palo Alto, CA.

The optimal treatment modalities for navicular stress fractures in athletes is currently unknown for this season-ending injury. The present study evaluated factors that might be significant and affect healing outcomes, specifically focusing on the return to activity (RTA) time and a decreased desired activity (DDA) after treatment in athletes. Such considerations included previous navicular stress fractures, patient demographic data and type of sport, and initiation time of treatment. The data from 59 patients with 62 fractures were prospectively analyzed from May 2005 through July 2016. The results showed a significant correlation between a previous navicular stress fracture and decreased desired activity. The average duration of symptoms before receiving definitive treatment was 8.8 months. Computed tomography as the initial imaging modality correlated positively with a correct diagnosis (1.00). In contrast, magnetic resonance imaging, when used initially, was only 71% accurate. Runners constituted most of the cohort at 38 (61.3%). Ten other athletes were involved in jumping sports. Of the 62 injuries, 21 (33.9%) were in elite or professional athletes, all of whom were able to RTA, with 1 patient, a 38-year-old world record holding runner, having a DDA. Seven refractures (11.2%) occurred an average >5 years after the initial injury, predominantly in those aged <21 years, none with previous surgery. Eight patients (12.9%) developed postinjury arthrosis, including 1 with DDA. Patients who underwent open reduction and internal fixation had a RTA of 4.56 months compared with those who had undergone nonoperative treatment, who had an average RTA of 3.97 months. Seven patients (11.2%) underwent screw removal and required a longer RTA. Overall, of the 62 injuries, the patients with 57 of the injuries (91.9%) were able to RTA at their preinjury level.
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http://dx.doi.org/10.1053/j.jfas.2017.06.009DOI Listing
June 2018

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Five-Year Prospective Cohort Study: Gottschalk et al.

Authors:
Amol Saxena

J Foot Ankle Surg 2017 Sep - Oct;56(5):937

Podiatrist, Department of Sports Medicine, Palo Alto Foundation Medical Group, Palo Alto, CA.

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http://dx.doi.org/10.1053/j.jfas.2017.05.048DOI Listing
August 2019

Should Sports Injuries and Surgeries Be "POLICED"?

Authors:
Amol Saxena

J Foot Ankle Surg 2017 Sep - Oct;56(5):916

Podiatrist, Deptartment of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA.

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http://dx.doi.org/10.1053/j.jfas.2017.06.012DOI Listing
March 2019

Randomized Placebo-Controlled Placebo Trial to Determine the Placebo Effect Size.

Pain Physician 2017 07;20(5):387-396

Dept. of Child and Adolescent Psychiatry and Psychotherapy, Center for Integrative Psychiatry, School of Medicine, Christian-Albrechts-University, Campus Kiel, Germany.

Background: It is the gold standard to use a placebo treatment as the control group in prospective randomized controlled trials (RCTs). Although placebo-controlled trials can reveal an effect of an active treatment, the pure effect of a placebo treatment alone has never been presented or evaluated. No evidence-based, placebo-therapeutic options are currently available, and no placebo-controlled trials have been performed to elucidate the pure placebo effect.

Objectives: To analyze the pure placebo effect on clinical, chronic pain through a blinded RCT.

Study Design: A prospective, randomized, placebo-controlled trial.

Setting: Medical University centers.

Methods: One-hundred eighty-two patients suffering from chronic plantar heel pain for over 6 months,who failed to respond to conservative treatments, were screened and 106 of these patients were enrolled into this study. The patients were randomly assigned to receive either a blinded placebo shockwave treatment or an unblinded placebo shockwave treatment. The primary outcome measure was the differences in percentage change of visual analogue scale (VAS) scores 6 weeks after the intervention. The secondary outcome measure was the differences in Roles and Maudsley pain score (RMS) 6 weeks after intervention. As an exploratory outcome, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the Mann-Whitney-U tests for group comparisons; treatment efficiency was calculated by the effect size coefficient and benchmarks for the Mann-Whitney estimator according to the t-test of 2 independent samples for quantitative data, as well as the Fisher's exact test for binary data.

Results: Patients from both groups did not differ with respect to heel pain ratings at baseline, for both the VAS (P = .476) and RMS (P = .810) scores. After 6 weeks, patients receiving the blinded placebo treatment reported less heel pain on both scales (VAS: P = .031; RMS: P = .004). Change scores of pain ratings were significantly higher in the blinded placebo group than in the un-blinded placebo group (VAS: P = .002; RMS: P = .002).

Limitations: As the study represents the first to use an inverse placebo RCT (IPRCT), further conceptual and methodological issues need to be addressed to describe detailed, underlying mechanisms. Specific contextual, intrapersonal, and interpersonal factors modulating the placebo effects should be addressed in future IPRCTs.

Conclusions: The present study indicated that true placebo effect sizes can be analyzed through a proper IPRCT design. Instead of treating high numbers of patients with placebos in a RCT, which increases the risk for subjects not receiving the active treatment, the IPRCT technique seems to be much more appropriate to analyze the effect sizes of any active treatment, in accordance with the Good Clinical Practice guidelines and Declarations of Helsinki.

Key Words: Pain, randomized controlled trial, RCT, placebo, effect size, inverse placebo, study, pain therapy.
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July 2017

Plate Fixation With Autogenous Calcaneal Dowel Grafting Proximal Fourth and Fifth Metatarsal Fractures: Technique and Case Series.

J Foot Ankle Surg 2017 Sep - Oct;56(5):975-981. Epub 2017 Jun 9.

Staff Podiatrist, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.

Metaphyseal and proximal diaphyseal fractures of the lateral column metatarsals can have problems with healing. In particular, those involving the fifth metatarsal have been associated with a high nonunion rate with nonoperative treatment. Although intramedullary screw fixation results in a high union rate, delayed healing and complications can occur. We describe an innovative technique to treat both acute and chronic injuries involving the metatarsal base from the metaphysis to the proximal diaphyseal bone of the fourth and fifth metatarsals. The surgical technique involves evacuation of sclerotic bone at the fracture site, packing the fracture site with compact cancellous bone, and plate fixation. In our preliminary results, 4 patients displayed 100% radiographic union at a mean of 4.75 (range 4 to 6) weeks with no incidence of refracture, at a mean follow-up point of 3.5 (range 1 to 5) years. The early results with our small series suggest that this technique is a useful treatment choice for metaphyseal and proximal diaphyseal fractures of the fourth and fifth metatarsals.
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http://dx.doi.org/10.1053/j.jfas.2017.04.035DOI Listing
June 2018

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

J Foot Ankle Surg 2017 Sep - Oct;56(5):922-928. Epub 2017 May 31.

Fellow, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2017.04.020DOI Listing
June 2018

Percutaneous Plating of Weber B Fibular Fractures.

J Foot Ankle Surg 2017 Mar - Apr;56(2):366-370. Epub 2017 Jan 12.

Fellow, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2016.11.012DOI Listing
November 2017

Medial Displacement Calcaneal Osteotomy: A Comparison of Screw Versus Locking Plate Fixation.

J Foot Ankle Surg 2016 Nov - Dec;55(6):1164-1168. Epub 2016 Sep 15.

Former Fellow, Palo Alto Medical Foundation, Palo Alto, CA.

Locking plate fixation is becoming more popular for fixation of lower extremity osteotomies. The present study evaluated locking plate fixation compared with screw fixation in the medial displacement calcaneal osteotomy procedure, measuring the outcomes and rate of hardware removal. The procedure was performed on 30 patients, 31 times, with 17 undergoing single screw fixation and 14 undergoing locking plate fixation. The return to activity was 6.87 ± 1.43 months, including some patients for whom running was their main activity. No malunions, nonunions, displacements, or infections developed. In 3 patients (21.4%), the locking plate was removed compared with 1 patient (5.9%) who required screw removal. The difference was not significant (p = .30). No differences were found in their postoperative American Orthopaedic Foot and Ankle Scale scores (91.9 ± 7.7 with plates versus 94.4 ± 5.8 with screws; p = .36). The Roles and Maudsley scores were the same in the 2 groups preoperatively at 4.0 ± 0.0, with the postoperative scores improving to 1.50 ± 0.5 and 1.41 ± 0.5 for the plate and screw group, respectively (p = .62). No significant increase was seen for patients undergoing hardware removal, regardless of the adjunctive procedure used (i.e., flexor digitorum longus/Kidner, Lapidus or midfoot fusion, subtalar arthroereisis, and endoscopic gastrocnemius recession). The stage of posterior tibialis dysfunction had no significant difference in the postoperative scores. From the results of the present study, we have concluded that using a locking plate or a single screw for fixation of the medial displacement calcaneal osteotomy provides acceptable patient outcomes and that the differences in the rate of hardware removal were not statistically significant between the 2 groups.
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http://dx.doi.org/10.1053/j.jfas.2016.06.006DOI Listing
July 2017

Radial Soundwave for Sesamoidopathy in Athletes: A Pilot Study.

J Foot Ankle Surg 2016 Nov - Dec;55(6):1333-1335. Epub 2016 Sep 8.

Professor, Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy.

The purpose of the present study was to evaluate the efficacy of radial soundwave therapy (RSW) for the management of sesamoiditis, symptomatic bipartite sesamoids, and avascular necrosis in athletic patients. The data from 10 patients undergoing RSW for sesamoiditis were retrospectively studied. Three treatments at 2.4 Bar and 13 Hz, for a total of 2500 pulses in each session, were administered to the affected sesamoid approximately 1 week apart. The Roles and Maudsley score and the visual analog scale (VAS) were used to assess disability and pain. An overall improvement was seen in reported pain after RSW. The pretreatment VAS score was 5.9 ± 1.7 and the post-treatment VAS score improved to 2.3 ± 2.4 (p = .0001). The activity pretreatment Roles and Maudsley score was 3.1 ± 0.3 and the post-treatment score was 1.5 ± 0.7 (p = .00003). All but 1 of the patients (90%) reported some or complete relief of pain. The mean time to return to activity was 10.1 ± 15.6 weeks, although this value was biased by 1 patient requiring 1 year to return to activity. Eliminating this patient, the average time to return to activity was 5.4 ± 5.6 weeks. Three patients in the cohort did not have to stop their desired activity at all, including 1 gymnast and 1 runner. Of these 3 patients, 2 (20% of all patients) reported complete relief of pain (VAS score of 0) after treatment. The third patient experienced a significant decrease in pain, with the VAS score, improving from 7 to 1. The results of the present study have demonstrated that RSW can be a viable treatment of certain symptomatic sesamoid pathologies and can be considered a valid alternative to surgery.
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http://dx.doi.org/10.1053/j.jfas.2016.07.024DOI Listing
July 2017

Letter to the Editor.

Authors:
Amol Saxena

J Am Podiatr Med Assoc 2016 05;106(3):239

Department of Sports Medicine, Clark Building, Palo Alto Foundation Medical Group-Palo Alto Division, 795 El Camino Real, Palo Alto, CA 94301.

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http://dx.doi.org/10.7547/15-067DOI Listing
May 2016

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

J Foot Ankle Surg 2017 Jan - Feb;56(1):182-186. Epub 2016 Apr 5.

Podiatrist, Kaiser Permanente, West Los Angeles Facility, Los Angeles, CA.

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.
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http://dx.doi.org/10.1053/j.jfas.2016.02.009DOI Listing
August 2017

Subtalar Arthroereisis Implant Removal in Adults: A Prospective Study of 100 Patients.

J Foot Ankle Surg 2016 May-Jun;55(3):500-3. Epub 2016 Feb 11.

Third Year Resident, Podiatric Medicine and Surgery Residency Program, Department of Veterans Affairs Healthcare System, Palo Alto, CA.

Subtalar joint arthroereisis (STA) can be used in the management of adult acquired flatfoot deformity (AAFD), including posterior tibial tendon dysfunction. The procedure is quick and normally causes little morbidity; however, the implant used for STA often needs to be removed because of sinus tarsi pain. The present study evaluated the rate and risk factors for removal of the implant used for STA in adults treated for AAFD/posterior tibial tendon dysfunction, including patient age, implant size, and the use of endoscopic gastrocnemius recession. Patients undergoing STA for adult acquired flatfoot were prospectively studied from 1996 to 2012. The inclusion criteria were an arthroereisis procedure for AAFD/posterior tibial tendon dysfunction, age >18 years, and a follow-up period of ≥2 years. The exclusion criteria were hindfoot arthritis, age <18 years, and a follow-up period of <2 years. A total of 100 patients (average age 53 years) underwent 104 STA procedures. The mean follow-up period was 6.5 (range 2 to 17) years. The overall incidence of implant removal was 22.1%. Patient age was not a risk factor for implant removal (p = .09). However, implant size was a factor for removal, with 11-mm implants removed significantly more frequently (p = .02). Endoscopic gastrocnemius recession did not exert any influence on the rate of implant removal (p = .19). After STA for AAFD, 22% of the implants were removed. No significant difference was found in the incidence of removal according to patient age or endoscopic gastrocnemius recession. However, a significant difference was found for implant size, with 11-mm implants explanted most frequently.
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http://dx.doi.org/10.1053/j.jfas.2015.12.005DOI Listing
June 2017

Naviculocuneiform Coalition: Case Reports of Two Sibling Soccer Players.

J Foot Ankle Surg 2016 Sep-Oct;55(5):1013-7. Epub 2015 Oct 17.

Physician, Gundersen Health System, LaCrosse, WI.

Tarsal coalitions are an abnormal union between 2 tarsal bones. They occur most commonly between the calcaneus and talus or the calcaneus and navicular but can also arise from other joints in the foot. Isolated cases of coalitions between the medial cuneiform and navicular are extremely rare, and only a few cases have been reported. Treatment recommendations are, therefore, sparse, and no long-term follow-up data have been reported. We present the case of 2 sisters, each diagnosed with a symptomatic naviculocuneiform coalition. To our knowledge, this is the first reported case in 2 first-degree relatives. Both sisters were involved in sports and presented with pain during physical activities. After conservative treatment had failed, they were both treated successfully with surgical excision of the coalition and arthrodiastasis, followed by a progressive return to activities. At the last follow-up examination at 5 and 3 years postoperatively, they remained pain free and fully involved in college soccer, making excision of a naviculocuneiform coalition with arthrodiastasis a valid treatment in the young athletic population.
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http://dx.doi.org/10.1053/j.jfas.2015.09.001DOI Listing
August 2017

Current evidence of extracorporeal shock wave therapy in chronic Achilles tendinopathy.

Int J Surg 2015 Dec 29;24(Pt B):154-9. Epub 2015 Aug 29.

Technical University of Munich, Dept. Orthopedics and Traumatology, Ismaninger Straße 22, D-81675 Munich, Germany.

Chronic Achilles tendinopathy has been described as the most common overuse injury in sports medicine. Several treatment modalities such as activity modification, heel lifts, arch supports, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading are known as standard treatment mostly without proven evidence. After failed conservative therapy, invasive treatment may be considered. Extracorporeal shock wave therapy (ESWT) has been successfully used in soft-tissue pathologies like lateral epicondylitis, plantar fasciitis, tendinopathy of the shoulder and also in bone and skin disorders. Conclusive evidence recommending ESWT as a treatment for Achilles tendinopathy is still lacking. In plantar fasciitis as well as in calcific shoulder tendinopathy shock wave therapy is recently the best evaluated treatment option. This article analysis the evidence based literature of ESWT in chronic Achilles tendinopathy. Recently published data have shown the efficacy of focused and radial extracorporeal shock wave therapy.
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http://dx.doi.org/10.1016/j.ijsu.2015.07.718DOI Listing
December 2015

Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study.

J Bone Joint Surg Am 2015 May;97(9):701-8

Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Schleswig Holstein, Arnold Heller Strasse, 24105 Kiel, Germany.

Background: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis.

Methods: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline.

Results: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed.

Conclusions: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.M.01331DOI Listing
May 2015

Fifth metatarsal fractures.

Foot Ankle Spec 2014 Apr 26;7(2):127-34. Epub 2014 Feb 26.

Orthopedic Foot and Ankle Center, Fellowship Director, Westerville, OH.

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http://dx.doi.org/10.1177/1938640014524399DOI Listing
April 2014

DPM foot and ankle fellowships.

Foot Ankle Spec 2013 Oct 22;6(5):356-63. Epub 2013 Aug 22.

Past Fellow, Advanced Foot and Ankle Fellowship, Orthopedic Foot and Ankle Center, Columbus, OH.

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http://dx.doi.org/10.1177/1938640013500767DOI Listing
October 2013

Vibration and pressure wave therapy for calf strains: a proposed treatment.

Muscles Ligaments Tendons J 2013 Apr 9;3(2):60-2. Epub 2013 Jul 9.

Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.

Calf (lower leg) strains have a variety of treatment regimens with variable outcomes and return to activity (RTA) time frames. These injuries involve disruption of portions or the entire gastrocnemius-soleus myo-tendinous complex. Conservative treatment initially consists of rest, ice, compression, elevation (RICE). Immediately following calf injury, patients can utilize cryotherapy, massage, passive range of motion, and progressive exercise. In general, Grade I through Grade III calf strains can take up to 6 weeks before the athlete can return to training. It can also involve the loss of more than 50% of muscle integrity. Recently, vibration therapy and radial pressure waves have been utilized to treat muscular strains and other myo-tendinous injuries that involve trigger points. Studies have suggested vibration therapy with rehabilitation can increase muscle strength and flexibility in patients. Segmental vibration therapy (SVT) is treatment to a more focal area. Vibration therapy (VT) is applied directly to the area of injury. VT is a mechanical stimulus that is thought to stimulate the sensory receptors, as well as decrease inflammatory cells and receptors. Therefore, VT could be a valuable tool in treating athlete effectively and decreasing their recovery time. The purpose of this paper is to give the reader baseline knowledge of VT and propose a treatment protocol for calf strains using this technology along with radial pressure waves.
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http://dx.doi.org/10.11138/mltj/2013.3.2.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711703PMC
April 2013