Publications by authors named "Eric Giza"

69 Publications

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

J ISAKOS 2022 Apr 13. Epub 2022 Apr 13.

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

Results: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

Conclusions: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.
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http://dx.doi.org/10.1016/j.jisako.2022.04.001DOI Listing
April 2022

Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

J ISAKOS 2022 04 14;7(2):62-66. Epub 2022 Jan 14.

Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%.

Results: A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT.

Conclusions: This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.
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http://dx.doi.org/10.1016/j.jisako.2021.12.001DOI Listing
April 2022

Incidence of Injury for Professional Soccer Players in the United States: A 6-Year Prospective Study of Major League Soccer.

Orthop J Sports Med 2022 Mar 24;10(3):23259671211055136. Epub 2022 Mar 24.

Department of Orthopaedics, University of California-Davis, Davis, California, USA.

Background: Despite an abundance of injury research focusing on European professional soccer athletes, there are limited injury data on professional soccer players in the United States.

Purpose: To describe the epidemiology of injury across multiple years in Major League Soccer (MLS) players.

Study Design: Descriptive epidemiology study.

Methods: A web-based health management platform was used to prospectively collect injury data from all MLS teams between 2014 and 2019. An injury was defined as an incident that required medical attention and was recorded into the health management platform anytime over the course of the 2014-2019 seasons. Injuries and exposure data were recorded in training and match settings to calculate injury incidence.

Results: A total of 9713 injuries were recorded between 2014 and 2019. A mean 1.1 injuries per year per player were identified, with midfielders sustaining the largest number of injuries. The most common injuries were hamstring strains (12.3%), ankle sprains (8.5%), and adductor strains (7.6%). The mean time missed per injury was 15.8 days, with 44.2% of injuries resulting in no days missed. Overall injury incidence was 8.7 per 1000 hours of exposure, declining over the course of the investigation, with a 4.1-times greater mean incidence during matches (14.0/1000 h) than training (3.4/1000 h).

Conclusion: Between 2014 and 2019, the most commonly reported injuries in MLS players were hamstring strains, ankle sprains, and adductor strains. Injury incidence during matches was 4.1 times greater when compared with training, while overall injury incidence was found to decline during the course of the study period.
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http://dx.doi.org/10.1177/23259671211055136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8961375PMC
March 2022

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

Foot Ankle Int 2022 03 5;43(3):448-452. Epub 2022 Jan 5.

Background: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

Results: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

Conclusion: These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

Level Of Evidence: Level V, mechanism-based reasoning.
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http://dx.doi.org/10.1177/10711007211049169DOI Listing
March 2022

Surgical Treatment for Osteochondral Lesions of the Talus.

Arthroscopy 2021 12;37(12):3393-3396

Department of Orthopaedics, University of California, Davis, Sacramento, California, U.S.A.

Osteochondral lesions of the talus (OLT) are often associated with ankle pain and dysfunction. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Chronic ankle ligament instability and subsequent microtrauma may lead to insidious development of an OLT. Medial-sided lesions are more common (67%) than lateral-sided lesions. For acute lesions that are nondisplaced, nonoperative management is initially performed, with a 4-6 week period of immobilization and protected weight bearing. Symptomatic improvement results in more than 50% of patients by 3 months. Acute osteochondral talus fractures, which have a bone fragment thickness greater than 3 mm with displacement will benefit from early surgical intervention. These injuries should undergo primary repair via internal fixation with bioabsorbable compression screws 3.0 mm or smaller using at least 2 points of fixation. Acute lesions that are too small for fixation can be treated with morselization and reimplantation of the cartilage fragments. If OLTs are persistently symptomatic following an appropriate course of nonoperative treatment, various reparative and restorative surgical options may be considered on the basis of diameter, surface area, depth, and location of the lesion. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. Cancellous bone graft augmentation may be used for subchondral cysts with volume greater than 100 mm or with those with a depth of more than 10 mm. Debridement, curettage, and bone marrow stimulation is a reparative technique that may be considered in lesions demonstrating a diameter less than 10 mm, with surface area less than 100 mm, and a depth less than 5 mm. This technique is commonly performed arthroscopically using curettes and an arthroscopic shaver to remove surrounding unstable cartilage. A microfracture awl of 1 mm or less is used to puncture the subchondral bone with 3-4 mm of spacing between to induce punctate bleeding. Initial (<5 year) results are good to excellent in 80% of cases, with some deterioration of improvement over time. Factors contributing to poor results include surface area greater than 1.5 cm, overall osteochondral lesion depth over 7.8 mm, smoking history, age over 40, and uncontained lesions. Lesions greater than 1.29 cm, cystic lesions, and lesions that have failed prior treatment are potential candidates for osteochondral autograft transplantation. The autograft is typically harvested from the lateral femoral condyle of the ipsilateral knee with an optimal plug depth and diameter of 12-15 mm. Transplantation often involves open technique and may even require malleolar osteotomy for perpendicular access to the defect, as well as visualization of a flush, congruent graft fit. Good to excellent outcomes have been reported in up 87.4% of cases with the most common complication being donor site morbidity in up to 15% of cases. Failure rates increased significantly in lesions larger than 225 mm. Scaffold-based therapies, such as matrix-associated chondrocyte implantation, can be employed in primary or revision settings in lesions larger than 1 cm, including uncontained shoulder lesions with or without cysts. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. This technique requires an initial procedure for chondrocyte harvest and a secondary procedure for transplantation of the scaffold. Outcomes have been good to excellent in up to 93% of cases; however, this technique requires a two-stage procedure and can be cost-prohibitive. Particulated juvenile cartilage is a restorative technique that employs cartilage allograft from juvenile donors. The cartilage is placed into the defect and secured with fibrin glue in a single-stage procedure. Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. This may be an alternative option for contained lesions between 10 and 15 mm in diameter. Osteochondral allograft plugs are an option for larger contained lesions (>1.5 cm in diameter) and in patients with knee osteoarthritis (OA) and concern for donor site morbidity. Furthermore, bulk osteochondral allograft from a size-matched talus can also be used for even larger, unstable/uncontained shoulder lesions. An anterior approach is often employed and fixation is achieved via placement of countersunk headless compression screws. Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis.
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http://dx.doi.org/10.1016/j.arthro.2021.10.002DOI Listing
December 2021

Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes.

Am J Sports Med 2021 09 6;49(11):3014-3020. Epub 2021 Aug 6.

University of California, Davis, Sacramento, California, USA.

Background: Sports-related fractures of the fifth metatarsal are common in professional athletes. Data regarding outcomes of surgical management including refracture, complications, and return-to-play statistics are available for other professional American sports with a notable exception of soccer.

Purpose: To quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) athletes, to compare outcomes as well as refracture and complication rates with other professional sports, to analyze factors that may contribute to treatment failure, and to report on return-to-play characteristics for affected players.

Study Design: Case series; Level of evidence, 4.

Methods: We searched all injuries in the prospectively collected HealtheAthlete database for MLS for operative fifth metatarsal fractures for seasons 2013 to 2017. Additional information regarding each fracture including demographics, treatment, postoperative course, and return-to-play statistics were compiled from HealtheAthlete and supplemented by teams' chief medical officers, coaches, trainers, and online sources.

Results: There were 21 fractures in 18 players during the study period. Mean time to radiographic healing was 8.5 weeks (n = 17). Mean time to return to play was 11.1 weeks (n = 19). Of 21 fractures, 20 (95%) players returned to sport. Of 18 players, 4 (22.2%) experienced refracture. Of 18 players, 5 (27.8%) and 2 (11.1%) reported previous stress injuries on the contralateral and ipsilateral limb, respectively. Player performance characteristics showed small declines in the first year of return that improved by the second year.

Conclusion: MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts.
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http://dx.doi.org/10.1177/03635465211030279DOI Listing
September 2021

Malignant neoplasms originating from the bones of the foot: Predilection of hematological malignancies and sex-related and ethnic disparities in amputation.

J Surg Oncol 2021 Dec 5;124(8):1468-1476. Epub 2021 Aug 5.

Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA.

Purpose: Neoplasms originating from the "small bones of the lower limb and the overlapping joints" are rare but portend a serious prognosis. Current study utilizes a population-based registry in the United States to characterize the malignancies of the foot.

Methods: National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 514 patients in the Uited States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival. Chi square test was used to assess the correlation.

Results: Hematological malignancies constituted 14.8% of the entire cohort. Incidence of the foot neoplasms was 0.024 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific-5-year survival for the entire cohort was 73%. On multivariate analysis younger age groups, "localized" stage and extent of surgical resection were predictors of improved outcomes. A significant correlation was found between amputation with male sex and Hispanic ethnicity.

Conclusions: The current study analyzes data from population-based registry reporting incidence and survival data for patients with neoplasms of the foot. Independent prognostic factors include age, stage and extent of surgical resection. Amputation was found to be associated with male sex and Hispanic ethnicity.
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http://dx.doi.org/10.1002/jso.26633DOI Listing
December 2021

Editorial Commentary: Drill and Fill: Bone Marrow Stimulation Plus Allograft Matrix May Optimize the Treatment of Osteochondral Lesions of the Talus.

Arthroscopy 2021 07;37(7):2270-2271

UC Davis Medical Center.

Osteochondral lesions of the talus remain a challenging pathologic entity facing orthopaedic foot and ankle surgeons. Although multiple treatment options exist, there is limited evidence supporting one technique over another. The ultimate goal of surgical intervention is to achieve lesion infill with tissue properties that best mimic those of hyaline articular cartilage. Restoring the anatomic surface of the talus may provide long-term clinical success and improve function. Augmentation of bone marrow stimulation with extracellular matrix cartilage allograft aims to achieve this goal.
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http://dx.doi.org/10.1016/j.arthro.2021.04.046DOI Listing
July 2021

Augmented Spring Ligament Repair in Pes Planovalgus Reconstruction.

J Foot Ankle Surg 2021 Nov-Dec;60(6):1212-1216. Epub 2021 Jun 2.

Associate Professor, Department of Orthopaedic Surgery, The University of Tennessee Erlanger Health System, Chattanooga, TN.

Patients with pes planovalgus deformity often have coexisting spring ligament pathology. A primary repair of the ligament may fail during weightbearing due to chronic degeneration of the ligamentous tissue. Augmentation with a suture tape has been suggested to strengthen the repair. Limited data exist regarding flatfoot reconstruction with augmented spring ligament repair using a suture tape. This is a review of 57 consecutive patients who had flatfoot reconstruction with concomitant spring ligament augmented repair between July 2014 and August 2017. Weightbearing radiographic parameters were obtained preoperatively and compared to radiographs at an average time of 62 ± 46.5 (range 20-220) weeks postoperative. Significant improvements were seen in the radiographic parameters evaluated. Five patients had subsequent operations including one deep infection, 2 hardware removals remote to the spring ligament augmentation, 1 ankle arthrodesis, and 1 triple arthrodesis. Concomitant spring ligament repair augmented with a suture tape was a safe procedure that contributed to radiographic correction in a consecutive series of 57 patients undergoing flatfoot deformity correction.
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http://dx.doi.org/10.1053/j.jfas.2021.05.010DOI Listing
November 2021

Acute foot and ankle injuries and time return to sport.

SICOT J 2021 15;7:27. Epub 2021 Apr 15.

Consultant Foot and Ankle Orthopedic Surgeon, Dr. Nasef OrthoClinic Medical Center, 11617 Cairo, Egypt.

Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete's sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.
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http://dx.doi.org/10.1051/sicotj/2021024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051311PMC
April 2021

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability.

Foot Ankle Int 2020 Oct 11;41(10):1307-1315. Epub 2020 Sep 11.

Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA.

Syndesmotic instability is a source of significant pain and disability. Both subtle instability and gross diastasis, whether acute or chronic, require stabilization and may benefit from reconstruction with ligamentous augmentation. The use of nonabsorbable suture-tape has emerged as a promising operative strategy, allowing surgeons to anatomically reconstruct the syndesmosis, in particular the anterior inferior tibiofibular ligament. The current work provides a detailed description of the technique and preliminary results of a patient cohort treated using nonabsorbable suture-tape for syndesmotic augmentation. Level V, expert opinion.
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http://dx.doi.org/10.1177/1071100720951172DOI Listing
October 2020

Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery.

Foot Ankle Int 2020 Dec 7;41(12):1466-1473. Epub 2020 Aug 7.

Department of Orthopaedic Surgery, University of California at Davis, Sacramento, CA, USA.

Background: There is controversy regarding the effectiveness of postoperative antibiotics to prevent wound infection. Some surgeons still use a routine postoperative oral antibiotic regimen. The purpose of this study was to review a series of cases and document statistically any difference in infection rates and whether routine postoperative antibiotics in foot and ankle surgery are justified.

Methods: A retrospective chart review of 649 patients was performed who underwent elective foot and ankle surgery. Six hundred thirty-one patient charts were included in the final analysis. Evaluated were patients who did and did not receive postoperative oral antibiotics in order to identify whether a difference in infection rate or wound healing occurred. The study also evaluated risk factors for developing infection following foot and ankle surgery.

Results: The number of infections in patients receiving postoperative oral antibiotics was 6 (3%), while the number of infections in those who did not receive postoperative oral antibiotics was 10 (2%) ( = .597). The difference of deep versus superficial infections and delays in wound healing between the 2 groups was not statistically significant. Patients who developed infections were older and had a higher prevalence of hypertension, a history of neoplasm, and a greater American Society of Anesthesiologists Classification of Physical Health.

Conclusion: This study suggests that routine use of postoperative antibiotics in foot and ankle surgery does not affect wound complications or infection rates. Additionally, patients who are older and those with multiple medical problems may be at higher risk for developing postoperative infection following foot and ankle surgeries.

Level Of Evidence: Level III, retrospective comparative series.
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http://dx.doi.org/10.1177/1071100720946742DOI Listing
December 2020

Comparison of Suture-Augmented Ligamentplasty to Transarticular Screws in a Lisfranc Cadaveric Model.

Foot Ankle Int 2020 06 1;41(6):735-743. Epub 2020 Mar 1.

Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago Metropolitan Region (RM), Chile.

Background: Lisfranc injuries represent a spectrum of trauma from high-energy lesions, with significant instability of the midfoot, to low-energy lesions, with subtle subluxations or instability without gross displacement. Recently, treatment options that allow for physiologic fixation of this multiplanar joint are being evaluated. The purpose of this study was to analyze the stability of a cadaveric Lisfranc injury model fixed with a novel suture-augmented neoligamentplasty in comparison with a traditional transarticular screw fixation construct.

Methods: Twenty-four fresh-frozen, matched cadaveric leg and foot specimens (12 individuals younger than 65 years of age) were used for this study. Two different types of Lisfranc ligament injuries were tested: partial and complete. Two different methods of fixation were compared: transarticular screws and augmented suture ligamentplasty with FiberTape. Specimens were fixed to a rotation platform in order to stress the joints while applying 400 N of axial load and internal and external rotation. Six distances were measured and compared between the intact, injured, and fixed states with a 3D Digitizer arm, in order to evaluate the stability between them. Analysis of variance was used with < .05 considered significant.

Results: Using distribution graphs and analyzing the grouped data, it was observed that there was no difference between the 2 stabilization methods, but the augmented suture ligamentplasty presented lower variability and observed distance shortenings were more likely to be around the mean. The variability of the stabilization with screws was 2.9 times higher than that with tape ( < .001).

Conclusion: We suggest that augmented suture ligamentplasty can achieve similar stability to classic transarticular screws, with less variability.

Clinical Relevance: This cadaveric study adds new information on the debate about Lisfranc lesions treatment. Flexible fixations, such as the synthethic ligamentplasty used, can restore good stability such as conventional transarticular screws.
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http://dx.doi.org/10.1177/1071100720907878DOI Listing
June 2020

Arthroscopic Anatomic Anterior Talofibular Ligament Repair for Anterolateral Ankle Instability.

Arthrosc Tech 2020 Jan 18;9(1):e29-e33. Epub 2019 Dec 18.

ORTIM Orthopaedic Clinic, Bialystok, Poland, U.S.A.

Ankle instability is due to repetitive inversion injuries and is usually treated conservatively; however, after repeated sprains, chronic instability occurs and usually requires a surgical procedure. Recently, arthroscopic repair of a torn anterior talofibular ligament (ATFL) has become more popular owing to its minimal invasiveness and high efficacy. An all-inside technique allows for anatomic restoration of the injured ATFL, provides stability to the ankle joint, prevents a limitation of ankle range of motion, and may prevent arthritic development. We present an all-inside arthroscopic ATFL repair technique.
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http://dx.doi.org/10.1016/j.eats.2019.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993110PMC
January 2020

InternalBrace has biomechanical properties comparable to suture button but less rigid than screw in ligamentous lisfranc model.

J Orthop 2020 Jan-Feb;17:7-12. Epub 2019 Jun 18.

Department of Orthopaedic Surgery, University of California Davis, 48600 Y St, Suite 3800, CA, 95817, USA.

Purpose: The aim of this study was to investigate the biomechanical properties of the InternalBrace for lisfranc injuries.

Methods: A Sawbone model was developed comparing screw, suture button and InternalBrace.

Results: When loaded in axial tension at 0.5 mm/s, the screw was stiffest (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Cyclic loading with 10,000 cycles of 69 N, 138 N, and 207 N showed the InternalBrace maintained stiffness, but fatigued earlier than the suture button.

Conclusion: The mechanical properties of the InternalBrace support clinical use, but further studies are needed regarding early weight bearing.
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http://dx.doi.org/10.1016/j.jor.2019.06.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919361PMC
June 2019

Flexible Fixation Technique for Lisfranc Injuries.

Foot Ankle Int 2019 Nov 30;40(11):1338-1345. Epub 2019 Aug 30.

Department of Orthopedics, University of California, Davis, Sacramento, CA, USA.

Injuries to the Lisfranc complex range from purely ligamentous disruptions to fracture-dislocations of the tarsometatarsal joint. Treatment options include closed/open reduction with percutaneous pinning, open reduction and internal fixation (ORIF), and primary arthrodesis. We present a ligament reinforcement technique utilizing a flexible fixation device for the treatment of ligamentous Lisfranc injuries. Level V, expert opinion.
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http://dx.doi.org/10.1177/1071100719873271DOI Listing
November 2019

Tarsal Tunnel Syndrome Secondary to Accessory Musculature: A Case Report.

Foot Ankle Spec 2019 Dec 13;12(6):549-554. Epub 2019 Aug 13.

St Luke's Department of Orthopaedic Surgery, Boise, Idaho (KCN).

Tarsal tunnel syndrome (TTS) is a relatively uncommon compression neuropathy caused by impingement of the tibial nerve or one of the terminal branches. The presence of accessory musculature at the posteromedial aspect of the ankle has been identified as a rare cause of this condition. Despite the rarity of this condition, it must be considered in patients with refractory symptoms consistent with tibial nerve dysfunction. The accurate diagnosis of this condition relies heavily on a detailed history and physical examination, adequate imaging read by both surgeon and trained musculoskeletal radiologist, as well as a high level of suspicion for such pathology. In this case report, we describe a 46-year-old male with history, examination, and imaging all consistent with TTS secondary to accessory musculature. Following excision of an accessory soleus and flexor digitorum accessorius longus, as well as simultaneous tarsal tunnel release, the patient experienced full resolution of his symptoms. This highlights the importance of considering accessory musculature as a potential cause of TTS in patients presenting with tibial compression neuropathy. Level V: Case Report.
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http://dx.doi.org/10.1177/1938640019863277DOI Listing
December 2019

Subchondroplasty of the Ankle and Hindfoot for Treatment of Osteochondral Lesions and Stress Fractures: Initial Imaging Experience.

Foot Ankle Spec 2020 Aug 17;13(4):306-314. Epub 2019 Jul 17.

Department of Radiology, University of California Davis School of Medicine, Sacramento, California (GDM, LBS, RDB).

To describe the imaging findings of patients treated with subchondroplasty (SCP) of the ankle and hindfoot. Eighteen patients (10 men, 8 women; age mean 43.1 years [range 20.1-67.7 years]) underwent ankle and hindfoot SCP at a single center over a 14-month period. Imaging data were reviewed retrospectively by 2 radiologists by consensus interpretation, including preoperative radiography (18), computed tomography (CT) (11), and magnetic resonance imaging (MRI) (13) and postoperative radiography (10), CT (4), and MRI (6). Follow-up imaging was acquired 1 month to 1.6 years following SCP. Indications for SCP included symptomatic bone marrow lesions (BMLs) secondary to an osteochondral lesion (OCL) (16/18) or stress fracture (2/18). While focal radiodensity related to the SCP procedure was retrospectively identifiable on postoperative radiography in all except 1 case (10/11), postprocedural findings were not described by the interpreting radiologist in 6/11 cases. On CT, the average injected synthetic calcium phosphate (CaP) volume was 1.15 cm (SD = 0.33 cm); mean CT attenuation of the injectate was 1220 HU (range 1058-1465 HU). In all patients who had pre- and postoperative MRI (5/18), BML size decreased on follow-up MRI. Extra-osseous extrusion of CaP was not seen on postoperative radiography, CT, or MRI. Physicians should be aware of the expanding preoperative indications and postoperative imaging findings of SCP, which is being performed with increasing frequency in the ankle and hindfoot. Diagnostic, Level III: Retrospective cohort study.
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http://dx.doi.org/10.1177/1938640019863252DOI Listing
August 2020

Injury Surveillance in Major League Soccer: A 4-Year Comparison of Injury on Natural Grass Versus Artificial Turf Field.

Am J Sports Med 2019 08 15;47(10):2279-2286. Epub 2019 Jul 15.

Investigation performed at Kerlan Jobe Institute, Santa Monica, California, USA.

Background: Artificial playing surfaces are becoming more common due to decreased cost of maintenance and increased field usability across different environmental conditions. The Fédération Internationale de Football Association (FIFA) has approved newer generation artificial turf for soccer competition at the elite level, but many elite-level athletes prefer to play on natural grass surfaces due to a perceived increase in injury rate, discomfort, and fatigability on artificial turf.

Hypothesis: Injury rates and rates of individually categorized types of injury experienced on artificial turf are noninferior to rates of injury on the standard comparator, natural grass, in elite-level Major League Soccer athletes.

Study Design: Cohort study; Level of evidence, 2.

Methods: Over the course of 4 Major League Soccer seasons (2013-2016), athlete injury data were recorded electronically. Injury data recorded in matches between 2 Major League Soccer teams were then analyzed. Playing surface was known for each venue, and all artificial turf surfaces were rated as 2-star according to FIFA criteria. Incidence rate ratios (Artificial Turf ÷ Natural Grass) were calculated with a 95% CI (α = .05) for both overall injury incidence and individual injury subgroups. A noninferiority margin (δ) of 0.15 was used to determine noninferiority of injury incidence rates.

Results: A total of 2174 in-game injuries were recorded during the study period, with 1.54 injuries per game on artificial turf and 1.49 injuries per game on natural grass (incidence rate ratio, 1.033; 95% CI, 0.937-1.139). Within injury subgroups, overall ankle injury, Achilles injury, and ankle fracture were found to have a statistically higher incidence on artificial turf. Artificial turf was found to be noninferior to natural grass for overall foot injury and forefoot injury. No statistically significant differences were found in knee injuries between the 2 surfaces.

Conclusion: The overall rate of injury on artificial turf was noninferior to that on natural grass. Within individual injury categories, a higher rate of ankle injury was found on artificial turf. No other injury subgroup demonstrated statistically significant differences between surfaces.

Clinical Relevance: FIFA 2-star rated artificial turf is a viable alternative to natural grass in elite-level soccer competition. Innovative research methods for comparing artificial turf versus natural grass may elucidate relative advantages with respect to player safety.
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http://dx.doi.org/10.1177/0363546519860522DOI Listing
August 2019

Lateral Ankle Sprain and Chronic Ankle Instability.

Foot Ankle Orthop 2019 Apr 13;4(2):2473011419846938. Epub 2019 Jun 13.

Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA.

A select 10-30% of patients with recurrent lateral ankle sprains develop chronic ankle instability (CAI). Patients with chronic ankle instability describe a history of the ankle "giving way" with or without pathological laxity on examination. Evaluation includes history, identification of predisposing risk factors for recurrent sprains, and the combination of clinical tests (eg, laxity tests) with imaging to establish the diagnosis. There are a variety of nonoperative strategies to address chronic ankle instability, which include rehabilitation and taping or bracing to prevent future sprains. Patients who fail conservative treatment are candidates for surgery. The anatomic approaches (eg, modified Broström) are preferred to nonanatomic procedures since they recreate the ankle's biomechanics and natural course of the attenuated ligaments. There is a growing interest in minimally invasive procedures via ankle arthroscopy that also address the associated intra-articular disorders. This article provides a review of chronic lateral ankle instability consisting of relevant anatomy, associated disorders, evaluation, treatment methods, and complications.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1177/2473011419846938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8696766PMC
April 2019

Use of Anatomical Landmarks in Ankle Arthroscopy to Determine Accuracy of Syndesmotic Reduction: A Cadaveric Study.

Foot Ankle Spec 2020 Jun 21;13(3):219-227. Epub 2019 May 21.

Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).

The aim of this study was to determine the accuracy of ankle arthroscopy as a means for diagnosing syndesmotic reduction or malreduction and to determine anatomical landmarks for diagnosis. Six matched-pair cadavers (n = 12) with through-knee amputations were studied. Component parts of the syndesmosis and distal 10 cm of the interosseous membrane (IOM) were sectioned in each. The 12 specimens were divided into 2 groups: 6 specimens in the in-situ group fixed with suture button technique and 6 specimens in the malreduced group rigidly held with a 3.5-mm screw. Specimens were randomized to undergo diagnostic arthroscopy by 3 fellowship-trained foot and ankle orthopaedic surgeons in a blinded fashion. Surgeons were asked to determine if the syndesmosis was reduced or malreduced and provide arthroscopic measurements of their findings. Of 36 arthroscopic evaluations, 34 (94%) were correctly diagnosed. Arthroscopic measurement of 3.5 mm diastasis or greater at the anterior aspect of the distal tibiofibular syndesmosis correlated with a posteriorly malreduced fibula. Arthroscopic evaluation of the Anterior inferior tibiofibular ligament (AITFL), IOM, Posterior inferior tibiofibular ligament (PITFL), lateral fibular gutter, and the tibia/fibula relationship were found to be reliable landmarks in determining syndesmotic reduction. An intraclass correlation coefficient (ICC) for interrater reliability of 1.00 was determined for each of these landmarks between 2 surgeons (P < .001). The ICCs between 2 surgeons' measurements and the computed tomography measurements were found to be 0.896 (P value < .001). Ankle arthroscopy is a reliable method to assess syndesmotic relationship when reduced in situ or posteriorly malreduced 10 mm. Level V: Cadaveric.
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http://dx.doi.org/10.1177/1938640019846972DOI Listing
June 2020

Knotless Modified Arthroscopic-Broström Technique for Ankle Instability.

Foot Ankle Int 2019 Apr 11;40(4):475-483. Epub 2019 Jan 11.

1 Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santiago, Chile.

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors' modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot-related complications. Level of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1177/1071100718820341DOI Listing
April 2019

Foot and Ankle Injuries in Soccer.

Am J Orthop (Belle Mead NJ) 2018 Oct;47(10)

University of California, Davis, Department of Orthopaedics, 3301 C St, Ste 1700, Sacramento, CA 95816, USA. Email:

The ankle is one of the most commonly injured joints in soccer and represents a significant cost to the healthcare system. The ligaments that stabilize the ankle joint determine its biomechanics-alterations of which result from various soccer-related injuries. Acute sprains are among the most common injury in soccer players and are generally treated conservatively, with emphasis placed on secondary prevention to reduce the risk for future sprains and progression to chronic ankle instability. Repetitive ankle injuries in soccer players may cause chronic ankle instability, which includes both mechanical ligamentous laxity and functional changes. Chronic ankle pathology often requires surgery to repair ligamentous damage and remove soft-tissue or osseous impingement. Proper initial treatment, rehabilitation, and secondary prevention of ankle injuries can limit the amount of time lost from play and avoid negative long-term sequelae (eg, osteochondral lesions, arthritis). On the other hand, high ankle sprains portend a poorer prognosis and a longer recovery. These injuries will typically require surgical stabilization. Impingement-like syndromes of the ankle can undergo an initial trial of conservative treatment; when this fails, however, soccer players respond favorably to arthroscopic debridement of the lesions causing impingement. Finally, other pathologies (eg, stress fractures) are highly encouraged to be treated with surgical stabilization in elite soccer players.
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http://dx.doi.org/10.12788/ajo.2018.0096DOI Listing
October 2018

The Influence of Percentage Weight-Bearing on Foot Radiographs.

Foot Ankle Spec 2019 Aug 31;12(4):363-369. Epub 2018 Oct 31.

Department of Orthopaedics (TJS, CDK, EG), University of California, Davis, Sacramento, California.

Clinical decisions are often made on weight-bearing radiographs. However, it is unknown whether various weight-bearing conditions alter specific radiographic measurements. The purpose of this study was to determine whether percentage weight-bearing influences radiographic measurements of the normal foot. A prospective study with 20 healthy individuals had radiographs of the foot under 5 weight-bearing conditions (non-weight-bearing, 10% body weight, 25% body weight, 50% body weight, and 100% body weight). Measurements were made of hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), talonavicular coverage angle (TNCA), talocalcaneal angle (TCA), forefoot width, LisFranc distance, cuboid height to ground (CHG), and talo-first metatarsal angle (TMA) of each weight-bearing condition. Statistical differences of each measurement for each weight-bearing condition were determined. The TNCA and TCA increased significantly, whereas the CHG decreased significantly with increased percentage body weight. There were no differences in HVA, IMA, forefoot width, LisFranc distance, and TMA with increased percentage body weight. This study shows an increase in TNCA and TCA, and decrease in CHG, demonstrating a flattening of the medial arch, increasing hindfoot valgus, and midfoot external rotation and abduction with increasing percentage body weight applied to a foot. Percentage weight-bearing does not change radiographs in the foot between 25% and 100% weight-bearing. The clinical relevance of this finding is that graduated postinjury or postoperative weight-bearing regimens may only be relevant if the patient is either less than or greater than 25% of body weight on their extremity. Case Series, Level IV: Prospective.
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http://dx.doi.org/10.1177/1938640018810412DOI Listing
August 2019

Conservative Management and Biological Treatment Strategies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

Foot Ankle Int 2018 07;39(1_suppl):9S-15S

1 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Conservative Management and Biological Treatment Strategies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

Results: A total of 12 statements on Conservative Management and Biological Treatment Strategies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Ten statements reached strong consensus (greater than 75% agreement), and 2 achieved consensus.

Conclusions: This international consensus derived from leaders in the field will assist clinicians with conservative management and biological treatment strategies for osteochondral lesions of the talus.
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http://dx.doi.org/10.1177/1071100718779390DOI Listing
July 2018

Effects of Micronized Cartilage Matrix on Cartilage Repair in Osteochondral Lesions of the Talus.

Cartilage 2020 07 29;11(3):316-322. Epub 2018 Aug 29.

Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA.

Background: The repair of osteochondral lesions remains a challenge due to its poor vascularity and limited healing potential. Micronized cartilage matrix (MCM) is dehydrated, decellularized, micronized allogeneic cartilage matrix that contains the components of native articular tissue and is hypothesized to serve as a scaffold for the formation of hyaline-like tissue. Our objective was to demonstrate that the use of MCM combined with mesenchymal stem cells (MSCs) can lead to the formation of hyaline-like cartilage tissue in a single-stage treatment model.

Design: In group 1 (no wash), 250 µL MCM was reconstituted in 150 µL Dulbecco's phosphate-buffered saline (DPBS) for 5 minutes. Group 2 (saline wash) included 250 µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated to remove all DPBS and reconstituted in 150 µL DPBS. Group 3 (serum wash): 250µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated and reconstituted in 150 µL fetal bovine serum. Each group was then added to 50 µL solution of MSC suspended in DPBS at a concentration of 1.2 × 10 cells/350 µL. After 3 weeks, the defects were extracted and sectioned to perform viability and histologic analyses.

Results: Stem cells without rehydration of the MCM showed almost no viability whereas near complete cell viability was seen after rehydration with serum or saline solution, ultimately leading to chondrogenic differentiation and adhesion to the MCM particles.

Conclusion: We have shown in this proof-of-concept study that MCM can serve as a scaffold for the growth of cartilage tissue for the treatment of osteochondral lesions.
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http://dx.doi.org/10.1177/1947603518796125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298590PMC
July 2020

Particulated Autograft Cartilage Implantation for the Treatment of Osteochondral Lesions of the Talus: A Novel Technique.

Foot Ankle Spec 2018 Aug 22;11(4):365-371. Epub 2018 Apr 22.

Department of Orthopaedics, University of California Davis, Sacramento, California (CD, JW, CK, EG).

Osteochondral lesions of the talus often occur following ankle sprains and fractures. Operative intervention is typically required because of the diminished intrinsic repair capability of talar articular cartilage. Several techniques have evolved that emphasize replacing the defect with cartilage that closely mimics the biological properties of hyaline articular cartilage. The goals of operative treatment are resolution of symptoms, physiologic healing, and restoration of function while eliminating the need for further intervention. This article describes a novel, single-step technique for the treatment of osteochondral lesions of the talus with the use of particulated autograft cartilage implantation.

Levels Of Evidence: Level V.
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http://dx.doi.org/10.1177/1938640018770277DOI Listing
August 2018

Osteochondral Defects of the Talus: Current Management Dilemmas.

Instr Course Lect 2018 Feb;67:283-295

Professor, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.

Osteochondral defects or lesions of the talus represent a management challenge. Arthroscopic débridement is the treatment of choice for patients with an osteochondral lesion of the talus in whom nonsurgical treatment fails. Although surgeons have a better understanding of the risk factors for failed débridement in patients with an osteochondral lesion of the talus, the treatment of patients in whom a high risk for failed débridement exists and patients in whom débridement fails is controversial. Surgeons should understand the current adjunct therapies available for the management of osteochondral lesions of the talus, including cartilage preparations, platelet-rich plasma, bone marrow aspirate, bone graft or bone graft substitutes, and whole bone cartilage transfer (osteochondral autograft transfer); however, evidence for the use of one adjunct therapy more than another is lacking.
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February 2018

Noninsertional Tendinopathy of the Achilles.

Foot Ankle Clin 2017 Dec 28;22(4):745-760. Epub 2017 Sep 28.

University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA. Electronic address:

Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.
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http://dx.doi.org/10.1016/j.fcl.2017.07.006DOI Listing
December 2017

Osteochondral Lesions of the Ankle.

Foot Ankle Spec 2017 10;10(5):455-457

Assistant Professor of Orthopaedic Surgery Foot and Ankle Fellowship Director University of Virginia Charlottesville, VA.

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http://dx.doi.org/10.1177/1938640017730166DOI Listing
October 2017
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