Background: A prospective study was conducted at a single outpatient surgery center, in order to ... more Background: A prospective study was conducted at a single outpatient surgery center, in order to evaluate the rate of foot and ankle surgical site infections (SSI), following a protocol implementation based on Surgical Care Improvement Project guidelines. Method: The study was conducted between August 2006 and December 2011 and a total of 2,854 elective, clean foot and ankle cases were included, performed by 8 surgeons. Only deep SSIs were reported, defined as: wound dehiscence, abscess formation or purulent drainage at the surgical site, regardless of culture results, involving deep soft tissue. Antibiotic prophylaxis was administered to patients undergoing foot and ankle surgery with placement or removal of hardware, diabetic, chemotherapy and immune compromised patients, Achilles tendon surgery and those with chronic renal failure. Results: There were 15 deep SSIs documented. The incidence of deep SSI was 0.53% during the 64 month study period. Conclusion: When antibiotic prophyl...
Sports Medicine and Arthroscopic Surgery of the Foot and Ankle, 2012
ABSTRACT Stress fractures of the foot and ankle can be a source of significant disability and rap... more ABSTRACT Stress fractures of the foot and ankle can be a source of significant disability and rapid deconditioning of the high-performance athlete, resulting in lost time in competitive play and training. Additionally, complications such as nonunions or delayed unions prolong the time for healing and can be a career-altering event. Certain anatomical regions in the foot and ankle are prone to fracture, delayed union and nonunion, along with re-fracture. Due to the high-demand of athletic and active patients, surgery is often recommended for specific injuries. The most well-known and notorious injuries involved are “Jones” fractures, proximal fifth metatarsal stress fractures, Navicular stress fractures; less common but equally debilating are medial malleolar stress fractures.
Plantar fasciitis is one of the more common injuries in the general population and can be debilit... more Plantar fasciitis is one of the more common injuries in the general population and can be debilitating for an athlete. In a retrospective study of 2002 running injuries, it was a found that 157 of the injuries were plantar fasciitis (7.8%) and another study found that there are more than one million patient visits per year to medical professionals.1,2 The plantar fascia is the main supporting structure of the foot and arch; it is vulnerable to injury.
Navicular stress fractures of the foot often are difficult to diagnose and treat. Nineteen athlet... more Navicular stress fractures of the foot often are difficult to diagnose and treat. Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender. Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fi...
The Journal of bone and joint surgery. American volume, Jan 6, 2015
The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is c... more 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. 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. Two hundred and forty-six patients (98.4%) were available fo...
Calf (lower leg) strains have a variety of treatment regimens with variable outcomes and return t... more 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...
Plantar fasciitis can be a chronic and debilitating condition affecting athletes of all levels. T... more Plantar fasciitis can be a chronic and debilitating condition affecting athletes of all levels. The aim of this study is to compare treatment outcomes for the treatment of chronic plantar fasciitis in athletes, comparing focused extra corporeal sound wave therapy (ESWT) and the surgical endoscopic plantar fasciotomy (EPF). A total of 37 eligible patients were enrolled in the study between May 2006 and December 2008 at a single institution. Patients were either enrolled in the surgical group, or to the ESWT group which included a placebo controlled, randomized group (P-ESWT). Pre and post Visual Analog Scores (VAS) and Roles and Maudlsey (RM) scores were recorded and compared between the three groups. The patient's return to activity (RTA) was also documented. The results showed statistical improvement within the EPF and ESWT groups with both VAS & RM scores, with EPF being significantly better than both ESWT and P-ESWT in terms of treatment outcomes. Patients enrolled in the ESW...
To educate sports medicine practitioners as to length of time for an athlete to return to activit... more To educate sports medicine practitioners as to length of time for an athlete to return to activity after sustaining a rupture of the plantar fascia. Athletic patients sustaining plantar fascia ruptures and subsequent treatment were reviewed. Diagnosis was based on clinical findings, although radiographic studies were done. Patients were treated for 2 to 3 weeks with a below-knee or high-top boot, nonweightbearing, with an additional 2 to 3 weeks of weightbearing in the boot. Patients used physical therapy. Eighteen athletes, including 6 elite athletes, were evaluated. Mean age was 40.9 +/- 13.2 years. There were 12 males and 6 females. Mean postinjury follow-up was 42 months. Duration of prior plantar fascia symptoms ranged from 0 to 52 weeks. All but 2 ruptures were of the medial portion. Four patients had injections prior to rupture. Five patients wore orthoses preinjury; 14 wore orthoses postinjury. All patients returned to activity after 2 to 26 weeks (mean, 9.1 +/- 6.0 weeks). ...
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT In 1934, Dr. Paul Lapidus described a procedure for correcting hallux valgus. It was fir... more ABSTRACT In 1934, Dr. Paul Lapidus described a procedure for correcting hallux valgus. It was first described as a fusion of the base of the first and second metatarsal and the medial cuneiform combined with distal soft tissue alignment.1 As with surgical procedures, it has been modified over the years, particularly with the advent of internal fixation. There are numerous benefits to performing the Lapidus procedure. The Lapidus procedure addresses hallux valgus at the apex of the deformity, increases the efficacy of the peroneal longus tendon, and stabilizes the medial longitudinal arch.
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT Foot and ankle surgeons routinely perform surgery of the first ray, such as correction o... more ABSTRACT Foot and ankle surgeons routinely perform surgery of the first ray, such as correction of hallux valgus deformity. The complication rate in hallux valgus surgery ranges between 10% and 55%.1 Although hallux valgus surgery is common, several common complications can occur that necessitate revision.
Journal of the American Podiatric Medical Association
A retrospective review of one surgeon's practice was conducted to assess the prevalence of wo... more A retrospective review of one surgeon's practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. A total of 219 surgical cases were available for review (140 males and 70 females; mean +/- SD age at the time of surgery, 46.5 +/- 12.6 years; age range, 16-75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after t...
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT Ankle joint equinus has been well known in the medical literature as a major deforming f... more ABSTRACT Ankle joint equinus has been well known in the medical literature as a major deforming force connected with an assortment of foot and ankle pathologies. Ankle equinus is defined as a limitation of dorsiflexion at the ankle joint.1,2 Limited ankle dorsiflexion has been defined as less than 3–15° with the knee extended.
Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the ge... more Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the general population, and most commonly diagnosed in the younger population. Coalitions between the cuboid and navicular are especially rare. In this case series, all patients were young (15-35 years of age), active patients with fibrous coalitions at the cuboid-navicular interface; 3 of the 4 patients related a past history of ankle sprains on the affected side. After conservative treatment was exhausted and a diagnostic injection was performed that eliminated the pain, surgical intervention was used that consisted of coalition resection and interposition of an adipose graft harvested from the lower leg. All patients were able to return to their previous level of activity and remain pain-free at the surgical site. Our series of 4 cases of this coalition suggests that, although rare, cuboid-navicular coalition should be included in the differential diagnosis when patients present with persistent foot pain and suspicion of tarsal coalition is high. We also demonstrate that surgical resection of this coalition with an interpositional adipose graft provides excellent results.
Stress fractures frequently occur from overtraining. When stress fractures recur, underlying meta... more Stress fractures frequently occur from overtraining. When stress fractures recur, underlying metabolic abnormalities should be ruled out. We report a middle-aged woman in whom such an evaluation demonstrated previously undiagnosed hypophosphatemic rickets after she presented with recurring stress fractures in her feet. Treatment with phosphate and calcitriol was associated with clinical improvement that would likely not have occurred without this intervention. Any patient with recurring stress fractures should be evaluated with several screening laboratory tests, metabolic bone x-rays, and a measurement of bone mineral density.
Background: A prospective study was conducted at a single outpatient surgery center, in order to ... more Background: A prospective study was conducted at a single outpatient surgery center, in order to evaluate the rate of foot and ankle surgical site infections (SSI), following a protocol implementation based on Surgical Care Improvement Project guidelines. Method: The study was conducted between August 2006 and December 2011 and a total of 2,854 elective, clean foot and ankle cases were included, performed by 8 surgeons. Only deep SSIs were reported, defined as: wound dehiscence, abscess formation or purulent drainage at the surgical site, regardless of culture results, involving deep soft tissue. Antibiotic prophylaxis was administered to patients undergoing foot and ankle surgery with placement or removal of hardware, diabetic, chemotherapy and immune compromised patients, Achilles tendon surgery and those with chronic renal failure. Results: There were 15 deep SSIs documented. The incidence of deep SSI was 0.53% during the 64 month study period. Conclusion: When antibiotic prophyl...
Sports Medicine and Arthroscopic Surgery of the Foot and Ankle, 2012
ABSTRACT Stress fractures of the foot and ankle can be a source of significant disability and rap... more ABSTRACT Stress fractures of the foot and ankle can be a source of significant disability and rapid deconditioning of the high-performance athlete, resulting in lost time in competitive play and training. Additionally, complications such as nonunions or delayed unions prolong the time for healing and can be a career-altering event. Certain anatomical regions in the foot and ankle are prone to fracture, delayed union and nonunion, along with re-fracture. Due to the high-demand of athletic and active patients, surgery is often recommended for specific injuries. The most well-known and notorious injuries involved are “Jones” fractures, proximal fifth metatarsal stress fractures, Navicular stress fractures; less common but equally debilating are medial malleolar stress fractures.
Plantar fasciitis is one of the more common injuries in the general population and can be debilit... more Plantar fasciitis is one of the more common injuries in the general population and can be debilitating for an athlete. In a retrospective study of 2002 running injuries, it was a found that 157 of the injuries were plantar fasciitis (7.8%) and another study found that there are more than one million patient visits per year to medical professionals.1,2 The plantar fascia is the main supporting structure of the foot and arch; it is vulnerable to injury.
Navicular stress fractures of the foot often are difficult to diagnose and treat. Nineteen athlet... more Navicular stress fractures of the foot often are difficult to diagnose and treat. Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender. Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fi...
The Journal of bone and joint surgery. American volume, Jan 6, 2015
The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is c... more 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. 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. Two hundred and forty-six patients (98.4%) were available fo...
Calf (lower leg) strains have a variety of treatment regimens with variable outcomes and return t... more 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...
Plantar fasciitis can be a chronic and debilitating condition affecting athletes of all levels. T... more Plantar fasciitis can be a chronic and debilitating condition affecting athletes of all levels. The aim of this study is to compare treatment outcomes for the treatment of chronic plantar fasciitis in athletes, comparing focused extra corporeal sound wave therapy (ESWT) and the surgical endoscopic plantar fasciotomy (EPF). A total of 37 eligible patients were enrolled in the study between May 2006 and December 2008 at a single institution. Patients were either enrolled in the surgical group, or to the ESWT group which included a placebo controlled, randomized group (P-ESWT). Pre and post Visual Analog Scores (VAS) and Roles and Maudlsey (RM) scores were recorded and compared between the three groups. The patient's return to activity (RTA) was also documented. The results showed statistical improvement within the EPF and ESWT groups with both VAS & RM scores, with EPF being significantly better than both ESWT and P-ESWT in terms of treatment outcomes. Patients enrolled in the ESW...
To educate sports medicine practitioners as to length of time for an athlete to return to activit... more To educate sports medicine practitioners as to length of time for an athlete to return to activity after sustaining a rupture of the plantar fascia. Athletic patients sustaining plantar fascia ruptures and subsequent treatment were reviewed. Diagnosis was based on clinical findings, although radiographic studies were done. Patients were treated for 2 to 3 weeks with a below-knee or high-top boot, nonweightbearing, with an additional 2 to 3 weeks of weightbearing in the boot. Patients used physical therapy. Eighteen athletes, including 6 elite athletes, were evaluated. Mean age was 40.9 +/- 13.2 years. There were 12 males and 6 females. Mean postinjury follow-up was 42 months. Duration of prior plantar fascia symptoms ranged from 0 to 52 weeks. All but 2 ruptures were of the medial portion. Four patients had injections prior to rupture. Five patients wore orthoses preinjury; 14 wore orthoses postinjury. All patients returned to activity after 2 to 26 weeks (mean, 9.1 +/- 6.0 weeks). ...
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT In 1934, Dr. Paul Lapidus described a procedure for correcting hallux valgus. It was fir... more ABSTRACT In 1934, Dr. Paul Lapidus described a procedure for correcting hallux valgus. It was first described as a fusion of the base of the first and second metatarsal and the medial cuneiform combined with distal soft tissue alignment.1 As with surgical procedures, it has been modified over the years, particularly with the advent of internal fixation. There are numerous benefits to performing the Lapidus procedure. The Lapidus procedure addresses hallux valgus at the apex of the deformity, increases the efficacy of the peroneal longus tendon, and stabilizes the medial longitudinal arch.
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT Foot and ankle surgeons routinely perform surgery of the first ray, such as correction o... more ABSTRACT Foot and ankle surgeons routinely perform surgery of the first ray, such as correction of hallux valgus deformity. The complication rate in hallux valgus surgery ranges between 10% and 55%.1 Although hallux valgus surgery is common, several common complications can occur that necessitate revision.
Journal of the American Podiatric Medical Association
A retrospective review of one surgeon's practice was conducted to assess the prevalence of wo... more A retrospective review of one surgeon's practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. A total of 219 surgical cases were available for review (140 males and 70 females; mean +/- SD age at the time of surgery, 46.5 +/- 12.6 years; age range, 16-75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after t...
International Advances in Foot and Ankle Surgery, 2012
ABSTRACT Ankle joint equinus has been well known in the medical literature as a major deforming f... more ABSTRACT Ankle joint equinus has been well known in the medical literature as a major deforming force connected with an assortment of foot and ankle pathologies. Ankle equinus is defined as a limitation of dorsiflexion at the ankle joint.1,2 Limited ankle dorsiflexion has been defined as less than 3–15° with the knee extended.
Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the ge... more Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the general population, and most commonly diagnosed in the younger population. Coalitions between the cuboid and navicular are especially rare. In this case series, all patients were young (15-35 years of age), active patients with fibrous coalitions at the cuboid-navicular interface; 3 of the 4 patients related a past history of ankle sprains on the affected side. After conservative treatment was exhausted and a diagnostic injection was performed that eliminated the pain, surgical intervention was used that consisted of coalition resection and interposition of an adipose graft harvested from the lower leg. All patients were able to return to their previous level of activity and remain pain-free at the surgical site. Our series of 4 cases of this coalition suggests that, although rare, cuboid-navicular coalition should be included in the differential diagnosis when patients present with persistent foot pain and suspicion of tarsal coalition is high. We also demonstrate that surgical resection of this coalition with an interpositional adipose graft provides excellent results.
Stress fractures frequently occur from overtraining. When stress fractures recur, underlying meta... more Stress fractures frequently occur from overtraining. When stress fractures recur, underlying metabolic abnormalities should be ruled out. We report a middle-aged woman in whom such an evaluation demonstrated previously undiagnosed hypophosphatemic rickets after she presented with recurring stress fractures in her feet. Treatment with phosphate and calcitriol was associated with clinical improvement that would likely not have occurred without this intervention. Any patient with recurring stress fractures should be evaluated with several screening laboratory tests, metabolic bone x-rays, and a measurement of bone mineral density.
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