Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this study was to characterize using MRI the effects of a 10-week supervised exercise program on lower extremity skeletal muscle composition, nerve microarchitecture, and metabolic function in individuals with diabetic peripheral neuropathy (DPN). RESEARCH DESIGN AND METHODS/METHODS:) and once following intervention to measure relaxation times (T1, T1ρ, and T2), phosphocreatine recovery, fat fraction, and diffusion parameters. RESULTS:and postintervention MRI metrics were: calf adipose infiltration -2.6%±6.4%, GM T1ρ -4.1%±7.7%, GM T2 -3.5%±6.4%, and gastrocnemius lateral T2 -4.6±7.4%. Insignificant changes were observed in gastrocnemius phosphocreatine recovery rate constant (p>0.3) and tibial nerve fractional anisotropy (p>0.6) and apparent diffusion coefficient (p>0.4). CONCLUSIONS:The 10-week supervised exercise intervention program successfully reduced adiposity and altered resting tissue properties in the lower leg in DPN. Gastrocnemius mitochondrial oxidative capacity and tibial nerve microarchitecture changes were not observed, either due to lack of response to therapy or to lack of measurement sensitivity.

BACKGROUND: The Internet has been reported to be the first informational resource for many fellowship applicants. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites. METHODS: The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants. RESULTS: Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range = 5% to 75%) of the total assessed content. The most commonly presented recruitment and educational content was a program description (94%) and description of fellow operative experience (83%), respectively. CONCLUSIONS: There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. CLINICAL RELEVANCE: Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online. LEVELS OF EVIDENCE: Level IV.

BACKGROUND: Numerous reconstructive techniques for midfoot collapse secondary to Charcot neuroarthropathy have been described, but few have been studied biomechanically. The purpose of this study was to biomechanically compare 2 of the most common techniques. METHODS: Seven paired below-knee specimens were amputated through the talonavicular and calcaneocuboid joints. The nonligamentous soft tissue was stripped proximal to the metatarsal heads and disarticulated through the tarsometatarsal (TMT) joints. For each paired specimen, the TMT joints were fused by plantar plating or intramedullary screw fixation for the contralateral side. The specimens were mounted, loaded, and cycled, and fixation stiffness was determined. Load versus displacement graphs were used to calculate overall construct stiffness, and data were analyzed by Student t tests. RESULTS: There was no failure of hardware. All failures were at the bone-implant interface. Failure was either by screw pull-out, bone fracture, or a combination of the two. There were no notable differences between the 2 fixation techniques with respect to stiffness or loads to failure. There was a trend toward a stiffer first TMT construct using the plantar plating method. Five of the 7 screw fixations failed by pullout of the base of the first metatarsal and the other 2 by pullout of screws from all MT bases. Seven of the 7 plantar plate fixations failed by separation of the fifth to third MT bases originating at the fifth, and 3 showed fracture of the fifth metatarsal base. CONCLUSIONS: There was no notable biomechanical difference between the 2 techniques. There was a trend toward a stiffer construct at the first TMT with plantar plating. CLINICAL RELEVANCE: This study biomechanically analyzes two common Charcot midfoot reconstruction techniques and highlights the need for further study of both techniques and combinations of these techniques.

Post-traumatic ankle arthritis can be a very disabling condition especially in young patients. Localization of the pain is important to allow appropriate treatment. Non-surgical treatment options include anti-inflammatory medications and use of bracing. Multiple surgical options range from joint sparing procedures for the younger patient to total ankle replacement for the older, less active patient. Arthrodesis remains the gold standard and is the procedure of choice for younger patients who are heavy laborers and in patients with severe arthritis who are not candidates for a total ankle replacement. Joint sparing operations include allograft resurfacing, arthroscopic debridement and osteophyte resection, joint distraction arthroplasty, and supramalleolar osteotomy. In older low demand patients, the surgeon may consider a total ankle arthroplasty as an alternative to arthrodesis.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Ankle sprain injuries are the most common injury sustained during sporting activities. Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body's center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability, resulting in chronic ankle instability. Treatment of acute ankle sprains generally can be successfully managed with a short period of immobilization that is followed by functional rehabilitation. Patients with chronic ankle instability who fail functional rehabilitation are best treated with a Brostrom-Gould anatomic repair or, in those patients with poor tissue quality or undergoing revision surgery, an anatomic reconstruction

Although ankle arthrodesis has been considered the gold standard for treatment of symptomatic end stage arthritis, recent improvements in arthroplasty designs and instrumentation have led to a resurgence in interest in ankle arthroplasty. While first generation arthroplasty systems had high failure rates due to cemented techniques or highly constrained designs, newer generations of ankle replacements have introduced more anatomic and pressfit techniques. Early results have been promising, with improved functional outcomes versus ankle arthrodesis. However, complication rates are still substantial, and the procedure should be restricted to properly indicated patients. Long-term follow-up studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis