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Background: Plantar fasciitis is the most common cause of plantar heel pain. Several recent randomized control trials (RCTs) have been published comparing the use of platelet-rich plasma (PRP) and corticosteroids (CSs) for the treatment of plantar fasciitis. Purpose: To perform a systematic review of RCTs to compare whether PRP or CS injections result in decreased pain levels and improved patient outcomes in the treatment of plantar fasciitis. Study Design: Systematic review; Level of evidence, 1. Methods: Medline, EMBASE, and the Cochrane Library were screened according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify RCTs comparing PRP and CS injections for plantar fasciitis. The visual analog scale (VAS) pain scores and the American Orthopaedic Foot and Ankle Society (AOFAS) scores were compared between groups at 1, 1.5, 3, 6, and 12 months, where possible. Statistical analysis was performed using RevMan, and P < .05 was considered to be statistically significant. Results: A total of 9 RCTs were identified comparing 239 patients with PRP with 240 patients with CS injections. At the follow-up time points, including 1-1.5, 3, 6, and 12 months, there were statistically significant differences in VAS scores in favor of PRP (P = .004, P < .00001, P < .00001, and P < .00001, respectively). At 1 and 3 months, there was no difference in AOFAS scores (P = .76 and P = .35, respectively). However, at 6 and 12 months, there was a difference in AOFAS scores in favor of PRP (P < .00001 and P < .00001, respectively). Conclusion: In patients with chronic plantar fasciitis, the current clinical evidence suggests that PRP may lead to a greater improvement in pain and functional outcome over CS injections.

Purpose The objective of the present study was to correlate macroscopic and microscopic anatomy of the lateral capsule of the knee joint with high-quality magnetic resonance imaging (MRI), with a hypothesis that a distinct lateral capsular ligament would be inconsistently observed via surgical dissection and that high-quality MRI imaging would correlate to findings from dissection. Methods Ten fresh-frozen human cadaveric knee specimens were utilized for this study. MRI of each knee was obtained pre- and post-dissection. The lateral knee was dissected and analysed for the presence or absence of a discrete capsular thickening or an independent ligamentous structure. A musculoskeletal radiologist analysed the pre- and post-dissection MRI. Subsequently, two specimens with positive lateral capsular thickening were prepared for histology. Results On macroscopic dissection, none of the ten specimens were found to have a discrete lateral capsular ligament. A palpable macroscopic thickening of the lateral capsule was identified in 4/10 specimens. MRI analysis revealed a 2–4 mm thickening of the central third of the lateral capsule in 3/10 specimens. On histological analysis, the lateral capsular thickening demonstrated properties similar to both capsule and ligament. Conclusions In fresh-frozen cadaveric specimens, macroscopic and MRI evaluation of the lateral capsule of the knee revealed variations in morphology without consistent capsuloligamentous anatomy and specifically no discrete lateral capsular ligament. Further investigation in the form of clinical and mechanical relevance of the lateral capsular structures is of paramount importance before limited anatomical data can be utilized to drive clinical decision-making and patient care.

Purpose To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair. Methods 24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment. Results Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment. Conclusions Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes. Level of evidence Retrospective cohort study, Level III.

Purpose The primary purpose of this study was to evaluate clinical outcomes following peroneal tendoscopy for the treatment of peroneal pathology. Correlation between pre-operative magnetic resonance imaging (MRI) and peroneal tendoscopic diagnostic findings was also assessed. Methods Twenty-three patients with a mean age of 34 ± 8.8 years undergoing peroneal tendoscopy were pre- and post-operatively assessed with the foot and ankle outcome score (FAOS) and the Short Form-12 (SF-12) outcome questionnaires. Follow-up was over 24 months in all patients. The sensitivity and specificity of MRI were calculated in comparison with peroneal tendoscopy, including the positive predictive value (PPV). Results Both the FAOS and the SF-12 improved significantly ( p  < 0.05) at a mean follow-up of 33 ± 7.3 months significantly. MRI showed an overall sensitivity of 0.90 (95 % confidence interval (CI) = 0.82–0.95) and specificity of 0.72 (95 % CI 0.62–0.80). The PPV for MRI diagnosis of peroneal tendon pathology was 0.76 (95 % CI 0.68–0.83). Conclusions The current study found good clinical outcomes in patients with peroneal tendon disorders, treated with peroneal tendoscopy. Although a relatively small number of patients were included, the study suggests good correlation between tendoscopic findings and pre-operative MRI findings of peroneal tendon pathology, supporting the use of MRI as a useful diagnostic modality for suspected peroneal tendon disorders. Level of evidence Level IV, retrospective case series.

Background: Pickleball has emerged as the fastest-growing sport in the United States, with participation increasing nearly 1000% since 2019 and now surpassing 36 million players. Within the same period, tennis participation has risen by 33%. Pickleball’s rapid rise, accelerated by the COVID-19 pandemic, has paralleled anecdotal reports of musculoskeletal injury, yet little is known regarding Achilles tendon rupture (ATR) risk in this population. Tennis, a sport with similar biomechanics, has long been studied in relation to ATR, but comparative data for pickleball is lacking. The purpose of this study is to compare ATR proportional frequency sustained during pickleball, tennis, and all other sports to identify patterns of risk and inform athlete counseling. Methods: A retrospective review was conducted from January 2018 through December 2022 to identify patients who underwent Achilles tendon repairs within a large, independent orthopaedic group (>100 surgeons). Procedures were identified through the Current Procedural Terminology (CPT) code 27650. Patients aged 18-75 years with acute ATR who were treated operatively were included. Exclusion criteria were chronic tears requiring graft augmentation, revision procedures, failed nonoperative management, <2 months of follow-up, or incomplete clinical documentation. Mechanism of injury was recorded and categorized as pickleball, tennis, or other sports. A total of 1035 ATRs were identified and reviewed, with 1028 patients undergoing operative repair of an acute ATR. This included 942 other sports, 46 tennis, and 40 pickleball injuries. The primary outcome was the percentage of surgical volume of pickleball-related ATRs compared with tennis and other sports, stratified by age and year of injury. Secondary outcomes included major complications and minor complications. Data were analyzed using χ2/Fisher exact tests and Wilcoxon rank-sum tests. Results: Pickleball ATRs occurred in significantly older patients (median 60 years) compared with tennis (45 years) and other sports (37 years) (P < .0001). The sex distribution and comorbidities were similar across groups. BMI was lower in tennis and pickleball vs other sports (P = .0004). Age distribution demonstrated that 82.5% of pickleball ruptures occurred in patients >50 years vs 32.6% in tennis and 18.9% in other sports. Pickleball-related ATRs increased from 0.5% in 2018 to 6.7% in 2021. There was no difference in complication rates between patients with pickleball-related ATRs and all other sports (15.0% vs 15.7%). Conclusion: Pickleball-associated Achilles tendon ruptures represent a distinct demographic pattern, predominantly affecting adults >50 years of age, with a marked increase in cases following 2020, suggesting a correlation with the start of the COVID-19 pandemic. With the numbers available, no significant difference in postoperative complication rates was detected; however, the relatively small number of pickleball injuries limits statistical power and precludes definitive conclusions regarding comparative safety or injury patterns compared with tennis or other sports. Level of Evidence: Level III, retrospective cohort study.

Purpose The purpose of this paper is to discuss risk and prognostic factors for concussion outcomes, review comprehensive approaches to assessment, and describe a new method for conceptualizing treatment for sport-related concussion using clinical experience. Methods Based on the current literature of sport-related concussion and clinical experience, an approach for conceptualizing concussion care using clinical trajectories and targeted treatments was developed. Results A comprehensive approach to assessment and targeted treatments for sport-related concussion was developed using specific clinical trajectories. Conclusion Sport-related concussions are heterogeneous and require an individualized clinical approach. The use of a comprehensive approach for assessing specific clinical trajectories following a sport-related concussion will help clinicians better conceptualize this injury. Clinicians can then match targeted treatment pathways to specific clinical trajectories to accelerate safe return to play for athletes following a sport-related concussion. Level of evidence V.

Purpose The purpose of this article was to discuss pre- and intra-operative considerations as well as surgical strategies for different femoral and tibial tunnel scenarios in revision surgery following primary double-bundle anterior cruciate ligament (ACL) reconstruction. Methods Based on the current literature of ACL revision surgery and surgical experience, an algorithm for revision surgery after primary double-bundle ACL reconstruction was created. Results A guideline and flowchart were created using a case-based approached for revision surgery after primary double-bundle ACL reconstruction. Conclusion Revision surgery after primary double-bundle ACL reconstruction can be a challenging procedure that requires flexibility and a repertoire of surgical techniques. The combination of pre-operative planning with 3D-CT reconstruction, in addition to careful intra-operative assessment, and the use of this flowchart can simplify the ACL revision procedure. Level of evidence V.

The management of osteoarthritis (OA) remains challenging and controversial. Although several clinical options exist for the treatment of OA, regeneration of the damaged articular cartilage has proved difficult due to the limited healing capacity. With the advancements in tissue engineering and cell-based technologies over the past decade, new therapeutic options for patients with osteochondral lesions potentially exist. This review will focus on the feasibility of tissue-engineered biphasic scaffolds, which can mimic the native osteochondral complex, for osteochondral repair and highlight the recent development of these techniques toward tissue regeneration. Moreover, basic anatomy, strategy for osteochondral repair, the design and fabrication methods of scaffolds, as well as the choice of cells, growth factor, and materials will be discussed. Specifically, we focus on the latest preclinical animal studies using large animals and clinical trials with high clinical relevance. In turn, this will facilitate an understanding of the latest trends in osteochondral repair and contribute to the future application of such clinical therapies in patients with OA.

Category: Trauma; Sports Introduction/Purpose: Achilles tendon ruptures remain the most common tendon injury within the lower extremity. While the incidence continues to rise, changing immobilization protocols, techniques, and surgeon preferences have evolved over the past few decades. The purpose of this study was to characterize the major complication rate in acute Achilles tendon repair by 54 orthopedic surgeons in a heterogenous major metropolitan area. Methods: Achilles tendon repairs (CPT 27650) performed from January 2018 through December 2022 with a minimum two-month follow-up were identified. Patients were excluded if they had chronic tears that required reconstruction, underwent a revision repair/reconstruction, or were initially treated nonoperatively. 1036 Achilles tendon ruptures met inclusion criteria. The primary outcome measure was total major complication rate (reoperation, deep infection, tendon re-rupture, and loss of Achilles tension requiring re-operation). Minor complication rate (sural neuritis, superficial infection, delayed wound healing, heel pain, and loss of Achilles tension not requiring re-operation) was also documented. Complication rate by procedure type (open, percutaneous, suture anchor fixation), surgeon training, patient age, mechanism of injury, and rehabilitation protocol were recorded. Rehabilitation was considered expedited if patients were weight-bearing less than 4 weeks after surgery. Standard demographic data was noted. Descriptive statistics and multivariate regression were utilized. Results: The overall complication rate was 15.8%—with 3% (N =31) having major complications (Table 1). Patients were 4.0 and 2.2 times more likely, respectively, to experience a major (p=0.0152) or minor complication (p=0.0039) with suture anchor fixation compared to open technique. Suture anchor fixation patients were more likely to experience heel pain (p< 0.01). There were no differences in major or minor complication rates between patients who underwent an open or percutaneous fixation (p=0.6855, p=0.1257). There was no difference in complication rate (16.1% and 15.3%, respectively) between expedited and conservative rehabilitation protocols (p=0.738). Smokers trended toward worse outcomes (OR=2.4, p=0.0712). Minor complication rate was higher amongst non-foot and ankle fellowship-trained surgeons (p=0.0314), but not different for major complications (p=0.9760). Conclusion: Acute Achilles tendon repair is associated with a major complication rate of 3% requiring reoperation. Patients undergoing suture anchor fixation of Achilles tendon injuries sustain major and minor complications at a significantly higher rate than percutaneous or open procedures. Heel pain is a significantly encountered complication in Achilles repair with suture anchor fixation. Expediting rehabilitation protocols continue to demonstrate similar results to conservative protocols encouraging physicians to advance patients weightbearing status within the first four weeks after surgery.

Purposes There is a lack of substantial clinical evidence endorsing the clinical outcomes of osteotomy for peroneal tendon dislocations. The aim of this study was to compare the post-operative reoperation rates following osteotomy techniques and soft tissues procedures using large database in order to investigate the efficacy of bony techniques. Methods Patients who underwent osteotomy and soft tissue procedures for peroneal tendon dislocations were identified and subsequently analysed using the United Healthcare Orthopedic and the Medicare datasets (PearlDiver Patient Record Database, PearlDiver Technologies Inc., Fort Wayne, IN). The investigated period was from 2005 to 2012. The annual incidence, gender distribution, and incidences of reoperation and wound dehiscence following primary operative procedures were determined in these cohorts. Results Of 6122 patients who received operative treatment for peroneal tendon dislocations, 1416 patients (23.1%) received the osteotomy technique, while 4706 (76.9%) were treated with the soft tissue techniques. The incidence of these operative procedures did not change significantly over the time periods of each database. In both databases, reoperation rates were 2.8% (40/1416) for osteotomy patients and 3.4% (158/4706) for soft tissue repair patients, with no statistical difference (2.8 vs. 3.4%. odds ratio 0.8, 95% confidence interval [CI] 0.6–1.2, [n.s.]) between them. Based on both databases, wound dehiscence occurred in 2.6% (37/1416) of the osteotomy patients and 2.3% (110/4706) of soft tissue repair patients with no statistical difference (2.6 vs. 2.3%, odds ratio 1.1, 95% CI 0.8–1.6, [n.s.]) between the groups. Conclusion The results of this study show that osteotomy techniques were frequently performed for patients with peroneal tendon dislocations. Nevertheless, osteotomy techniques for peroneal tendon dislocations are not associated with a lower risk of reoperation. In conclusion, soft tissue procedures offer a satisfactory method of treating peroneal tendon dislocations without any additional risk of reoperation when compared to osteotomy techniques that have potentially greater complication rates. Level of evidence III.