Benedict Digiovanni - Academia.edu (original) (raw)

Papers by Benedict Digiovanni

Journal of the American Academy of Orthopaedic Surgeons, 2021

Introduction: Most orthopaedic subinternships function as month-long interviews. These rotations ... more Introduction: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. Methods: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. Results: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. Conclusion: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

Foot and Ankle Specialist, Jun 22, 2019

Background. The purpose of this study was to evaluate changes in posterior compartment muscle vol... more Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.

PubMed, Nov 1, 1995

Dorsal perilunate dislocations (PLDs) and dorsal transscaphoid perilunate dislocations (TS-PLDs) ... more Dorsal perilunate dislocations (PLDs) and dorsal transscaphoid perilunate dislocations (TS-PLDs) are reviewed in this paper, including the diagnosis, initial treatment, and options for definitive treatment. Closed reduction to obtain gross carpal alignment is performed on an urgent basis. Anatomic reduction is essential and is most consistently obtained by open-reduction, percutaneous pin fixation. A dorsal approach alone provides good visualization of the radiocarpal and midcarpal joints and allows efficient stabilization of dislocations and fracture-dislocations. To achieve stable fixation of the carpal bones, the senior author (JS) has developed a surgical technique that employs a specific order and configuration of Kirschner-wire placement. The stabilized joints parallel the major ligaments disrupted in PLD and TS-PLD: the volar radiocapitate, radiotriquetral, and radioscaphoid ligaments. Maintenance of stable anatomic reduction of the radiocarpal and midcarpal joints during healing is the key to satisfactory early and long-term clinical results.

Spine, Jul 1, 1989

Changes consistent with Scheuermann's kyphosis were noted in 103 specimens (7.4%) of a sa... more Changes consistent with Scheuermann's kyphosis were noted in 103 specimens (7.4%) of a sample of 1,384 thoracic spines in the Hamann-Todd collection of human skeletons. In 94% of the affected vertebrae, a distinct anterior elongation of the vertebral centrum was present. This anterior extension was composed of mature cancellous bone and was morphologically and roentgenographically different from marginal osteophyte formation. It was not present in any vertebrae of a control group of 50 unaffected spines. Associated findings included vertebral wedging and Schmorl's nodes.

Techniques in Foot & Ankle Surgery, Dec 1, 2003

Chronic symptoms from proximal plantar fasciitis develop in about 10% of patients with plantar he... more Chronic symptoms from proximal plantar fasciitis develop in about 10% of patients with plantar heel pain. A subset of these patients will develop chronic disabling plantar heel pain with associated nerve pain. Surgical intervention, which allows for complete resolution of symptoms and return to full activity without limitations, has been difficult to achieve in this group of patients. This paper reviews the typical presentation and appropriate evaluation for patients with chronic proximal plantar fasciitis and distal tarsal tunnel syndrome. The authors present a surgical approach that has yielded promising results with improved rates of total patient satisfaction. The surgical technique employs a complete plantar fascia release combined with a proximal and distal tarsal tunnel release. A detailed postoperative protocol is presented, and it is felt to play a major role in successful surgical outcomes. Data are presented from a study of 33 patients with a minimum 2-year follow-up. In primary surgery patients, high rates of total patient satisfaction (82%) can be expected, with corresponding high rates of resolution of pain and elimination of activity limitations. However, revision surgery results utilizing this technique are much more unpredictable, and further modification of treatment approach is needed.

Operative Techniques in Orthopaedics, Oct 1, 2008

ABSTRACT Ankle anterolateral soft-tissue impingement is a relatively common disorder, especially ... more ABSTRACT Ankle anterolateral soft-tissue impingement is a relatively common disorder, especially among athletes with a history of ankle inversion injuries. The diagnosis can be challenging, and surgical treatment by arthroscopy may be underutilized because of unfamiliarity with contemporary ankle arthroscopic techniques. Anterolateral impingement is characterized by chronic pain at the anterolateral ankle with physical activity. Physical examination findings are highly sensitive and specific for the diagnosis of anterolateral impingement. Ankle arthroscopic debridement is the procedure of choice for surgical management. Optimal patient positioning and portal establishment, as well as specialized instrumentation use, are key components to efficient and successful arthroscopic debridement. Ankle arthroscopic debridement for anterolateral soft-tissue impingement has been shown to be a safe and effective treatment. This article highlights the key elements involved in the diagnosis and surgical management.

Foot & Ankle International, Dec 1, 2016

Background: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pa... more Background: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective operative treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. As an alternative, we proposed to release the medial gastrocnemius at the division between the proximal one-third and distal two-thirds of the gastrocnemius muscle to correct equinus contracture, while minimizing risk to other structures. The aim of this study was to describe an anatomic basis for a medial gastrocnemius recession (MGR) and to investigate the anatomic structures at risk in comparison to PMGR. Methods: Eight cadaveric lower leg specimens were used in the study. The standard PMGR and the novel MGR were performed on each specimen. After completion of the 2 procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures, including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve, and popliteal artery. The mean distances were calculated and the shortest distances for each structure were reported. Results: Proximities of anatomic structures to surgically released gastrocnemius fascia at the medial and lateral margins were notably different between the 2 techniques. For the PMGR, the semimembranosus tendon (95% confidence interval of 2.4-7.4 mm), small saphenous vein (3.4-10.0 mm), popliteal artery (3.9-9.3 mm), and tibial nerve (5.0-11.1 mm) were in greater proximity to the operative margin. For the MGR, the greater saphenous vein (5.3-17.6 mm) and saphenous nerve (5.1-18.6 mm) were at greater risk. Conclusions: MGR at the proximal one-third of the gastrocnemius muscle may be a safe alternative for operative treatment of IGC. Clinical Relevance: We identified the major structures at risk when performing the proximal medial gastrocnemius release and propose a novel, possibly safer alternative for the medial gastrocnemius release.

Journal of Bone and Joint Surgery, American Volume, May 1, 2007

Background: Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. E... more Background: Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy. Methods: We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure. Results: After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure. Conclusions: The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.

Foot & Ankle Orthopaedics, Jul 1, 2018

Foot and Ankle Surgery, Sep 1, 2017

Gastrocnemius recession (GR) has emerged as a potential alternative to traditional surgical treat... more Gastrocnemius recession (GR) has emerged as a potential alternative to traditional surgical treatments in patients with recalcitrant Achilles tendinopathy (AT). Recent retrospective studies have shown positive results. However, there is limited long-term prospective data regarding the results of this surgery. We are reporting two-year results of a prospective analysis of isolated GR for Achilles tendinopathy on pain, self reported function, and satisfaction. Methods: 8 patients (mean age 52± 10.2 years) with chronic unilateral AT (> 6 months duration) and an isolated gastrocnemius contracture participated. All subjects received a GR (Strayer) procedure. Data were collected pre-and post-operatively at 6 months and 2 years. Pain and function were assessed using the Visual Analog Scale(VAS) and the Foot and Ankle Ability Measure(FAAM). Clinical measure of calf endurance was assessed by single limb heel raises and compared to the uninvolved limb. Calf circumference was evaluated and patients were queried regarding satisfaction with the GR procedure and need for further treatment. Descriptive analysis was used to assess changes across the repeated timelines. Results: All subjects returned at 6 month follow-up and 7/8 patients participated in the final follow-up (mean 23 +/-5.5 months). Pain was reduced by 50% at 6 months and 90% at 2 years; with 6 of 7 subjects reporting no pain. Pre-op FAAM ADL subscale was 75%, improving to 90% and 97% at 6 months and 2 years, respectively. Pre-op FAAM Sports subscale was 40%, improving to 69% and 87% at 6 months and 2 years, respectively. There were no side-to-side differences in the number of heel raises performed across time frames; involved mean 26 +/-7, uninvolved 28 +/-6. Five (of seven) subjects reported complete satisfaction with the procedure and two were satisfied with minor reservations.

JB & JS open access, Sep 4, 2021

Introduction: Away rotations are a valuable experience for medical students when applying for res... more Introduction: Away rotations are a valuable experience for medical students when applying for residency. In light of the coronavirus disease 2019 pandemic, there has been significant interest in the development of virtually based substitutes. This study evaluates the utility of a formal virtual fourth-year medical student away rotation in orthopaedic surgery by surveying participants and provides recommendations for success. Methods: A 2-week virtual orthopaedic elective was offered to fourth-year medical students in lieu of traditional in-person away rotations. The course consisted of multiple components such as subspecialty case-based didactics, “happy hours” with residents, assigned resident mentors, student case presentations, and observation of resident lectures. After course completion, anonymous surveys were administered to participants to evaluate the rotation. Results: Twenty-three of 24 participating students (96%) completed the student survey, and 22 of 24 participating faculty and residents (82%) completed the resident/faculty survey. Most students were very (87%) or somewhat (9%) satisfied with their experience and found the rotation to be a very (35%) or somewhat useful (61%) substitute for an in-person rotation. Students indicated that the rotation very (91%) or somewhat positively (9%) influenced their perception of the program. All students indicated that the rotation was very educational. Most students (91%) reported that the rotation was very useful for learning about the program and culture, with subspecialty didactics and happy hours most useful. Faculty and residents indicated that the rotation was useful for getting to know the students (17% “very useful” and 83% “somewhat useful”) and for assessing student characteristics, such as knowledge base and communication skills. Conclusions: A formal virtual orthopaedic surgery away rotation can be a valuable experience for medical students which provides educational value, insight into program culture, and an opportunity to demonstrate interest in the program. The curriculum and recommendations presented in this study can be used as a preliminary template for others interested in creating successful virtual rotations.

Foot & Ankle International, Mar 17, 2016

Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemiu... more Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy. Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests. Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance. The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients' self-reported difficulty during more challenging activities. Level III, comparative study.

Foot and Ankle Surgery, Oct 1, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Foot & Ankle International, Feb 1, 2013

Foot & Ankle International, Jan 11, 2013

Open reduction with direct visualization of the fracture fragments and joint surface for an avuls... more Open reduction with direct visualization of the fracture fragments and joint surface for an avulsion of the extensor mechanism of the great toe has not been described in the English literature to our knowledge. Prior authors have reported on closed reduction, percutaneous reduction techniques, and extension block methods. Although treatment of an avulsion of the extensor mechanism of the hallux has been described only in case reports, a similar injury in the hand, the mallet finger, has been described extensively. Nonoperative and operative indications and treatment have been well described for the mallet finger. As such, the principles of treatment for mallet finger have been used to guide treatment of the mallet toe. The mechanism of injury, treatment, and rehabilitation for the acute, unstable mallet toe of the hallux are described in this case report.

Foot & Ankle Orthopaedics, 2022

Category: Other Introduction/Purpose: Away rotations are a valuable experience for medical studen... more Category: Other Introduction/Purpose: Away rotations are a valuable experience for medical students when applying for residency. However, in light of the ongoing coronavirus disease 2019 (COVID-19) pandemic, traditional in-person away rotations were largely suspended during the 2020-2021 residency application cycle. As such, there has been significant interest in the development of virtually-based substitutes. The purpose of this study is to evaluate the utility of a formal virtual fourth year medical student away rotation in orthopaedic surgery by surveying student, resident, and faculty participants. Methods: A two-week virtual orthopaedic elective was offered to fourth-year medical students from outside institutions in lieu of a traditional in-person away rotation. The course was conducted via online video conferencing and consisted of multiple components including nightly subspecialty case-based didactics, weekly social events with residents, assigned resident mentors, student c...

Foot and ankle clinics, Mar 1, 2007

Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to... more Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to conservative measures. Therefore, continuous effort is afforded to the development of additional treatment options for such patients. Distraction arthroplasty has been proposed as one of these options for the patient in whom fusion or joint replacement is not appropriate. Although the mechanism of action remains unknown, the reports of several researchers support the potential beneficial effects that can be obtained from joint distraction arthroplasty in the severely osteoarthritic ankle. Furthermore, the studies published to date suggest that these effects may not only persist for years but also improve as time progresses during the first several years after treatment. Although additional laboratory studies are needed to understand the biochemical and biomechanical effects of distraction, additional prospective clinical studies are also needed to further understand its efficacy and appropriate patient population. The data thus far suggests that joint distraction arthroplasty may be a viable alternative treatment to arthrodesis and replacement for the young patient who has a congruent, painful, mobile, arthritic ankle joint.

Foot & Ankle Orthopaedics, Jul 1, 2018

Foot & Ankle International, May 24, 2021

Background: Hallux rigidus is a common and painful degenerative condition of the great toe limiti... more Background: Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient’s physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS). Methods: PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests. Results: Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively ( P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals ( P < .01). PI t scores were similar between the 2 procedures across time points. Conclusion: The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame. Level of Evidence: Level IV, case series.

Foot & Ankle International, May 23, 2018

The use of patient-reported outcomes (PROs) is rapidly increasing in foot and ankle surgery as he... more The use of patient-reported outcomes (PROs) is rapidly increasing in foot and ankle surgery as health care evolves to value-based care models. 1,11,20 Generic health metrics like the Patient Reported Outcome Measurement Instrumentation System (PROMIS) are appealing given their applicability across many medical conditions, allowing a common measurement metric to be followed throughout a medical system. 2,3 In support of this approach, recent head-to-head

Journal of the American Academy of Orthopaedic Surgeons, 2021

Introduction: Most orthopaedic subinternships function as month-long interviews. These rotations ... more Introduction: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. Methods: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. Results: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. Conclusion: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

Foot and Ankle Specialist, Jun 22, 2019

Background. The purpose of this study was to evaluate changes in posterior compartment muscle vol... more Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.

PubMed, Nov 1, 1995

Dorsal perilunate dislocations (PLDs) and dorsal transscaphoid perilunate dislocations (TS-PLDs) ... more Dorsal perilunate dislocations (PLDs) and dorsal transscaphoid perilunate dislocations (TS-PLDs) are reviewed in this paper, including the diagnosis, initial treatment, and options for definitive treatment. Closed reduction to obtain gross carpal alignment is performed on an urgent basis. Anatomic reduction is essential and is most consistently obtained by open-reduction, percutaneous pin fixation. A dorsal approach alone provides good visualization of the radiocarpal and midcarpal joints and allows efficient stabilization of dislocations and fracture-dislocations. To achieve stable fixation of the carpal bones, the senior author (JS) has developed a surgical technique that employs a specific order and configuration of Kirschner-wire placement. The stabilized joints parallel the major ligaments disrupted in PLD and TS-PLD: the volar radiocapitate, radiotriquetral, and radioscaphoid ligaments. Maintenance of stable anatomic reduction of the radiocarpal and midcarpal joints during healing is the key to satisfactory early and long-term clinical results.

Spine, Jul 1, 1989

Changes consistent with Scheuermann's kyphosis were noted in 103 specimens (7.4%) of a sa... more Changes consistent with Scheuermann's kyphosis were noted in 103 specimens (7.4%) of a sample of 1,384 thoracic spines in the Hamann-Todd collection of human skeletons. In 94% of the affected vertebrae, a distinct anterior elongation of the vertebral centrum was present. This anterior extension was composed of mature cancellous bone and was morphologically and roentgenographically different from marginal osteophyte formation. It was not present in any vertebrae of a control group of 50 unaffected spines. Associated findings included vertebral wedging and Schmorl's nodes.

Techniques in Foot & Ankle Surgery, Dec 1, 2003

Chronic symptoms from proximal plantar fasciitis develop in about 10% of patients with plantar he... more Chronic symptoms from proximal plantar fasciitis develop in about 10% of patients with plantar heel pain. A subset of these patients will develop chronic disabling plantar heel pain with associated nerve pain. Surgical intervention, which allows for complete resolution of symptoms and return to full activity without limitations, has been difficult to achieve in this group of patients. This paper reviews the typical presentation and appropriate evaluation for patients with chronic proximal plantar fasciitis and distal tarsal tunnel syndrome. The authors present a surgical approach that has yielded promising results with improved rates of total patient satisfaction. The surgical technique employs a complete plantar fascia release combined with a proximal and distal tarsal tunnel release. A detailed postoperative protocol is presented, and it is felt to play a major role in successful surgical outcomes. Data are presented from a study of 33 patients with a minimum 2-year follow-up. In primary surgery patients, high rates of total patient satisfaction (82%) can be expected, with corresponding high rates of resolution of pain and elimination of activity limitations. However, revision surgery results utilizing this technique are much more unpredictable, and further modification of treatment approach is needed.

Operative Techniques in Orthopaedics, Oct 1, 2008

ABSTRACT Ankle anterolateral soft-tissue impingement is a relatively common disorder, especially ... more ABSTRACT Ankle anterolateral soft-tissue impingement is a relatively common disorder, especially among athletes with a history of ankle inversion injuries. The diagnosis can be challenging, and surgical treatment by arthroscopy may be underutilized because of unfamiliarity with contemporary ankle arthroscopic techniques. Anterolateral impingement is characterized by chronic pain at the anterolateral ankle with physical activity. Physical examination findings are highly sensitive and specific for the diagnosis of anterolateral impingement. Ankle arthroscopic debridement is the procedure of choice for surgical management. Optimal patient positioning and portal establishment, as well as specialized instrumentation use, are key components to efficient and successful arthroscopic debridement. Ankle arthroscopic debridement for anterolateral soft-tissue impingement has been shown to be a safe and effective treatment. This article highlights the key elements involved in the diagnosis and surgical management.

Foot & Ankle International, Dec 1, 2016

Background: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pa... more Background: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective operative treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. As an alternative, we proposed to release the medial gastrocnemius at the division between the proximal one-third and distal two-thirds of the gastrocnemius muscle to correct equinus contracture, while minimizing risk to other structures. The aim of this study was to describe an anatomic basis for a medial gastrocnemius recession (MGR) and to investigate the anatomic structures at risk in comparison to PMGR. Methods: Eight cadaveric lower leg specimens were used in the study. The standard PMGR and the novel MGR were performed on each specimen. After completion of the 2 procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures, including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve, and popliteal artery. The mean distances were calculated and the shortest distances for each structure were reported. Results: Proximities of anatomic structures to surgically released gastrocnemius fascia at the medial and lateral margins were notably different between the 2 techniques. For the PMGR, the semimembranosus tendon (95% confidence interval of 2.4-7.4 mm), small saphenous vein (3.4-10.0 mm), popliteal artery (3.9-9.3 mm), and tibial nerve (5.0-11.1 mm) were in greater proximity to the operative margin. For the MGR, the greater saphenous vein (5.3-17.6 mm) and saphenous nerve (5.1-18.6 mm) were at greater risk. Conclusions: MGR at the proximal one-third of the gastrocnemius muscle may be a safe alternative for operative treatment of IGC. Clinical Relevance: We identified the major structures at risk when performing the proximal medial gastrocnemius release and propose a novel, possibly safer alternative for the medial gastrocnemius release.

Journal of Bone and Joint Surgery, American Volume, May 1, 2007

Background: Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. E... more Background: Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy. Methods: We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure. Results: After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure. Conclusions: The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.

Foot & Ankle Orthopaedics, Jul 1, 2018

Foot and Ankle Surgery, Sep 1, 2017

Gastrocnemius recession (GR) has emerged as a potential alternative to traditional surgical treat... more Gastrocnemius recession (GR) has emerged as a potential alternative to traditional surgical treatments in patients with recalcitrant Achilles tendinopathy (AT). Recent retrospective studies have shown positive results. However, there is limited long-term prospective data regarding the results of this surgery. We are reporting two-year results of a prospective analysis of isolated GR for Achilles tendinopathy on pain, self reported function, and satisfaction. Methods: 8 patients (mean age 52± 10.2 years) with chronic unilateral AT (> 6 months duration) and an isolated gastrocnemius contracture participated. All subjects received a GR (Strayer) procedure. Data were collected pre-and post-operatively at 6 months and 2 years. Pain and function were assessed using the Visual Analog Scale(VAS) and the Foot and Ankle Ability Measure(FAAM). Clinical measure of calf endurance was assessed by single limb heel raises and compared to the uninvolved limb. Calf circumference was evaluated and patients were queried regarding satisfaction with the GR procedure and need for further treatment. Descriptive analysis was used to assess changes across the repeated timelines. Results: All subjects returned at 6 month follow-up and 7/8 patients participated in the final follow-up (mean 23 +/-5.5 months). Pain was reduced by 50% at 6 months and 90% at 2 years; with 6 of 7 subjects reporting no pain. Pre-op FAAM ADL subscale was 75%, improving to 90% and 97% at 6 months and 2 years, respectively. Pre-op FAAM Sports subscale was 40%, improving to 69% and 87% at 6 months and 2 years, respectively. There were no side-to-side differences in the number of heel raises performed across time frames; involved mean 26 +/-7, uninvolved 28 +/-6. Five (of seven) subjects reported complete satisfaction with the procedure and two were satisfied with minor reservations.

JB & JS open access, Sep 4, 2021

Introduction: Away rotations are a valuable experience for medical students when applying for res... more Introduction: Away rotations are a valuable experience for medical students when applying for residency. In light of the coronavirus disease 2019 pandemic, there has been significant interest in the development of virtually based substitutes. This study evaluates the utility of a formal virtual fourth-year medical student away rotation in orthopaedic surgery by surveying participants and provides recommendations for success. Methods: A 2-week virtual orthopaedic elective was offered to fourth-year medical students in lieu of traditional in-person away rotations. The course consisted of multiple components such as subspecialty case-based didactics, “happy hours” with residents, assigned resident mentors, student case presentations, and observation of resident lectures. After course completion, anonymous surveys were administered to participants to evaluate the rotation. Results: Twenty-three of 24 participating students (96%) completed the student survey, and 22 of 24 participating faculty and residents (82%) completed the resident/faculty survey. Most students were very (87%) or somewhat (9%) satisfied with their experience and found the rotation to be a very (35%) or somewhat useful (61%) substitute for an in-person rotation. Students indicated that the rotation very (91%) or somewhat positively (9%) influenced their perception of the program. All students indicated that the rotation was very educational. Most students (91%) reported that the rotation was very useful for learning about the program and culture, with subspecialty didactics and happy hours most useful. Faculty and residents indicated that the rotation was useful for getting to know the students (17% “very useful” and 83% “somewhat useful”) and for assessing student characteristics, such as knowledge base and communication skills. Conclusions: A formal virtual orthopaedic surgery away rotation can be a valuable experience for medical students which provides educational value, insight into program culture, and an opportunity to demonstrate interest in the program. The curriculum and recommendations presented in this study can be used as a preliminary template for others interested in creating successful virtual rotations.

Foot & Ankle International, Mar 17, 2016

Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemiu... more Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy. Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests. Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance. The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients' self-reported difficulty during more challenging activities. Level III, comparative study.

Foot and Ankle Surgery, Oct 1, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Foot & Ankle International, Feb 1, 2013

Foot & Ankle International, Jan 11, 2013

Open reduction with direct visualization of the fracture fragments and joint surface for an avuls... more Open reduction with direct visualization of the fracture fragments and joint surface for an avulsion of the extensor mechanism of the great toe has not been described in the English literature to our knowledge. Prior authors have reported on closed reduction, percutaneous reduction techniques, and extension block methods. Although treatment of an avulsion of the extensor mechanism of the hallux has been described only in case reports, a similar injury in the hand, the mallet finger, has been described extensively. Nonoperative and operative indications and treatment have been well described for the mallet finger. As such, the principles of treatment for mallet finger have been used to guide treatment of the mallet toe. The mechanism of injury, treatment, and rehabilitation for the acute, unstable mallet toe of the hallux are described in this case report.

Foot & Ankle Orthopaedics, 2022

Category: Other Introduction/Purpose: Away rotations are a valuable experience for medical studen... more Category: Other Introduction/Purpose: Away rotations are a valuable experience for medical students when applying for residency. However, in light of the ongoing coronavirus disease 2019 (COVID-19) pandemic, traditional in-person away rotations were largely suspended during the 2020-2021 residency application cycle. As such, there has been significant interest in the development of virtually-based substitutes. The purpose of this study is to evaluate the utility of a formal virtual fourth year medical student away rotation in orthopaedic surgery by surveying student, resident, and faculty participants. Methods: A two-week virtual orthopaedic elective was offered to fourth-year medical students from outside institutions in lieu of a traditional in-person away rotation. The course was conducted via online video conferencing and consisted of multiple components including nightly subspecialty case-based didactics, weekly social events with residents, assigned resident mentors, student c...

Foot and ankle clinics, Mar 1, 2007

Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to... more Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to conservative measures. Therefore, continuous effort is afforded to the development of additional treatment options for such patients. Distraction arthroplasty has been proposed as one of these options for the patient in whom fusion or joint replacement is not appropriate. Although the mechanism of action remains unknown, the reports of several researchers support the potential beneficial effects that can be obtained from joint distraction arthroplasty in the severely osteoarthritic ankle. Furthermore, the studies published to date suggest that these effects may not only persist for years but also improve as time progresses during the first several years after treatment. Although additional laboratory studies are needed to understand the biochemical and biomechanical effects of distraction, additional prospective clinical studies are also needed to further understand its efficacy and appropriate patient population. The data thus far suggests that joint distraction arthroplasty may be a viable alternative treatment to arthrodesis and replacement for the young patient who has a congruent, painful, mobile, arthritic ankle joint.

Foot & Ankle Orthopaedics, Jul 1, 2018

Foot & Ankle International, May 24, 2021

Background: Hallux rigidus is a common and painful degenerative condition of the great toe limiti... more Background: Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient’s physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS). Methods: PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests. Results: Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively ( P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals ( P < .01). PI t scores were similar between the 2 procedures across time points. Conclusion: The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame. Level of Evidence: Level IV, case series.

Foot & Ankle International, May 23, 2018

The use of patient-reported outcomes (PROs) is rapidly increasing in foot and ankle surgery as he... more The use of patient-reported outcomes (PROs) is rapidly increasing in foot and ankle surgery as health care evolves to value-based care models. 1,11,20 Generic health metrics like the Patient Reported Outcome Measurement Instrumentation System (PROMIS) are appealing given their applicability across many medical conditions, allowing a common measurement metric to be followed throughout a medical system. 2,3 In support of this approach, recent head-to-head