Background: Patellofemoral Pain Syndrome (PFPS), a common cause of anterior knee pain, is successfully treated in over 2/3 of patients through rehabilitation protocols designed to reduce pain and return function to the individual. Applying preventive medicine strategies, the majority of cases of PFPS may be avoided if a pre-diagnosis can be made by clinician or certified athletic trainer testing the current researched potential risk factors during a Preparticipation Screening Evaluation (PPSE). We provide a detailed and comprehensive review of the soft tissue, arterial system, and innervation to the patellofemoral joint in order to supply the clinician with the knowledge required to assess the anatomy and make recommendations to patients identified as potentially at risk. The purpose of this article is to review knee anatomy and the literature regarding potential risk factors associated with patellofemoral pain syndrome and prehabilitation strategies. A comprehensive review of knee anatomy will present the relationships of arterial collateralization, innervations, and soft tissue alignment to the possible multifactoral mechanism involved in PFPS, while attempting to advocate future use of different treatments aimed at non-soft tissue causes of PFPS.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Ochronotic arthropathy occurs in patients with alkaptonuria, manifesting first in the intervertebral discs of the lumbar spine, with subsequent degeneration most often observed in the knee, hip, and shoulder joints. Efforts at treatment are targeted at minimizing the damaging effects of the underlying metabolic disorder on the articular cartilage. Vitamin E and N-acetyl cysteine are potential therapies because of their scavenging of free radicals and consequent limitation of oxidative damage to joint tissue. Arthroscopy has been found to be an effective diagnostic tool in cases of suspected ochronosis. Arthroplasty performed in patients with ochronotic arthropathy suggests that the procedure is effective in the alleviation of joint pain and the improvement of mobility. Perioperative management of these patients may require more careful consideration pertinent to the associated comorbidities of this disorder.

Background: Early recognition of syndesmotic instability is critical for optimizing clinical outcome. Injuries causing a more subtle instability, however, can be difficult to diagnose. The purpose of this study was to evaluate both distal tibiofibular articulations using weightbearing computed tomography (CT) in patients with known syndesmotic instability, thereafter comparing findings between the injured and uninjured sides. We also aimed to define the range of normal measurement variation among patients without syndesmotic injury. Methods: Patients with unilateral syndesmotic instability requiring operative fixation ( n = 12) underwent preoperative bilateral ankle weightbearing CT. A separate cohort of patients without ankle injury who also underwent bilateral ankle weightbearing CT were included as comparative controls ( n = 24). For each weightbearing CT, a series of 7 axial plane tibiofibular joint measurements, including 1 angular measurement, were utilized to evaluate parameters of the syndesmotic anatomy at a level 1 cm above the tibial plafond. Values were recorded by 2 independent observers to assess for interobserver reliability. Results: Among those with unilateral syndesmotic instability, values differed between the injured and uninjured sides in 4 of the 7 measurements performed including the syndesmotic area: direct anterior, middle, and posterior differences, and sagittal translation ( P < .001, < .001, < .001, and < .001, respectively). In the control population without ankle injury, no differences were identified between any of the bilateral measurements ( P value range, .172-.961). Conclusion: This study highlights the ability of weightbearing CT to effectively differentiate syndesmotic diastasis among patients with surgically confirmed syndesmotic instability from those without syndesmotic instability. It underscores the substantial utility and importance of using the contralateral, uninjured side as a valid internal control whenever the need for confirming potential syndesmotic instability arises. Prospective studies are necessary to fully understand the accuracy of weightbearing CT in diagnosing occult syndesmotic instability among patients for whom the diagnosis remains in question. Level of Evidence: Level III, comparative diagnostic study.

Background: Weight-bearing computed tomography (WBCT) allows evaluation of the distal syndesmosis under physiologic load. We hypothesized that WBCT volumetric measurement of the distal syndesmosis would be increased on the injured as compared to the contralateral uninjured side and that these 3-dimensional (3D) calculations would be a more sensitive determinant than 2-dimensional (2D) methodology among patients with syndesmotic instability. Methods: Twelve patients with unilateral syndesmotic instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT were included in the study group. The control group consisted of 24 patients without ankle injury who underwent similar imaging. On WBCT scan, 2D measurements of the syndesmosis joint were first measured 1 cm above the joint line in the axial plane via syndesmotic area and distances between the anterior, middle, and posterior quadrants. Thereafter, comparative 3D volumetric measurements of the syndesmotic joint were also calculated: (1) from the tibial plafond extending until 3 cm proximally, (2) 5 cm proximally, and (3) 10 cm proximally. Results: In patients with unilateral syndesmotic instability, all 3 weight-bearing volumetric measurements were significantly larger on the injured side as compared to the contralateral, uninjured side ( P < .001). In the control group, there was no difference between syndesmotic volumes at any level. Of these 3 anatomic reference points, the 3D measurement spanning from the tibial plafond to a level 5 cm proximally had the highest relative volumetric ratio between the injured and uninjured side, suggesting it is the most sensitive in distinguishing between stable and unstable syndesmotic injury ( P < .001). Notably, this 3D volumetric measurement was also more sensitive than 2D measurements ( P = .001). Conclusion: 3D volumetric measurement of the syndesmosis joint appears to be the most effective way to diagnose syndesmotic instability, compared with more traditional 2D syndesmosis measurement. Level of Evidence: Level III, retrospective comparative study.

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Background: Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. Methods: Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. Results: Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state ( P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). Conclusion: Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. Clinical Relevance: These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.

Background: The rapid increase in the consumption of prescription opioids has become one of the leading medical, economic, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among all operative specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures and identify risk factors associated with higher use. Methods: A total of 535 patients who underwent foot and/or ankle surgery between August 2016 and March 2018 were included in the study. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the 2-week postoperative visit, the patients self-reported the amount of consumed opioids. Prescription details, number of opioid pills consumed, refill requests, pain-issue-related telephone calls, and additional physician/emergency department visits were documented. Patient demographics, comorbidities, use of regional anesthesia, hospitalization, surgery type/severity, and preoperative opioid use were collected. A total of 244 patients had a sufficiently complete data set for inclusion in the final cohort. Subjects had a mean age of 50 years (±16.3) and a body mass index (BMI) of 29 (±6.1). Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure. Results: On average, patients consumed 46.6% of the prescribed pills following a bony procedure and 42.4% after a soft tissue procedure, which resulted in a total of 4496 leftover pills. BMI, procedure type (bony vs soft tissue)/severity, and number of opioids prescribed were positively correlated with elevated consumption rates ( P = .008, P < .001, P < .001, P < .001, respectively). Conclusion: BMI, procedure type, and higher initial pill dispensation correlated with a larger number of consumed pills during the postoperative period. On average, patients took 42.4% of the prescribed opioid after soft tissue procedures and 46.6% after bony procedures, resulting in a significant number of unused pills. Future guidelines are necessary to improve postoperative pain management to prevent narcotic overprescription and minimize the downstream potential for unprescribed community opioid access. Level of Evidence: Level III, retrospective case series, analytic.