Study Design & Demographics

Foot/ankle research methodology: addressing statistical pitfalls, clinically meaningful effect sizes, and injury surveillance standardization.

Overview

Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines for rehabilitation following hip arthroscopy [1]. Patient characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [2]. Factors leading to impactful conclusions and clinical change include the role of outcome selection, study design, presentation of results, and stakeholder involvement [5].

Indications and contraindications for three-dimensional metallic implants for reconstruction of critical bone defects after trauma will continue to be refined as more outcomes data become available [6]. High-level studies on medial unicompartmental knee replacement after failed high tibial osteotomy are lacking, and further prospective comparative studies reporting long-term outcomes are needed [9]. Further studies with structured study protocols should be performed to better understand risk factors and improve treatment outcomes for infection following fractures of the proximal tibia [11].

Clinical outcomes of patients aged 50 and younger who underwent reverse total shoulder arthroplasty (RTSA) are comparable to those of patients aged at least 65 presenting matched indications [27]. Advancements in prosthesis design, expanding indications, a trend toward younger patient populations, and the management of postoperative complications are anticipated to emerge as research hotspots for reverse total shoulder arthroplasty [50]. Clinical results and survivorship for short stems were very good despite widened indications [48]. Overall retrospective evaluation of short stems was similar to primary hip implants [48].

Providers and registries should consider the relative prevalence of published outcome measures when selecting patient-reported outcome measures (PROMs) to better facilitate future cross-study comparison [29]. Studies on secondary patella resurfacing for dissatisfaction following primary knee arthroplasty lacked standardized objective selection criteria [32]. Available data on secondary patella resurfacing for dissatisfaction following primary knee arthroplasty was predominantly retrospective [32]. Studies on secondary patella resurfacing for dissatisfaction following primary knee arthroplasty exhibited high heterogeneity and variation in outcome reporting [32].

Selection of instruments to measure health outcomes in a study protocol should be guided by careful consideration of the rationale and objectives of the study [37]. Instruments used to measure health outcomes should capture a comprehensive representation of health and be reliable, valid, and responsive to change [37].

Anatomy & Pathophysiology

General Biomechanics and Evaluation

Accurate evaluation and appropriate treatment of adult flatfoot require careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot [24]. The textbook chapter provides a descriptive overview of foot and ankle biomechanics, gait analysis, and treatment principles for common nail disorders [82]. The anatomy of the lower extremity relates directly to the ability to run, the running gait cycle, and abnormal anatomy and biomechanics related to running injuries [94].

Osseous and Soft Tissue Kinematics

The existence of the Achilles tendon and ankle position significantly influence the kinematic coupling relationship between tarsal bones, whereas increased stiffness of the Achilles tendon has no influence on this relationship [84]. Dynamic fluoroscopy combined with a plantar pressure plate can be used to obtain in vivo viscoelastic properties and other data of the heel pad during actual gait [62]. Foot bone motion was described using a biomechanically near-physiological gait simulator with 6 degrees of freedom of the tibia [38]. Subject-specific, dynamic, multisegment ankle and foot models can be generated to develop linked inverse dynamic and forward dynamic biomechanical foot models for predicting the effect of and improving the efficacy of orthotic devices [68].

Gait and Joint-Specific Kinematics

Changing toe direction significantly affects knee kinetics and kinematics during landing [26]. Gait biomechanics after total knee arthroplasty are not restored to normal [74]. The kinematics of cruciate stabilizing (CS) and cruciate retaining (CR) total knee joint replacements are comparable [89]. The study clarified rearfoot, midfoot, and forefoot kinematics when running in participants with normal foot and flatfoot [85]. The term 'adaptation of running biomechanics' reflects the outcome of an intervention rather than a final adaptation to barefoot running [87]. Significant differences in support leg kinematics at flat-foot contact with the ground during the kicking cycle were seen between soccer players with and without chronic ankle instability [98].

Pediatric and Adolescent Considerations

There is a statistically significant correlation between morphological variables of the foot and postural stability in children aged 10–15 years [92]. Altered sagittal plane biomechanics were observed in female adolescents, but not in male adolescents, during a jump-landing task [103].

Lesser Toe Anatomy and Pathology

The paper describes the normal anatomy and biomechanics of the lesser toes [95]. The paper describes the pathology of commonly adult lesser toe deformities [95].

Tenorrhaphy and Stability

All four side-to-side suture configurations for tenorrhaphy sustained loads well above physiologic loads expected in tendons in the foot and ankle [88]. None of the four side-to-side suture configurations for tenorrhaphy distended appreciably during cyclic loading [88]. Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability [100].

Comparative Therapeutic Outcomes

Cognitive functional therapy achieved better improvements in gait kinetics compared to movement system impairment treatment in chronic low back pain patients [102].

Classification

Classification systems and the identification of differences among products are necessary to understand the implications of variability in Platelet-rich Plasma [21]. Classification systems must be both reliable and valid to be useful [69]. Because confirming validity is difficult, a minimum criterion for acceptance of classification systems is a high degree of both interobserver and intraobserver reliability [69]. Epidemiology and non-epidemiology-trained reviewers can apply the levels-of-evidence guide to published studies with acceptable interobserver agreement [46], although the validity of the levels-of-evidence system remains a question for future research [46].

General Risk and Evidence: A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay for primary knee arthroplasty [41]. A more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes in critically injured adults [45].

Osteochondritis Dissecans (OCD): The ROCK Osteochondritis Dissecans Knee Arthroscopy Classification System facilitates multi-center studies for OCD [51]. A simpler classification system for osteochondritis dissecans could be widely applicable because the results could more accurately drive clinical treatment decision making for clinicians [61].

Tibial Plateau Fractures: Employing individualized classification systems remains the most logical approach for tibial plateau fractures [54].

Congenital Upper Limb Anomalies: The Oberg, Manske, and Tonkin (OMT) classification system was straightforward to use and allowed for the classification of all individuals with congenital upper limb anomalies [59].

Total Knee Arthroplasty (TKA): The proposed classification system for TKA with the Kinematic Alignment technique describes six specific issues to consider, with specific recommendations for each situation type to improve the reliability of prosthetic implantation [64]. The classification developed for condylar-stabilized designs in total knee arthroplasty allows for appropriate grouping and comparison of distinct CS implants [67].

Total Hip Arthroplasty (THA): A consensus on a comprehensive and reliable classification system and management algorithm for femoral bone defects in revision total hip arthroplasty is still lacking [66].

Lateral Discoid Meniscus: A novel classification system that more comprehensively and descriptively characterizes the spectrum of lateral discoid meniscus pathology demonstrated moderate or substantial agreement in most diagnostic categories analyzed [70].

Cemented Femoral Stem Design: The authors propose a new four-part classification system to aid in the comparison of results and better understanding of implant biomechanics for cemented femoral stem design and cementation techniques [75].

Open Fractures: The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to collect enough data to assess reliability, validity, and ideal usage of the open fracture classification [76].

Clinical Presentation

Diagnostic Limitations: Clinical findings in isolation demonstrate inadequate diagnostic performance for acute compartment syndrome, with sensitivity ranging from 13% to 54% [22]. Similarly, patients presenting with signs and symptoms of subacromial pain syndrome exhibit a high prevalence of conflicting and concomitant diagnoses [34].

Symptomatology and Demographics: A range of symptom severity endorsement is observed at the initiation of a graduated return-to-play protocol, with higher endorsement associated with higher baseline symptom endorsement and select demographic and medical history factors [20]. The most influential studies in sports-related concussion focus most heavily on symptomatology and epidemiology/demographics [39]. Understanding sex-based differences in the incidence, clinical presentation, and functional outcomes of common sports injuries is important to optimize musculoskeletal care and improve treatment outcomes [47].

Patient Profiles and Heterogeneity: Cluster analysis offers the opportunity to develop a whole-patient profile that reflects the contextual interactions of sociodemographic and clinical variables in predicting outcomes of total knee arthroplasty [35]. No differences in patient characteristics and clinical symptoms were found between groups in children with culture-negative osteoarticular infections [36]. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines for rehabilitation following hip arthroscopy [1].

Investigations

Plain radiography: Indications and Timing: Repeat radiographic assessment 2–3 weeks post-injury is supported prior to making definitive treatment decisions for completely displaced adolescent clavicle fractures regarding shortening changes in the first 2 weeks [106]. Limitations and Protocols: Radiological evaluation protocols for calcaneal fracture reduction and fixation require evaluation of more aspects than currently used, according to a Delphi consensus [90]. In the assessment of the anterolateral ligament of the knee after primary versus revision anterior cruciate ligament reconstruction, no definite relevance was observed between image and functional outcome [109].

MRI: Diagnostic Utility and Sequencing: MRI is evolving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities, serving as a complete answer for cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [101]. There is currently no best MRI method for visualizing bone, despite MRI-based synthetic CT showing promise as a radiation-free alternative to conventional CT in orthopaedics [111]. Optimal MRI sequences for characterizing and diagnosing individual syndesmotic structures in asymptomatic and injured cohorts should be clinically implemented to aid in future pre-operative planning and post-operative assessment [110]. Magnetic resonance imaging is emerging as a valuable tool to confirm the diagnosis and guide treatment for fatigue fractures of the femoral neck in athletes [108]. MRI during the initial management of lower limb fractures associated with multiligament knee injury can lead to better outcomes [91]. Prognostic Value: MRI at 12 months can predict longer-term clinical outcomes up to 17 years after autologous chondrocyte implantation [113]. Specific Pathologies: Abnormal preoperative MRI findings do not influence the outcome of unicompartmental knee arthroplasty (UKA) when modern radiographic and clinical criteria are met [31]. Clinical and radiological outcomes for arthroscopic distal tibial allograft with endobutton fixation for anterior shoulder instability were excellent at 2 years, though this is interpreted in the context of a high lost to follow-up rate [16]. The first report of osteochondral allograft transplant of the patella using femoral condylar allografts showed encouraging short-term clinical and MRI results, while improved matching is noted as desirable [112]. MRI-based imaging results for osteochondral lesion repair using MaioRegen® allograft require further clarification by mid-term studies [57].

CT: Parameters and Outcomes: CT parameters were independent of clinical or patient variables, and osseous incorporation was the most reliable CT parameter for evaluating osseous incorporation after osteochondral allograft transplantation [104].

Other Considerations: There is a limited correlation between structural and clinical outcomes in autologous osteochondral transfer, as clinical outcomes improved despite stable MRI findings at a mean 4-year follow-up [83]. Functional scores and radiological outcomes were improved in the surgical treatment of patellar instability in children with Down syndrome [105]. Magnetic Resonance Imaging-based 3-dimensional models of the pelvis and hip using machine learning for automatic bone segmentation in dynamic hip impingement simulation are feasible with routine MRI and short image acquisition time [96]. Prospective studies are needed to critically evaluate the diagnostic utility of imaging for preoperative assessment before radical prostatectomy, as economic and radiation protection reasons suggest avoiding unnecessary CT/MRI while their omission in indicated cases is unjustified [97].

Treatment

Non-Operative

Non-operative management is often the initial strategy for various orthopaedic conditions, though outcomes vary significantly by pathology. For primary and posttraumatic elbow arthritis, conservative treatment is almost always initiated, with surgery reserved for refractory cases [127]. Similarly, nonoperative treatment is recommended initially for Morton’s interdigital neuroma, with operative intervention indicated only after conservative measures fail [125]. In the management of Ehlers-Danlos syndromes, non-operative treatment is preferable, although specific joint stabilization and nerve decompression procedures can provide symptomatic relief for carefully selected patients when conservative measures fail [123]. For juvenile osteochondritis dissecans of the knee, no significant difference in outcomes was observed between non-operative methods with unloader bracing versus those without or other modalities [115]. Nonoperative treatment is also preferable for teenagers with completely displaced clavicle fractures, supporting nearly perfect outcomes and questioning the role of acute operative management given its associated risks and costs [107]. For rotator cuff tears, nonoperative treatment should be performed early for optimal outcomes [129]. Additionally, both nonsurgical management (immobilization and nonweight bearing) and surgical management have demonstrated good results for navicular stress fractures [128].

However, non-operative approaches may yield suboptimal results in specific scenarios. Nonoperative treatment or delayed surgery for distal semimembranosus tendon avulsions may result in poor outcomes [116]. Conservative treatment or non-anatomical repair of rupture of the distal tendon of the biceps brachii results in significant loss of supination strength and variable loss of flexion strength [117]. In elbows with osteochondritis dissecans of the capitellum, those that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically, although an initial trial of non-operative treatment did not adversely impact the success of future surgery at long-term follow-up [120]. For proximal hamstring avulsions in middle-aged patients, no difference in patient-reported outcome measures (LEFS) was identified between surgically and non-surgically treated patients [126].

Operative

Indications: Clinical results for total knee arthroplasty using hinge joints generally depend on implant design, appropriate technical use, and adequate indications [30]. Indications and contraindications for three-dimensional metallic implants for reconstruction of critical bone defects after trauma will continue to be refined as more outcomes data become available [6]. For Ehlers-Danlos syndromes, specific joint stabilization and nerve decompression procedures are indicated for carefully selected patients when conservative measures fail [123]. Operative treatment for Morton’s interdigital neuroma is indicated after nonoperative management has failed [125]. Surgery may be indicated for elbow arthritis in cases refractory to conservative management [127].

Surgical Approach / Technique: Both operative management (open reduction and internal fixation) and nonoperative management have demonstrated good results for navicular stress fractures [128]. For grade III medial collateral ligament (MCL) tears, both operative and nonoperative management demonstrated clinical improvements between study enrollment and 2-year follow-up [99]. In the context of distal biceps rupture, non-anatomical repair is associated with significant functional loss [117].

Other Considerations: The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [2]. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines for rehabilitation following hip arthroscopy [1]. Confounding by indication and patient selection bias make it difficult to compare dual-mobility cups with conventional total hip arthroplasty (THA) designs based on registry data alone [58]. Reclassification using standardized definitions demonstrated changes in reported treatment efficacy for periprosthetic joint infections in oncologic endoprostheses [63].

Complications

Long-term Durability and Outcomes: Long-term studies are warranted to determine if head impacts in youth football influence long-term health [3]. Long-term follow-up is necessary to evaluate differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [4]. There is a paucity of studies showing long-term differences in functional outcomes or implant survivorship for robotic unicompartmental knee arthroplasty, and further clinical studies are required to establish how statistical differences in accuracy translate to long-term outcomes [7]. Longer-term follow-up is required to determine whether the excellent results of isolated polyethylene insert exchange for flexion instability after primary total knee arthroplasty are durable over time [8]. Further prospective comparative studies reporting long-term outcomes are needed for medial unicompartmental knee replacement after failed high tibial osteotomy, as high-level studies on this topic are lacking [9]. Longer term follow-up data are needed to more adequately assess the outcomes and durability of ulnar collateral ligament repair with collagen-coated suture tape augmentation [10]. Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes for infection following fractures of the proximal tibia [11]. Further follow-up studies are needed to determine the long-term outcomes of patients undergoing open repair of quadriceps tendon with suture anchors and semitendinosus tendon allograft augmentation [12]. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm observations regarding patient reported outcomes following fixation of Jones fractures in elite athletes with BMAC [15]. Further clinical studies are needed to clarify the long-term outcomes of titanium versus carbon fiber peek nailing for impending or pathologic fracture of the long bone [77].

Natural History and Disease Progression: Studies of natural history and retrospective studies of treatment for scoliosis and kyphosis should adopt a 10-degree difference as an indication of a true change [13]. The natural history of osteoarthritic patients undergoing primary TKA or THA provides data to accurately advise patients about the natural history of their disease in other joints [17]. The natural history of neonatal brachial palsy with absent biceps function at three months of age provides a benchmark for comparing outcomes with microsurgical repair [18]. Melorheostosis progresses in both childhood and adult life, often causing contractures, deformities, and pain that may require surgical treatment but frequently progress despite intervention [19]. The natural history of Achilles tendinopathy is typically a long protracted course where management focuses on physiotherapy; while exercises improve function in the majority, 40% of patients report ongoing pain even after five years of therapy [122]. Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist [93].

Other Considerations: Lower rates of ceramic femoral head use in non-white patients in the United States did not translate into worse clinical outcomes on a short-term follow-up [14]. The morbidity and mortality in radical cystectomy are comparable to large published series [114]. Registry studies use inconsistent methods to account for patients lost to follow-up, and rates of patients lost to follow-up are unacceptably high [118]. In a study of spine-fusion operation for tuberculosis of the spine, 100 of 192 patients were followed for five years or more, with the remaining patients followed for less time or having died [124].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or desk work return.

Full activity (months): Evidence does not specify a month range for full activity, manual work, or sport return.

Complete recovery / outcome plateau (months): Long-term follow-up is necessary to determine if head impacts in youth football influence long-term health [3]. Long-term follow-up is necessary to evaluate differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [4]. Further clinical studies are required to establish how statistical differences in accuracy translate to long-term functional outcomes or implant survivorship in robotic unicompartmental knee arthroplasty [7]. Longer-term follow-up is required to determine whether the excellent results of isolated polyethylene insert exchange for flexion instability after primary total knee arthroplasty are durable over time [8]. Longer term follow-up data are needed to more adequately assess the outcomes and durability of ulnar collateral ligament repair with collagen-coated suture tape augmentation [10]. Further follow-up studies are needed to determine the long-term outcomes of open repair of quadriceps tendon with suture anchors and semitendinosus tendon allograft augmentation [12]. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm observations regarding patient-reported outcomes following fixation of Jones fractures with BMAC in elite athletes [15]. Long-term clinical and radiographic follow-up is necessary to determine the natural history of asymptomatic talar bone marrow edema in professional ballet dancers [136].

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, or weight-bearing progression.

Functional milestones: Differences in ceramic femoral head use rates among non-white patients did not translate into worse clinical outcomes on short-term follow-up [14]. Clinical and radiological outcomes of arthroscopic distal tibial allograft with endobutton fixation for anterior shoulder instability were excellent at 2 years, but this should be interpreted in the context of a high lost to follow-up rate [16]. Functional outcomes of post-traumatic bone defect reconstruction by the induced membrane technique can be expected to be satisfactory despite the retrospective design and loss to follow-up [56]. Primary meniscal allograft transplantation in the adolescent population resulted in predictable improvements in functional outcomes maintained at an average follow-up of 9.5 years [72]. Unicompartmental knee arthroplasty caseload and usage can achieve results similar to long-term series with an average 10-year survival of 94% [134].

Other Considerations: Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change in scoliosis and kyphosis radiographs [13]. The study on the fate of remaining knee(s) or hip(s) in osteoarthritic patients includes the largest cohort and longest follow-up time ever reported, providing data to accurately advise patients about the natural history of their disease in other joints [17]. The natural history of neonatal brachial palsy with absent biceps function at three months of age provides a benchmark for comparing outcomes with microsurgical repair [18]. Melorheostosis progresses in both childhood and adult life, often causing contractures, deformities, and pain that may require surgical treatment but frequently progress despite intervention [19]. Defining comparison groups based on an exposure that occurs after the beginning of the study follow-up results in a period of immortal time in the analysis of time-to-event outcomes [130]. From a cohort of consecutive patients from a tertiary referral centre, no prognostic demographic or lesion factors for procedure survival could be identified for arthroscopic bone marrow stimulation for osteochondral lesions of the talus at 15 years [131]. Long-term survival of femoral stems in total hip prostheses was associated with a tumor-free interval of more than two years and one to four thoracotomies at which few foci were present [132]. Prognosis of neonatal septic arthritis is significantly influenced by follow-up duration, anatomic site of involvement (particularly the hip), and the timeliness of intervention [133]. Prognosis of malignant hemangioendothelioma of bone is poor, with a five-year survival for only two of the six patients in the series [135].

Key Evidence

• [L2] Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. (10.3389/fsurg.2015.00021)
• [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. (10.1007/s11999-008-0585-9)
• [L2] Longitudinal studies are warranted to determine if these impacts influence long-term health. (10.1177/2325967119s00001)
• [L1] Long-term follow-up will be necessary to evaluate any differences in long-term durability. (10.1016/j.arth.2019.10.002)
• [Paper] The purpose of this review is to discuss which factors lead to impactful conclusions and clinical change, including the role of outcome selection, study design, presentation of results, and stakeholder involvement. (10.1016/j.injury.2019.10.082)
• [L5] With increased use and as more outcomes data become available, indications and contraindications will continue to be refined and best practices established. (10.5435/jaaos-d-22-00676)
• [L4] However, there is a paucity of studies showing long-term differences in functional outcomes or implant survivorship, and further clinical studies are required to establish how statistical differences in accuracy translate to long-term outcomes. (10.1302/2058-5241.5.190089)
• [L4] Longer-term follow-up is required to determine whether these results are durable over time. (10.1016/j.arth.2020.01.006)
• [L4] Further prospective comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are lacking. (10.1530/eor-21-0133)
• [L4] Longer term follow-up data are needed to more adequately assess the outcomes and durability of this procedure. (10.1177/23259671211038320)
• [L1] Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes. (10.1186/s12891-017-1847-z)
• [Paper] However, further follow-up studies are needed to determine the long-term outcomes of these patients. (10.1016/j.eats.2017.08.005)
• [L4] Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change. (10.2106/00004623-199072030-00003)
• [L3] These differences did not translate into worse clinical outcomes on a short-term follow-up. (10.1016/j.arth.2022.03.050)
• [L3] A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations. (10.1177/2325967118s00160)
• [L3] Clinical and radiological outcomes were excellent at 2 years, but this should be interpreted in the context of a high lost to follow-up rate in this cohort. (10.1016/j.arthro.2024.11.028)
• [L3] This study includes the largest cohort and longest follow-up time ever reported, providing data to accurately advise patients about the natural history of their disease in other joints. (10.1016/j.arth.2012.10.008)
• [L2] A range of symptom severity endorsement was observed at GRTP protocol initiation, with higher endorsement among those with higher baseline symptom endorsement and select demographic and medical history factors. (10.1177/0363546520913252)
• [L4] Classification systems and identification of differences among products are needed to understand the implications of variability. (10.5435/jaaos-21-12-739)
• [L4] Clinical findings in isolation have inadequate diagnostic performance characteristics with sensitivity ranging from 13% to 54%. (10.2106/jbjs.rvw.17.00016)
• [L5] Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, will allow accurate evaluation and appropriate treatment. (10.5435/00124635-199509000-00005)
• [L1] The efficacy of future RCTs can be enhanced by randomizing patients in specific patient cohorts stratified to age and gender in multicenter RCTs. (10.1007/s11999-010-1459-5)
• [L4] Changing toe direction significantly affects knee kinetics and kinematics during landing. (10.1007/s00167-013-2815-2)
• [L3] The study shows that clinical outcomes of patients aged 50 and younger who underwent RTSA are comparable to those of aged at least 65 and presenting matched indications. (10.1016/j.jisako.2025.100759)
• [L4] Providers and registries should consider the relative prevalence of published outcome measures when selecting which PROMs to use, to better facilitate future cross-study comparison. (10.1016/j.arth.2018.06.034)
• [L4] Clinical results generally depend on implant design, appropriate technical use, and adequate indications. (10.1302/2058-5241.4.180056)
• [L3] The results of this study suggest abnormal preoperative MRI findings do not have an influence on the outcome of UKA when modern radiographic and clinical criteria are met. (10.1016/j.arth.2013.05.011)
• [L1] However, studies lacked standardized objective selection criteria for the procedure and the available data was predominantly retrospective, with high heterogeneity and variation in outcome reporting. (10.1016/j.arth.2023.10.027)
• [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. (10.1177/23259671251332942)
• [L3] Cluster analysis offers the opportunity to develop a whole-patient profile that reflects the contextual interactions of sociodemographic and clinical variables in predicting outcomes. (10.1016/j.arth.2024.09.039)
• [L3] However, no differences in patient characteristics and clinical symptoms were found between the two groups. (10.1530/eor-24-0048)
• [Paper] In designing a study protocol, the selection of instruments to measure health outcomes should be guided by careful consideration of the rationale and objectives of the study, ensuring instruments capture a comprehensive representation of health and are reliable, valid, and responsive to change. (10.1016/j.injury.2010.11.049)
• [L5] This study described foot bone motion using a biomechanically near-physiological gait simulator with 6 DOF of the tibia. (10.1186/s13018-020-01830-3)
• [L4] The most influential studies in sports-related concussion are predominantly cohort studies (Level IV evidence) and descriptive articles (Level V evidence) published in the United States after 2006, with current research focusing most heavily on symptomatology and epidemiology/demographics. (10.1016/j.asmr.2021.06.016)
• [L3] A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay. (10.1016/j.arth.2008.02.010)
• [L3] In this subset a more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes. (10.1016/j.injury.2009.03.004)
• [L4] Epidemiology and non-epidemiology-trained reviewers can apply the levels-of-evidence guide to published studies with acceptable interobserver agreement, though the validity of this system remains a question for future research. (10.2106/00004623-200408000-00016)
• [L5] Understanding sex-based differences in the incidence, clinical presentation, and functional outcomes of common sports injuries is important to optimize musculoskeletal care and improve treatment outcomes. (10.5435/jaaos-d-16-00607)
• [L4] Clinical results and survivorship were very good despite widened indications, giving an overall retrospective evaluation similar to primary hip implants. (10.1530/eor-2025-0056)
• [L5] Advancements in prosthesis design, expanding indications, a trend toward younger patient populations, and the management of postoperative complications are anticipated to emerge as research hotspots. (10.1530/eor-23-0106)
• [L4] This classification system will facilitate multi-center studies for OCD. (10.1177/2325967113s00074)
• [L2] Therefore, employing individualized classification systems remains the most logical approach at present. (10.1530/eor-2024-0184)
• [L5] The article outlines essential methodological criteria for clinical trials, including prospective design with concurrent controls, random allocation, and blind assessment, to ensure new therapeutic approaches are adequately evaluated before widespread clinical introduction. (10.2106/00004623-198567080-00027)
• [Paper] Functional outcomes can be expected to be satisfactory despite the retrospective design and loss to follow-up. (10.1016/j.otsr.2018.11.012)
• [L4] MRI based imaging results need further clarification by mid term studies. (10.1177/2325967116s00046)
• [L1] The authors note that confounding by indication and patient selection bias make it difficult to compare the two groups based on registry data alone. (10.1097/corr.0000000000002275)
• [L3] The OMT classification system was straightforward to use and allowed for the classification of all individuals. (10.1016/j.jhsa.2014.10.038)
• [L5] Understanding the difference between efficacy and effectiveness in clinical trials is very important in interpreting the results, and deciding if you can use the conclusions to inform your clinical practice. (10.1302/0301-620x.99b4.bjj-2016-1247)
• [L4] This simpler classification system could be widely applicable because the results could more accurately drive clinical treatment decision making for clinicians. (10.1177/2325967120s00262)
• [L4] By using dynamic fluoroscopy combined with the plantar pressure plate, the in vivo viscoelastic properties and other data of the heel pad in the actual gait can be obtained. (10.1186/s12891-022-05197-w)
• [L2] Reclassification using standardized definitions demonstrated changes in reported treatment efficacy. (10.5435/jaaos-d-25-00523)
• [L5] The proposed classification system describes six specific issues to consider, with specific recommendations for each situation type to improve the reliability of prosthetic implantation. (10.1302/2058-5241.6.210042)
• [L5] Despite promising findings, heterogeneity limits generalizability, and further high-quality, standardized research is required to determine optimal treatment lengths. (10.1302/0301-620x.107b11.bjj-2025-0374.r2)
• [L4] A consensus on a comprehensive and reliable classification system and management algorithm is still lacking. (10.1530/eor-21-0088)
• [L4] The classification developed allows for appropriate grouping and comparison of distinct CS implants. (10.1016/j.arth.2025.05.039)
• [L4] This protocol will lead to the generation of unique datasets which will be used to develop linked inverse dynamic and forward dynamic biomechanical foot models that may be beneficial in predicting the effect of and thus improving the efficacy of orthotic devices for the foot and ankle. (10.1186/1471-2474-12-256)
• [L5] Classification systems must be both reliable and valid to be useful; however, because confirming validity is difficult, a minimum criterion for acceptance is a high degree of both interobserver and intraobserver reliability. (10.5435/00124635-200207000-00007)
• [L4] A novel classification system that more comprehensively and descriptively characterizes the spectrum of LDM pathology demonstrated moderate or substantial agreement in most diagnostic categories analyzed. (10.1177/2325967120s00244)
• [L4] At midterm follow-up, primary MAT in the adolescent population resulted in predictable improvements in functional outcomes maintained at an average follow-up of 9.5 years. (10.1177/2325967123s00060)
• [L5] Future studies should prospectively evaluate the effectiveness of individual or combined identified aspects for their influence on patient adherence in longitudinal study designs. (10.1186/s12891-023-06724-z)
• [L3] Gait biomechanics after TKA are not restored to normal. (10.1016/j.arth.2017.09.061)
• [L4] The authors propose a new four-part classification system to aid in the comparison of results and better understanding of implant biomechanics. (10.1302/2058-5241.5.190034)
• [L5] The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to collect enough data to assess reliability, validity, and ideal usage of the open fracture classification. (10.1016/j.injury.2012.12.016)
• [L3] Further clinical studies are needed to clarify the long-term outcomes of these implants. (10.1530/eor-22-0001)
• [Paper] The article reviews the hierarchy of evidence, quality indicators, and the balance between efficacy and effectiveness to guide clinicians in appraising intervention studies and applying evidence to individual patients. (10.1016/j.csm.2018.03.008)
• [L5] Well-conducted non-randomised studies, including case-series and observational cohort studies, can provide reasonably valid answers to clinically important questions regarding safety and effectiveness when RCTs are not feasible, provided methodological strengths and weaknesses are carefully considered. (10.1016/j.injury.2006.01.026)
• [L5] While a 2-year minimum follow-up period is generally preferred to ensure methodologic rigor and meaningful assessment of treatment durability, the authors encourage authors to justify shorter durations when clinical outcomes plateau earlier, depending on the research question, diagnosis, treatment, and primary outcome measure. (10.1016/j.arthro.2025.08.019)
• [L4] High proportions of retrospectively registered or unregistered trials and a very high proportion of inconsistencies in reporting of primary outcomes compared to the trial registries were found. (10.1016/j.arth.2022.02.105)
• [L4] The further improvement in clinical outcomes, despite stable MRI findings, suggests a limited correlation between structural and clinical outcomes. (10.1177/23259671251356267)
• [L5] The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, while increased stiffness of the Achilles tendon has no influence. (10.1186/s13018-020-01728-0)
• [L3] The study aimed to clarify rearfoot, midfoot, and forefoot kinematics when running in participants with normal foot and flatfoot. (10.1002/jor.24877)
• [L5] Undertaking more high-quality randomized clinical trials can improve the evidence available for determining treatment effectiveness, resulting in better patient care. (10.5435/00124635-201008000-00002)
• [L5] The authors conclude that the terminology used in their study does not interfere with the interpretation of their results, as the term 'adaptation of running biomechanics' reflects the outcome of their intervention rather than a final adaptation to barefoot running. (10.1177/0363546519878154)
• [L5] All four side-to-side configurations sustained loads well above physiologic loads expected in tendons in the foot and ankle, and none distended appreciably during cyclic loading. (10.2106/jbjs.l.01552)
• [L1] The kinematics of CS and CR TKJR are comparable. (10.1177/2325967116s00091)
• [Paper] This Delphi consensus shows that more aspects require evaluation than currently used in radiological evaluation protocols. (10.1007/s00402-013-1823-5)
• [L4] We consider an MRI during the initial management can lead to better outcomes. (10.1177/2325967117s00029)
• [L4] There is a statistically significant correlation between morphological variables of the foot and postural stability. (10.1186/s12891-019-2923-3)
• [L5] Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist. (10.1016/j.csm.2010.09.008)
• [Paper] This article discusses the anatomy of the lower extremity as it relates to the ability to run, the running gait cycle, and abnormal anatomy and biomechanics related to running injuries. (10.1016/j.csm.2011.10.001)
• [L5] The paper describes the normal anatomy and biomechanics of the lesser toes, the pathology of commonly adult deformities, and discusses the rationale behind various treatment strategies, proposing management algorithms based on current literature. (10.1302/2058-5241.1.160017)
• [L3] The method was feasible with routine MRI and a short image acquisition time. (10.1177/23259671251334138)
• [L4] The study highlights the need for prospective studies to critically evaluate the diagnostic utility of imaging, as economic and radiation protection reasons suggest avoiding unnecessary CT/MRT, while their omission in indicated cases is also unjustified. (10.1007/s00120-009-2207-x)
• [L4] Significant differences between players with and without CAI were seen in the support leg kinematics at flat-foot contact with the ground during the kicking cycle. (10.1177/23259671221112966)
• [L3] Both operative and nonoperative management of MCL tears demonstrated clinical improvements between study enrollment and 2-year follow-up. (10.1177/2325967117s00126)
• [L5] Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability. (10.1177/23259671211021352)
• [L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. (10.2106/jbjs.rvw.15.00093)
• [L1] CFT also achieved better improvements in gait kinetics. (10.1186/s12891-023-06815-x)
• [L3] Altered sagittal plane biomechanics were observed in female adolescents, but not in male adolescents during a jump-landing task. (10.1177/2325967120s00281)
• [L4] CT parameters were independent of clinical or patient variables within the study population, and osseous incorporation was the most reliable CT parameter. (10.1177/23259671211022682)
• [L4] Functional scores and radiological outcomes were improved. (10.1186/s13018-024-04730-y)
• [L3] The findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions. (10.1177/2325967121s00455)
• [L2] This study further supports the role of non-operative treatment for teenagers, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs. (10.1177/2325967123s00041)
• [L4] Magnetic resonance imaging is emerging as a valuable tool to both confirm the diagnosis and guide treatment. (10.5435/00124635-199711000-00001)
• [L3] Regardless of observational differences between the 2 groups, no definite relevance was observed between the image and the functional outcome. (10.1177/23259671211026237)
• [L4] The authors propose that the optimal MRI sequences defined in this study be clinically implemented to aid in future pre-operative planning and post-operative assessment. (10.1177/2325967114s00075)
• [L4] There is currently no best MRI method for visualizing bone. (10.2106/jbjs.25.00976)
• [L5] The authors conclude that while improved matching is desirable, the first report of this technique showed encouraging short-term clinical and MRI results. (10.1177/23259671211000096)
• [L3] MRI at 12 months can predict longer-term clinical outcomes after ACI. (10.1177/2325967118788280)
• [L4] The morbidity and mortality in the studied series are comparable to large published series. (10.1007/s00120-013-3401-4)
• [L4] No significant difference was seen between outcomes of patients treated with non-operative methods that included unloader bracing versus non-unloader bracing or other modalities. (10.1177/2325967116s00198)
• [L4] Nonoperative management or delayed surgery may result in poor outcomes. (10.1177/2325967117731102)
• [L4] Conservative treatment or non-anatomical repair results in significant loss of supination strength and variable loss of flexion strength. (10.2106/00004623-198567030-00011)
• [L2] Registry studies use inconsistent methods to account for patient lost to follow-up, and rates of patients lost to follow-up are unacceptably high. (10.1016/j.asmr.2021.07.016)
• [L3] Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically, though an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. (10.1177/2325967123s00024)
• [L5] Non-operative treatment is preferable, but for carefully selected patients, specific joint stabilization and nerve decompression procedures can provide symptomatic relief when conservative measures fail. (10.1002/ajmg.c.31551)
• [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. (10.1302/2058-5241.4.180025)
• [L3] The study was unable to identify any difference in patient-reported outcome measures (LEFS) between surgically and non-surgically treated patients. (10.1136/bmjsem-2019-000511)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
• [L5] Both nonsurgical management (immobilization and nonweight bearing) and surgical management (open reduction and internal fixation) have demonstrated good results. (10.5435/jaaos-d-20-00869)
• [L2] The results suggest that nonoperative treatment should be performed early for optimal outcomes. (10.1177/2325967118788531)
• [L5] In analysis of time-to-event outcomes, defining comparison groups based on an exposure that occurs after the beginning of the study follow-up results in a period of immortal time. (10.1016/j.arth.2021.06.012)
• [L3] From this cohort of consecutive patients from a tertiary referral centre no prognostic demographic or lesion factors for procedure survival could be identified. (10.1016/j.jisako.2023.03.007)
• [L4] Long-term survival was associated with a tumor-free interval of more than two years and one to four thoracotomies at which few foci were present. (10.2106/00004623-197658050-00006)
• [L1] Prognosis is significantly influenced by follow-up duration, anatomic site of involvement (particularly the hip), and the timeliness of intervention. (10.1186/s13018-026-06662-1)
• [L2] If they do this, they can expect to achieve results similar to long-term series with an average 10-year survival of 94%. (10.1016/j.arth.2017.04.063)
• [L4] Prognosis is poor, with a five-year survival for only two of the six patients in this series. (10.2106/00004623-197557010-00015)
• [L4] Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions. (10.1177/23259671231159910)

See Also

• Surgical Management

References

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[95] The pathology and management of lesser toe deformities. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.160017

[96] Magnetic Resonance Imaging–Based 3-Dimensional Models of the Pelvis and Hip Using Machine Learning for Automatic Bone Segmentation in a Dynamic Hip Impingement Simulation. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251334138

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[98] Biomechanical Characteristics of the Support Leg During Side-Foot Kicking in Soccer Players With Chronic Ankle Instability. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221112966

[99] Outcomes Following ACL and Grade III MCL Injuries. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00126

[100] Current Concepts on Subtalar Instability. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211021352

[101] Magnetic Resonance Imaging of Articular Cartilage. JBJS Reviews. 2016. DOI: 10.2106/jbjs.rvw.15.00093

[102] Comparison of cognitive functional therapy and movement system impairment treatment in chronic low back pain patients: a randomized controlled trial. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06815-x

[103] EFFECTS OF SPORTS SPECIALIZATION ON LOWER EXTREMITY SAGITTAL PLANE LOADING IN ADOLESCENT MALES AND FEMALES. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00281

[104] Evaluation of Osseous Incorporation After Osteochondral Allograft Transplantation: Correlation of Computed Tomography Parameters With Patient-Reported Outcomes. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211022682

[105] Outcomes of surgical treatment of patellar instability in children with Down syndrome. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04730-y

[106] Does Shortening Change in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures?. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00455

[107] Paper 15: 5 Year Radiographic and Functional Outcomes of Non-Operative Treatment of Completely Displaced Clavicle Fractures in Teenagers, A Prospective Study. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00041

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