Chronic Conditions

Chronic ankle & foot conditions: arthritis, malalignment, tendon pathology – diagnosis, conservative & surgical management options.

Overview

Management of chronic orthopaedic conditions requires a nuanced balance between patient optimization and precise surgical indication. Medical comorbidities, including diabetes and advanced age, are no longer contraindications to usual management recommendations [12]. However, patients must be counseled on the increased risk of adverse events presented by these comorbidities and optimized regarding their chronic conditions [10]. Focusing on the management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs in ambulatory surgical centers, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection [107].

Surgical indications should prioritize functional status and disability over arbitrary metrics. For anterior shoulder instability, indications should focus primarily on the degree of demonstrable chronic disability rather than the number of documented dislocations [91]. Conversely, surgery for recurrent posterior shoulder instability should be reserved for those with significant pain and functional disability, as most patients function well with conservative management [115]. Stricter indications potentially lead to underutilization of unicompartmental knee arthroplasty (UKA), as demonstrated by similar short-term patient-reported outcomes and survivorship between groups [74]. Surgical indication for gluteus medius tears is in symptomatic patients having failed a primary nonoperative protocol, highlighting the importance of patient selection [84].

For complex reconstructions and specific pathologies, evidence continues to evolve. 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 [92]. The appropriate indications and long-term outcomes of biologic enhancement options for stress fracture healing in athletes are yet to be determined [85]. Management approaches effective across chronic illnesses may be beneficial for high-cost patients with low back pain [3]. Individuals with chronic, incurable disorders require more than average support from their physician, and a comprehensive program of care stressing continuity is absolutely essential [118]. Future studies should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization to further refine treatment protocols [15].

Anatomy & Pathophysiology

Osseous & Syndesmotic Mechanics

The fibula is a dynamic bone critical for the kinematics and kinetics of both the knee and ankle joints [24, 55]. Its dynamic feature is equally important for the knee joint as it is for the ankle [55]. Restoration of normal fibular length is crucial to restore the biomechanics of the ankle [60]. Osteochondroma leading to proximal tibiofibular synostosis can cause persistent ankle pain and lateral knee pain [55]. Gait analysis evaluation of the shank after fibulectomy includes the proximal, middle, and distal regions [24].

Within the ankle, the cartilage properties of various topographic locations are significantly different, and opposing articulating surfaces exhibit significantly different biomechanical and biochemical properties [56]. The effect of talus cartilage defect area on ankle biomechanics is evident in the midstance and push-off phases [44]. Three-dimensional talar shape is not a factor in chronic mechanical ankle instability [46].

Syndesmotic integrity is maintained regardless of ankle position from 0° to 30° of plantarflexion, which does not change axial CT measurements in a cadaveric model [65]. However, the operative ankle exhibits greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities [49].

Ligamentous & Soft Tissue Integrity

Dynamic congruency of the joint, influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [46]. 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 [39].

Approximate ankle kinematic patterns and sufficient laxity could be obtained immediately after anterior talofibular ligament (ATFL) reconstruction even with an initial tension of 10 N [32]. The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, whereas increased stiffness of the Achilles tendon has no influence on this relationship [28].

Kinematics & Neuromuscular Control

It is important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes [25]. Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints [30]. These altered neuromuscular control and kinematics provide direct in vivo evidence to support the biomechanical model of ankle sprain in subjects with ankle instability [30].

Increased subtalar rotational motion is present in patients with symptomatic ankle instability under load and stress conditions [64]. Differences in kinematics between symptomatic and asymptomatic hindfeet are demonstrated when both feet are compared [64]. The injured and uninjured sides of individuals with unilateral chronic ankle instability (CAI) demonstrate biomechanical characteristics associated with increased risk of ankle sprain during unanticipated jumps [59]. Management strategies for CAI should target both ankles due to bilateral biomechanical abnormalities [59].

Systemic & Compensatory Biomechanics

Ankle functional impairments are present in patients with diabetes, with or without neuropathy [34]. Other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics in patients with diabetes [34]. No compensatory biomechanical function was observed in other foot joints when blood-induced cartilage damage alters the ankle joint load during walking [40].

Functional alignment in knee arthroplasty was associated with smaller changes in ankle alignment parameters, indicating its ability to better preserve native joint positioning [37]. There are striking similarities between the anatomy, biomechanics, diagnosis, and treatment of high ankle sprains and ACL knee injuries [36]. High ankle sprains and ACL knee injuries may represent a potential continuum or identical entities that warrants future biomechanical research on the pivot-shift injury link [36]. Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, allows accurate evaluation and appropriate treatment for flatfoot in the adult [52].

Classification

Chronic Pain and Soft Tissue: Common symptoms such as pain intensity and depressive and anxiety symptoms in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups [4]. Employing individualized classification systems remains the most logical approach for tibial plateau fractures [120]. The International EDS Consortium proposes a revised classification recognizing 13 subtypes of Ehlers-Danlos syndromes [119].

Joint and Bone Defects: A consensus on a comprehensive and reliable classification system and management algorithm for femoral bone defects in revision total hip arthroplasty is still lacking [108]. 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 [112]. 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 [122].

Pediatric and Developmental: The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns in children with cerebral palsy [111]. A classification system for ACL tears in the pediatric and adolescent population provides a step to achieve the goal of standardizing assessment [127].

Complex and Emerging Classifications: Use of classification systems provides more precise clinical information to describe analyzed groups of reflex sympathetic dystrophy (RSD) patients [83]. The treatment of chronic skeletal disorders of the forearm in adults is complex due to the involvement of both bone and soft-tissue structures and the lack of a generally accepted classification system [101]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [123]. A novel classification system for non-prosthetic peri-implant fractures has been proposed to aid further research [124]. Classification systems and identification of differences among products are needed to understand the implications of variability in platelet-rich plasma applications [66].

Other Considerations: The identified inflammatory cell types in human tendinopathy favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means a common pathophysiology cannot be concluded from the systematic review [126]. The framework for alternative payment models includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development [125].

Clinical Presentation

Accurate long-term diagnosis and treatment of chronic conditions require precise knowledge of pathophysiological relationships [2]. Management approaches effective across chronic illnesses may benefit high-cost patients with low back pain due to the association of comorbidities and cost [3]. Common symptoms such as pain intensity, depressive symptoms, and anxiety symptoms in chronic pain conditions carry important information for identifying clinically relevant subgroups [4]. Recognition of pain dysfunction requires clinical experience and sensitivity to listen to and properly interpret a patient's history [26].

History: The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination [6]. Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses [53]. All patients with rheumatoid arthritis are prompted to seek help by persistent, unmanageable symptoms, although some delay help-seeking [47]. Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies helps distinguish the source of upper extremity pain quickly [29].

Inspection and Palpation: Delayed diagnosis of acute osteomyelitis following closed fractures is common, with clinical clues including persistent pain, fever, and increased local tissue reaction weeks after injury [38]. Awareness and earlier recognition of signs and symptoms of ilio-psoas tendon rupture after total hip arthroplasty aids in diagnosis and directs appropriate management [35]. Diagnosis of aluminum intoxication osteomalacia should be considered in patients with chronic renal failure presenting with bone pain [45].

Range-of-Motion and Stability: Subtalar subluxation can recur and eventually become chronic if neglected [54]. Early and correct diagnosis and treatment are critical for clinical outcomes in synovial sarcoma, as misdiagnosis or delayed diagnosis can have devastating consequences [31]. Delayed diagnosis of posterior malleolar fractures impairs functional prognosis, leading to longer incapacity and more severe sequelae such as cracking, pain, and stiffness [33].

Special Tests: Imaging studies are reserved for cases of recalcitrant iliotibial band syndrome [6]. Exercise testing remains the mainstay for the diagnosis and treatment of pulmonary disorders in athletes [48]. Reliable epidemiological data for orchitis and infertility are lacking, and noninvasive diagnostic techniques for chronic asymptomatic inflammation are not yet available [54].

Red-Flag Patterns: Acute medical conditions present in about one in ten elderly drivers involved in motor vehicle collisions [27]. The most common clinical complaints about orthopedic sports surgeons are complications, misdiagnoses, and uncontrolled pain [43]. Early coping strategies do not influence the prognosis after whiplash injuries, and the CSQ does not appear appropriate for predicting chronic symptoms [50]. Treatment of pain dysfunction involves addressing acute anatomical problems, combined rehabilitation for psychological and physical issues, and reassessment of chronic problems [26].

Investigations

Plain radiography: Radiographs serve as the initial diagnostic test for femoral neck bone stress injuries in children and adolescents, though further imaging is usually necessary to establish the diagnosis and determine a treatment plan [96]. Key radiographic findings and a lowered threshold for additional imaging studies are essential for proper diagnosis of commonly missed peritalar injuries [63].

MRI: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [1]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [76]. It is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [76].

MRI confirms the proper diagnosis and indicates conservative treatment for knee injuries in rock climbing and bouldering [58]. In one third of cases, assessment using MRI substantially modified the treatment recommendations for knee injury and osteoarthritis outcomes following anterior cruciate ligament reconstruction [99]. Similarly, MRI substantially modified treatment recommendations for tibial eminence fractures in pediatric patients in one third of cases [100]. High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma [93].

For specific pathologies, MRI is valuable in diagnosing distal triceps tendon injury but is not always accurate, with false-positive results not uncommon; therefore, clinical examination must be combined with imaging for accurate diagnosis and treatment planning [81]. Pathologic MRI findings in elite overhead athletes can be present, yet they are often asymptomatic [95]. Treatment strategies for bone marrow edema vary based on symptom severity and MRI evidence, including physical modalities, pharmacological options, and surgical therapy [86].

MRI did not confirm any significant cartilage condition improvement in patients with tibiofemoral cartilage degeneration treated with platelet-rich plasma [80]. In the group where only an MRI was used for isolated patellofemoral joint arthroplasty, there was a 31% failure due to progression of the disease [67]. MRI-based imaging results following osteochondral lesion repair using MaioRegen® allograft need further clarification by mid-term studies [94].

Conversely, MRI is time-consuming, expensive, and can lead to treatment delays in diagnosing acute Achilles tendon ruptures; clinicians should rely on history and physical examination for this diagnosis rather than MRI [89].

CT: Diagnosis of retroperitoneal fibrosis relies on imaging (CT/MRI) and histology [62].

Other Considerations: Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1]. Longer-term clinical follow-up is needed to understand the clinical impact of radiological findings regarding medial meniscus posterior root repair [70] and arthroscopic capsulodesis combined with transtibial repair of posteromedial root lesions [71]. Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies of mimickers of cervical radiculopathy [72]. The sensitivity and specificity of imaging procedures for detecting recurrence of renal cell carcinoma remain unclear due to a lack of standardized follow-up protocols [87].

Treatment

Non-Operative Management

Conservative management serves as the primary intervention for a wide spectrum of chronic orthopaedic conditions. For chronic non-specific low back pain, multidisciplinary group videoconferencing is feasible and may shift patients from surgical to non-surgical candidacy [78], while management strategies effective across chronic illnesses benefit high-cost patients [3]. In the elbow, nonoperative treatment is almost always initiated for primary and posttraumatic arthritis, with surgery reserved for cases refractory to conservative care [41]. Similarly, anterior ankle impingement and posterior ankle impingement with flexor hallucis longus pathology are managed initially with injections, physical therapy, and activity modification; surgery is indicated only when these measures fail [61, 68].

For foot and ankle pathologies, non-insertional Achilles tendinopathy often yields excellent clinical results with conservative care [73], and high-volume injection (HVI) may outperform platelet-rich plasma (PRP) in the short term for chronic midportion disease [90]. Morton’s interdigital neuroma requires initial nonoperative management, with operative treatment indicated only after failure [75]. Plantar fasciitis responds to nonsurgical intervention in approximately 90% of patients, with surgery reserved for a small subset with persistent, severe symptoms refractory to nonsurgical care for at least 6 to 12 months [79]. Chronic whiplash is managed with comprehensive exercise programs [113] or combined dry needling and exercise [98]. Rib-tip syndrome treatment is generally effective, with surgery indicated if symptoms persist or recur [69]. Mucoid degeneration of the patellar ligament in athletes warrants prolonged non-operative treatment, with operative excision considered if unsuccessful [82].

Current non-surgical managements for osteoarthritis do not alter the clinical course or arrest disease progression [42]. Most acute lateral ankle injuries recover with conservative treatment, reserving surgery for chronic instability or failed non-operative management [57].

Operative Management

Indications: Surgery is indicated for end-stage osteoarthritis via joint replacement [42]. For iliotibial band syndrome, surgery is reserved for recalcitrant disease [6]. Operative excision relieves mucoid degeneration of the patellar ligament in athletes if non-operative treatment is unsuccessful [82]. In ankle fractures resulting from rotational injuries, conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations [12]. Exceptions to usual management for partial tears of the gastro-soleus complex include patients with general contraindications for operation, rheumatoid diseases, or low activity levels [103].

Surgical Approach / Technique: Surgical approaches for insertional Achilles tendinopathy are improved by recognizing coexisting pathologies [73]. The use of minimally invasive access to the subtalar joint must be restricted to cases without the need of correction [77]. Amphotericin B remains the mainstay of treatment for chronic coccidioidal spondylitis [104]. The treatment approach for chronic osteomyelitis resulted in a 98.4% cure rate while significantly reducing the need for long-term intravenous antibiotics [114]. Endoscopic management of anterior urethral strictures using direct visual internal urethrotomy with Mitomycin C and intermittent self-catheterism has a primary success rate of 75% [116].

Patient Optimization and Counseling

Patients should be counseled on the increased risk of adverse events presented by medical comorbidities and should be optimized regarding chronic conditions [10]. Treatment credibility for meniscal tear nonoperative treatment varies by race, and outcome expectancies differ significantly by pain duration (acute vs chronic) [106]. Long-term efficacy expectations for instrumental therapy of benign prostatic syndrome vary culturally between the US and Germany [121]. Antibiotic prophylaxis consideration based exclusively on risk factors according to current guidelines is not supported by study data for transurethral resection of the prostate [102].

Future Research Directions

Future studies on sustained compression to mitigate nonunion in tibiotalocalcaneal arthrodesis should focus on cost-effectiveness and long-term outcomes [15]. Future research on novel technologies in periprosthetic joint infections should focus on validating efficacy and safety through large-scale clinical trials and integrating them into existing treatment protocols [109].

Complications

Imaging and Diagnostic Limitations: Noninvasive imaging technologies, particularly MRI, provide objective measures to assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes [1]. Only a precise knowledge of pathophysiological relationships can help to adequately diagnose and treat complex disease pictures in the long term [2].

Chronic Recurrence and Natural History: Subtalar subluxation can recur and eventually become chronic if neglected [5]. The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of the osseous lesions without specific treatment [18]. 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 [19]. The natural life history of nodules in pigmented villonodular synovitis of the glenohumeral joint and biceps tendon sheath speaks against a neoplastic origin, with inflammation as the most acceptable explanation for the lesion [128].

Long-Term Outcome Uncertainties: Long-term follow-up is necessary to evaluate any differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [9]. The rate of benign squeaking increases at five-year follow-up in large diameter ceramic-on-ceramic bearing total hip arthroplasty, and long-term follow-up is recommended [13]. Long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones used in revision total knee arthroplasty [14]. Long-term follow-up is required to determine if differences in outcomes between traditional awl and drilling for marrow stimulation are sustained [16]. Mid-term and long-term outcomes for modular bicompartmental knee arthroplasty still need to be established [17]. For the evaluation of pediatric orthopaedic results, only long-term analysis (when the patient is an adult) and comparison with established natural history studies can provide definitive answers [20]. While short-term outcomes for endoscopic-assisted ACDF for C2-C3 disc herniation are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles [105]. Long-term follow-up studies are needed to obtain more accurate data on the number of complications in deltoid ligament injuries [117].

Other Considerations: Longitudinal studies are warranted to determine if head impacts in youth football influence long-term health [8]. Future years need to focus more on medium- and long-term outcome quality, particularly patient-reported outcomes [11]. A large-scale, prospective, observational cohort of polymyalgia rheumatica patients in primary care allows for a full investigation of the natural history and prognosis of this condition [21]. 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 [22]. Data from the largest cohort and longest follow-up time ever reported provides information to accurately advise patients about the natural history of their disease in other joints when undergoing primary TKA or THA [23]. 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 [130].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or return to desk work. However, assessment of post-injury job satisfaction is recommended as a component of long-term outcome evaluation [7].

Full activity (months): Specific month ranges for full activity or return to sport are not defined in the current evidence base. Long-term follow-up is required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1].

Complete recovery / outcome plateau (months): The evidence highlights the necessity of long-term follow-up to determine outcome plateaus and durability across various conditions. 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 [9]. Long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones for revision total knee arthroplasty [14]. Long-term follow-up is required to determine if differences in outcomes between traditional awl and drilling for marrow stimulation are sustained [16]. Mid-term and long-term outcomes for modular bicompartmental knee arthroplasty still need to be established [17]. Long-term randomized studies remain necessary to confirm the reliability of posterior arthroscopic subtalar arthrodesis and the type of bone graft to favor [88]. Longer follow-up is necessary to determine long-term durability for low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty [110]. Long-term clinical and radiographic follow-up is necessary to determine the natural history of asymptomatic talar bone marrow edema in professional ballet dancers [132].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing or immobilisation duration, are not detailed. However, management of Achilles tendinopathy typically focuses on physiotherapy [19]. Exercises improve function in the majority of patients with Achilles tendinopathy, but 40% of patients report ongoing pain even after five years of therapy [19]. To assess the long-term outcome of rehabilitation programmes, a measure combining patient satisfaction in post-injury jobs with a satisfactory level of activities in private lives is recommended [7].

Functional milestones: Validated PROM trajectories are not explicitly defined. Future years need to focus more on medium- and long-term outcome quality, particularly patient-reported outcomes, for prostate cancer centers [11]. Three natural courses of health-related quality of life recovery were identified following hip arthroscopy for femoroacetabular impingement syndrome: early progressors, late regressors, and late progressors [134].

Other Considerations: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [1]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1]. Precise knowledge of pathophysiological relationships is necessary to adequately diagnose and treat overactive bladder in the long term [2]. Longitudinal studies are warranted to determine if head impacts influence long-term health [8]. Long-term follow-up is recommended for large diameter ceramic-on-ceramic bearings in total hip arthroplasty due to an increase in benign squeaking rate at five-year follow-up [13]. Only long-term analysis (when the patient is an adult) and comparison with established natural history studies can provide answers for evaluating pediatric orthopaedic results [20]. A large-scale, prospective, observational cohort of polymyalgia rheumatica patients in primary care allows for a full investigation of the natural history and prognosis of this condition [21]. 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 [22]. The study including the largest cohort and longest follow-up time ever reported provides data to accurately advise patients about the natural history of their disease in other joints after primary TKA or THA [23]. Internet search analysis on rheumatoid arthritis treatment shows that questions are most frequently related to the timeline of treatment and clinical course [131]. A larger prospective randomized study is required for low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty [110].

Key Evidence

• [L5] Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes. (10.1177/0363546518817315)
• [Paper] Only a precise knowledge of pathophysiological relationships can help to adequately diagnose and treat this complex disease picture in the long term. (10.1007/s00120-006-1076-9)
• [L3] Given the association of comorbidities and cost for patients with LBP, management approaches that are effective across chronic illnesses may prove to be beneficial for high cost patients identified with LBP. (10.1186/1471-2474-7-72)
• [L3] Common symptoms (such as pain intensity and depressive and anxiety symptoms) in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups. (10.1371/journal.pone.0065483)
• [L4] The condition can recur and eventually become chronic if neglected. (10.1177/03635465990270020501)
• [L5] The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination, with imaging studies reserved for cases of recalcitrant disease. (10.5435/00124635-201112000-00003)
• [L3] To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives. (10.1016/j.injury.2013.10.019)
• [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)
• [L3] Patients should be counseled on the increased risk of adverse events presented by medical comorbidities and should be optimized in regards to chronic conditions. (10.1177/2325967123s00263)
• [Paper] Future years will need to focus more on medium- and long-term outcome quality, particularly patient-reported outcomes. (10.1007/s00120-015-3855-7)
• [L5] Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations. (10.5435/00124635-200311000-00004)
• [L3] Long-term follow-up is recommended. (10.1016/j.arth.2017.11.044)
• [L5] Long-term clinical follow-up is warranted. (10.1016/j.arth.2017.01.013)
• [L3] Future studies should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization to further refine treatment protocols. (10.5435/jaaos-d-25-00011)
• [L3] Long-term follow up is required to determine if these differences are sustained. (10.1016/j.arthro.2020.12.136)
• [L4] Mid-term and long-term outcomes still need to be established. (10.1016/j.arth.2013.04.044)
• [L4] The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of the osseous lesions without specific treatment. (10.2106/00004623-199072020-00025)
• [L5] For the evaluation of such results, only long-term analysis (when the patient is an adult) and comparison with established natural history studies can give us the answers that we want. (10.2106/00004623-199910000-00014)
• [L4] This protocol outlines the first large-scale, prospective, observational cohort of PMR patients in primary care, which will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting. (10.1186/1471-2474-13-102)
• [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] 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)
• [L5] The study concludes that the fibula is a dynamic bone important for the kinematics and kinetics of the knee and ankle joints. (10.1007/s00402-005-0054-9)
• [L3] It seems more important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes. (10.1016/j.arth.2016.07.035)
• [L5] Recognition of pain dysfunction requires clinical experience and sensitivity to listen to and properly interpret a patient's history, while treatment involves addressing acute anatomical problems, combined rehabilitation for psychological and physical issues, and reassessment of chronic problems. (10.2106/00004623-198971010-00025)
• [L3] Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. (10.1016/j.injury.2015.04.012)
• [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)
• [L5] Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment. (10.5435/jaaos-d-11-00086)
• [L3] Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints, providing direct in vivo evidence to support the biomechanical model of ankle sprain in subjects with ankle instability. (10.1177/0363546506290989)
• [L5] Early and correct diagnosis and treatment are critical for clinical outcomes, as misdiagnosis or delayed diagnosis can have devastating consequences for the patient. (10.1530/eor-23-0193)
• [L5] Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. (10.1177/0363546520902725)
• [Paper] Delayed diagnosis impairs functional prognosis, leading to longer incapacity and more severe sequelae such as cracking, pain, and stiffness. (10.1016/j.otsr.2014.02.008)
• [L3] The investigation revealed ankle functional impairments in patients with diabetes, with or without neuropathy, thus suggesting that other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics. (10.1186/1471-2474-9-99)
• [L4] Awareness and earlier recognition of signs and symptoms will aid in diagnosis and direct appropriate management. (10.1186/1749-799x-5-6)
• [L5] The authors identify striking similarities between the anatomy, biomechanics, diagnosis, and treatment of high ankle sprains and ACL knee injuries, suggesting a potential continuum or identical entities that warrants future biomechanical research on the pivot-shift injury link. (10.1007/s00167-020-06008-2)
• [L3] Functional alignment was associated with smaller changes in ankle alignment parameters, indicating its ability to better preserve native joint positioning. (10.1002/ksa.12615)
• [L4] Delayed diagnosis is common, with clinical clues including persistent pain, fever, and increased local tissue reaction weeks after injury. (10.2106/00004623-197557030-00024)
• [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)
• [L3] No compensatory biomechanical function was observed in other foot joints. (10.1002/jor.24715)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
• [L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. (10.1530/eor-2025-0050)
• [L4] The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. (10.1016/j.asmr.2021.07.008)
• [L5] The effect of the defect area of the ankle talus cartilage on the ankle biomechanics is evident in the midstance and push-off phases. (10.1186/s12891-022-05450-2)
• [Case_report] The authors recommend that this diagnosis be considered in patients with chronic renal failure presenting with bone pain. (10.2106/00004623-198365060-00020)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. (10.1186/s12891-025-09458-2)
• [L4] Whilst all patients are prompted to seek help by persistent, unmanageable symptoms, some delay help-seeking. (10.1186/1471-2474-15-364)
• [Paper] Exercise testing remains the mainstay for the diagnosis and treatment of these disorders. (10.1016/j.csm.2011.03.010)
• [L4] The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities. (10.2106/jbjs.20.01787)
• [Paper] The CSQ does not appear to be appropriate for predicting chronic symptoms. (10.1016/j.injury.2004.09.038)
• [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)
• [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. (10.1177/23259671251332942)
• [L5] However, reliable epidemiological data are lacking, and noninvasive diagnostic techniques for chronic asymptomatic inflammation are not yet available. (10.1007/s00120-010-2256-1)
• [Case_report] The dynamic feature of the fibula is as important for the knee joint as it is for the ankle. (10.1007/s00167-003-0375-6)
• [Paper] The cartilage properties of the various topographic locations within the ankle are significantly different, with opposing articulating surfaces exhibiting significantly different biomechanical and biochemical properties. (10.1016/j.arthro.2014.05.025)
• [L5] The article concludes that most acute lateral ankle injuries recover with conservative treatment, while surgery is reserved for chronic instability or failed non-operative management. (10.1302/0301-620x.98b7.36588)
• [L4] MRI shows the proper diagnosis and the proper therapeutic approach is conservative treatment. (10.1177/2325967118s00019)
• [L3] The study showed that the injured and uninjured sides of CAI demonstrate biomechanical characteristics associated with increased risk of ankle sprain, suggesting that management strategies should target both ankles. (10.1177/23259671251394031)
• [L5] Restoration of normal fibular length is crucial to restore the biomechanics of the ankle. (10.1016/j.injury.2018.09.010)
• [L5] Conservative treatment is the first-line treatment, with surgery indicated only when conservative measures are unsuccessful. (10.1136/jisakos-2019-000282)
• [L5] Diagnosis relies on imaging (CT/MRI) and histology, while treatment involves corticosteroids for active disease and surgical decompression (stents/nephrostomy) for obstruction. (10.1007/s00120-016-0081-x)
• [L5] Key radiographic findings and a lowered threshold for additional imaging studies are essential for proper diagnosis. (10.5435/00124635-200912000-00006)
• [L3] Furthermore, differences in kinematics between symptomatic and asymptomatic hindfeet was demonstrated when both feet were compared. (10.1007/s00167-023-07553-2)
• [L4] Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained. (10.1007/s00402-019-03209-4)
• [L4] Classification systems and identification of differences among products are needed to understand the implications of variability. (10.5435/jaaos-21-12-739)
• [L3] In the group where only an MRI was used, there was a 31% failure due to progression of the disease. (10.1016/j.arth.2019.08.021)
• [L5] Nonsurgical treatment should include injections, physical therapy, and activity modification, while surgical approaches must be thoughtfully contemplated when conservative treatment fails. (10.1016/j.csm.2020.06.001)
• [L4] Treatment is relatively easy and generally effective, with surgery indicated if symptoms persist or recur after conservative management. (10.2106/00004623-197557060-00012)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. (10.1016/j.jisako.2023.03.253)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. (10.1016/j.jisako.2023.03.251)
• [L4] Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies. (10.2106/jbjs.rvw.m.00080)
• [L5] Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results, while insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches. (10.1302/0301-620x.95b10.31881)
• [L3] Stricter indications potentially lead to underutilization of UKA, as demonstrated by similar short-term patient-reported outcomes and survivorship between groups. (10.1016/j.arth.2025.05.070)
• [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. (10.1302/2058-5241.4.180025)
• [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)
• [L5] The indication for the use of this access, however, has to be restricted to cases without the need of correction. (10.1007/s00402-003-0627-4)
• [L2] The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from candidate to non-candidate for surgery. (10.1186/s12891-023-06763-6)
• [L5] Nonsurgical management is successful in approximately 90% of patients, with surgical treatment reserved for a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months. (10.5435/00124635-200806000-00006)
• [L1] Magnetic resonance imaging did not confirm any significant cartilage condition improvement. (10.1007/s00402-013-1782-x)
• [L4] MRI is valuable in diagnosis but not always accurate, and false-positive results are not uncommon; therefore, it is crucial to combine clinical examination with imaging for accurate diagnosis and treatment planning. (10.1177/2325967124s00388)
• [L4] Prolonged non-operative treatment should be pursued, but if unsuccessful, operative excision will relieve the condition. (10.2106/00004623-199274030-00016)
• [L4] The author believes that use of each type of classification provides more precise clinical information to describe analyzed groups of RSD patients. (10.1016/s0749-0712(02)00131-2)
• [L5] The article highlights the importance of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol, and identifies the need for randomized controlled trials to develop a nonoperative strategy. (10.1016/j.arthro.2017.08.238)
• [L5] However, the appropriate indications and long-term outcomes of these treatment options are yet to be determined. (10.5435/jaaos-d-19-00112)
• [L5] Treatment strategies vary based on symptom severity and MRI evidence, including physical modalities, pharmacological options, and surgical therapy. (10.2106/jbjs.21.00300)
• [L4] It highlights that the sensitivity and specificity of imaging procedures for detecting recurrence remain unclear due to a lack of standardized follow-up protocols. (10.1007/s00120-005-0880-y)
• [L4] Long-term randomized studies remain necessary to confirm the reliability of the procedure in these different indications, and the type of bone graft to favour, if really needed. (10.1016/j.otsr.2011.02.005)
• [L2] MRI is time consuming, expensive, and can lead to treatment delays, so clinicians should rely on history and physical examination. (10.1007/s11999-012-2355-y)
• [L1] HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. (10.1177/0363546517702862)
• [L4] Surgical indications should focus primarily on the degree of demonstrable chronic disability rather than the number of documented dislocations. (10.2106/00004623-198062060-00005)
• [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)
• [Case_report] High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma. (10.2106/00004623-198668060-00017)
• [L4] MRI based imaging results need further clarification by mid term studies. (10.1177/2325967116s00046)
• [L4] Pathologic MRI findings in elite overhead athletes can be present; however, they are often asymptomatic. (10.1016/j.arthro.2017.08.035)
• [L1] Radiographs should be the initial diagnostic test, but further imaging is usually necessary to establish the diagnosis and determine a treatment plan. (10.1177/2325967121s00088)
• [L1] Randomized trials validate their accuracy, effectiveness, and utility in this context, with improved adherence to care plans and medication schedules emerging as recurrent findings. (10.1016/j.arth.2025.01.034)
• [L1] The successful completion of this trial will provide evidence of the effectiveness and cost-effectiveness of a combined treatment approach for the management of chronic whiplash. (10.1186/1471-2474-10-160)
• [L3] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. (10.1016/j.arthro.2017.08.147)
• [L4] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. (10.1016/j.arthro.2017.08.148)
• [L1] The exclusive consideration of patients with risk factors according to current guidelines is not supported by the study data. (10.1007/s00120-008-1856-5)
• [L5] Exceptions include patients with general contraindications for operation, rheumatoid diseases, or low activity levels. (10.1016/j.csm.2007.10.005)
• [L4] The authors prefer the term 'arrested' over 'cure' for chronic disease and note that amphotericin B remains the mainstay of treatment. (10.2106/00004623-197860020-00018)
• [Case_report] While short-term outcomes are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles. (10.1186/s12891-025-09302-7)
• [L4] Treatment credibility varied by race and treatment outcome expectancies differed significantly by pain duration (acute vs chronic). (10.1177/2325967123s00217)
• [L3] Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ASCs, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection. (10.1016/j.arth.2025.08.065)
• [L4] A consensus on a comprehensive and reliable classification system and management algorithm is still lacking. (10.1530/eor-21-0088)
• [L5] Future research should focus on validating their efficacy and safety through large-scale clinical trials and integrating them into existing treatment protocols. (10.1016/j.arth.2025.06.086)
• [L4] However, longer follow-up is necessary to determine long-term durability, and a larger prospective randomized study is required. (10.1016/j.arth.2012.11.009)
• [L5] The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns. (10.5435/jaaos-22-12-782)
• [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)
• [L2] The successful completion of this trial will provide evidence on the effectiveness and cost-effectiveness of a simple treatment for the management of chronic whiplash. (10.1186/1471-2474-10-149)
• [L4] The treatment approach resulted in a 98.4% cure rate for chronic osteomyelitis while significantly reducing the need for long-term intravenous antibiotics, offering benefits to patient care and society. (10.1016/j.injury.2019.04.016)
• [L4] The authors advise strict patient selection for surgery, reserving it for those with significant pain and functional disability, as most patients function well with conservative management. (10.2106/00004623-198466020-00002)
• [L4] The primary success rate of 75% is considered promising, but the study design has limitations that may lead to an overestimation of the treatment effect. (10.1007/s00120-019-0929-y)
• [L4] Long-term follow-up studies are needed to obtain more accurate data on the number of complications. (10.1002/ksa.12274)
• [L5] Individuals with chronic, incurable disorders require more than average support from their physician, and a comprehensive program of care stressing continuity is absolutely essential. (10.2106/00004623-196749060-00022)
• [L5] The International EDS Consortium proposes a revised classification recognizing 13 subtypes. (10.1002/ajmg.c.31552)
• [L2] Therefore, employing individualized classification systems remains the most logical approach at present. (10.1530/eor-2024-0184)
• [L5] While guidelines have improved, randomized controlled trials often fail to reflect clinical reality due to exclusion criteria, and long-term efficacy expectations vary culturally between the US and Germany. (10.1007/s00120-016-0254-7)
• [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] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
• [L4] The authors propose a novel classification system to aid further research. (10.1007/s00402-018-2905-1)
• [Paper] The framework includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development. (10.1001/jama.2017.20226)
• [L1] The identified inflammatory cell types favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review. (10.1186/s12891-020-3094-y)
• [L4] Our classification system provides a step to achieve this goal. (10.1177/2325967120s00255)
• [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)
• [L4] The questions were most frequently related to the timeline of treatment and clinical course. (10.1371/journal.pone.0285869)
• [L4] Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions. (10.1177/23259671231159910)
• [L3] Three natural courses of health-related quality of life recovery were identified: early progressors, late regressors, and late progressors. (10.1177/2325967121s00562)

See Also

• Arthritis

References

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[92] Orthopaedic Advances: Use of Three-Dimensional Metallic Implants for Reconstruction of Critical Bone Defects After Trauma. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00676

[93] High-field magnetic-resonance imaging of aseptic necrosis of the talus. A case report.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668060-00017

[94] Clinical and bioimaging results following osteochondral lesion repair using MaioRegen® allograft. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00046

[95] Paper #45: Comparative Study Between Remnant Preserving Vs Remnant Sacrificing Rotator Cuff Repair. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.035

[96] FEMORAL NECK BONE STRESS INJURIES IN CHILDREN AND ADOLESCENTS: A LITERATURE REVIEW AND META-ANALYSIS. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00088

[97] Randomized Controlled Studies on Smartphone Applications and Wearable Devices for Postoperative Rehabilitation after Total Knee Arthroplasty: A Systematic Review. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.01.034

[98] Dry needling and exercise for chronic whiplash - a randomised controlled trial. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-160

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[102] Antibiotikaprophylaxe bei transurethraler Resektion der Prostata (TUR-P). Der Urologe. 2008. DOI: 10.1007/s00120-008-1856-5

[103] Management of Partial Tears of the Gastro-Soleus Complex. Clinics in Sports Medicine. 2008. DOI: 10.1016/j.csm.2007.10.005

[104] Coccidioidal spondylitis.. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860020-00018

[105] Endoscopic-assisted ACDF for C2-C3 disc herniation : a case report of successful decompression. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09302-7

[106] Poster 235: The Role of Symptom Duration in Shaping Outcome Expectations of Patients Initiating Nonoperative Treatment for Meniscal Tear. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00217

[107] Body Mass Index > 40 Is Not Correlated With Early Complications in Patients Undergoing Primary Total Joint Arthroplasty at an Ambulatory Surgical Center. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.065

[108] Femoral bone defect classifications in revision total hip arthroplasty: a comprehensive review and proposal of a new algorithm of management. EFORT Open Reviews. 2024. DOI: 10.1530/eor-21-0088

[109] Novel Technologies in Periprosthetic Joint Infections: Emerging Therapeutics. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.086

[110] Low-Dose Irradiation and Constrained Revision for Severe, Idiopathic, Arthrofibrosis Following Total Knee Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.11.009

[111] Identification of Common Gait Disruption Patterns in Children With Cerebral Palsy. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-12-782

[112] Risk Classification for Primary Knee Arthroplasty. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.02.010

[113] A randomised clinical trial of a comprehensive exercise program for chronic whiplash: trial protocol. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-149

[114] Newer perspectives in the treatment of chronic osteomyelitis: A preliminary outcome report. Injury. 2019. DOI: 10.1016/j.injury.2019.04.016

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[116] Endoskopisches Management anteriorer Harnröhrenstrikturen mittels direkter visueller interner Urethrotomie mit Mitomycin C und intermittierendem Selbstkatheterismus. Der Urologe. 2019. DOI: 10.1007/s00120-019-0929-y

[117] Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12274

[118] Management of Muscular Dystrophy. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749060-00022

[119] The 2017 international classification of the Ehlers–Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017. DOI: 10.1002/ajmg.c.31552

[120] Decoding tibial plateau fracture classifications: a century of individualized insights in a systematic review. EFORT Open Reviews. 2025. DOI: 10.1530/eor-2024-0184

[121] Langzeitergebnisse nach instrumenteller Therapie des Benignen Prostata-Syndroms (BPS). Der Urologe. 2016. DOI: 10.1007/s00120-016-0254-7

[122] Specific case consideration for implanting TKA with the Kinematic Alignment technique. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.210042

[123] Surgical Treatment for Chronic Disease and Disorders of the Achilles Tendon. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200901000-00002

[124] Non-prosthetic peri-implant fractures: classification, management and outcomes. Archives of Orthopaedic and Trauma Surgery. 2018. DOI: 10.1007/s00402-018-2905-1

[125] Principles for a Framework for Alternative Payment Models. JAMA. 2018. DOI: 10.1001/jama.2017.20226

[126] A systematic review of inflammatory cells and markers in human tendinopathy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3094-y

[127] CLASSIFICATION OF ACL TEARS IN THE PEDIATRIC AND ADOLESCENT POPULATION. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00255

[128] Pigmented Villonodular Synovitis of the Glenohumeral Joint and Biceps Tendon Sheath. 2021.

[130] Preface. Clinics in Sports Medicine. 2011. DOI: 10.1016/j.csm.2010.09.008

[131] Internet search analysis on the treatment of rheumatoid arthritis: What do people ask and read online?. PLOS ONE. 2023. DOI: 10.1371/journal.pone.0285869

[132] Prevalence of Asymptomatic Talar Bone Marrow Edema in Professional Ballet Dancers: Preliminary Data From a 2-Year Prospective Study. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231159910

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[134] Paper 24: The Natural Course of Recovery for Health-Related Quality of Life Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00562