The Journal of Bone & Joint Surgery最新文献

{"title":"Thirty-five Years of Reporting of Sex and Race in Clinical Studies of U.S. FDA-Authorized Orthopaedic Devices.","authors":"Hongying Jiang,Katherine Kavlock,Qin Li,Shruti Mistry,Valerie Hermes,Alonza Gibbs,Elizabeth Adegboyega-Panox,Raquel Peat","doi":"10.2106/jbjs.24.00201","DOIUrl":"https://doi.org/10.2106/jbjs.24.00201","url":null,"abstract":"BACKGROUNDAt the U.S. Food and Drug Administration (FDA), the mission of the Center for Devices and Radiological Health (CDRH) is to ensure that all patients and providers have timely and continued access to safe, effective, and high-quality medical devices and safe radiation-emitting products. Although the CDRH has observed enrollment differences in some clinical trials, no systematic analysis has been conducted regarding enrollment differences in baseline demographics, to our knowledge.METHODSThe CDRH has summarized information on study participants and their baseline demographics in public-facing documentation for all authorized medical devices that involved orthopaedic clinical studies from 1985 to 2020. Descriptive analyses and exploratory statistical testing have been conducted to investigate the reported percentages by sex and race compared with those reported in the U.S. National Census and the American Joint Replacement Registry (AJRR), respectively.RESULTSWe identified 94 submissions and corresponding combined clinical trials from 261 original clinical study arms with 34,193 participants. Most of the submissions reported age and sex, while only 36 submissions (38.3%) reported racial demographics. Among the 88 trials providing enrollment by sex, the female enrollment percentage ranged from 22.2% to 88.7%, with a mean of 55.0%. In the submissions that reported racial data (38.3%), White and Black patients had a mean enrollment of 89.2% (range, 64.8% to 98.7%) and 6.2% (range, 0.4% to 20.7%), respectively. The enrollment for other minority groups ranged from 0% to 3.0%. These clinical trials have shown numerically lower female representation (55.0%) but higher White representation (89.2%) than what has been reported in the AJRR. The other racial groups have participated much less than their corresponding percentages in the U.S. population, but they are similarly represented in the AJRR.CONCLUSIONSThe clinical trials supporting the FDA's authorization of orthopaedic devices had a wide range of sex and racial enrollments. It appears that female enrollment mirrors the percentage of women in the U.S. population. However, despite prior efforts, some racial groups are still underrepresented. The FDA has made a commitment to advancing health equity as part of the 2022-2025 Strategic Priorities of the CDRH. We hope that the results of this study will help health-care professionals make informed clinical decisions when using medical devices.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142231331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Feasibility of the Non-Window-Type 3D-Printed Porous Titanium Cage in Posterior Lumbar Interbody Fusion: A Randomized Controlled Multicenter Trial.","authors":"Dae-Woong Ham,Sang-Min Park,Youngbae B Kim,Dong-Gune Chang,Jae Jun Yang,Byung-Taek Kwon,Kwang-Sup Song","doi":"10.2106/jbjs.23.01245","DOIUrl":"https://doi.org/10.2106/jbjs.23.01245","url":null,"abstract":"BACKGROUNDThree-dimensionally printed titanium (3D-Ti) cages can be divided into 2 types: window-type cages, which have a void for bone graft, and non-window-type cages without a void. Few studies have investigated the necessity of a void for bone graft in fusion surgery. Therefore, the present study assessed the clinical and radiographic outcomes of window and non-window-type 3D-Ti cages in single-level posterior lumbar interbody fusion.METHODSA total of 70 patients were randomly assigned to receive either a window or non-window cage; 61 patients (87%) completed final follow-up (32 from the window cage group, 29 from the non-window cage group). Radiographic outcomes, including fusion rates, subsidence, and intra-cage osseointegration patterns, were assessed. Intra-cage osseointegration was measured using the intra-cage bridging bone score for the window cage group and the surface osseointegration ratio score for the non-window cage group. Additionally, we looked for the presence of the trabecular bone remodeling (TBR) sign on computed tomography (CT) images.RESULTSOf the 61 patients, 58 achieved interbody fusion, resulting in a 95.1% fusion rate. The fusion rate in the non-window cage group was comparable to, and not significantly different from, that in the window cage group (96.6% and 93.8%, p > 0.99). The subsidence rate showed no significant difference between the window and non-window cage groups (15.6% and 3.4%, respectively; p = 0.262). The intra-cage osseointegration scores showed a significant difference between the groups (p = 0.007), with the non-window cage group having a higher proportion of cases with a score of 4 compared with the window cage group. The TBR sign was observed in 87.9% of patients who achieved interbody fusion, with a higher rate in the non-window cage group across the entire cohort although the difference was not significant (89.7% versus 78.1%, p = 0.385).CONCLUSIONSNon-window-type 3D-Ti cages showed equivalent clinical outcomes compared with window-type cages and comparable interbody fusion rates. These results suggest that the potential advantages of 3D-Ti cages could be optimized in the absence of a void for bone graft by providing a larger contact surface for osseointegration.LEVEL OF EVIDENCETherapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142174815","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What's Important: Engaging Meaningfully with Sustainability Efforts as an Orthopaedic Surgeon.","authors":"Laura L Bellaire","doi":"10.2106/jbjs.24.00641","DOIUrl":"https://doi.org/10.2106/jbjs.24.00641","url":null,"abstract":"","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142174814","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rapid Prototyping: The Future of Trauma Surgery?","authors":"George A. Brown, K. Firoozbakhsh, T. Decoster, J. Reyna, M. Moneim","doi":"10.2106/00004623-200300004-00006","DOIUrl":"https://doi.org/10.2106/00004623-200300004-00006","url":null,"abstract":"Surgeons frequently must perform delicate surgery without the benefit of a firsthand look at what they will be operating on. Fracture orientation can be difficult to conceptualize, especially in the acetabulum or spine. Anatomic reduction and stable fixation remain a challenge and have required long incisions with wide exposure, sometimes with increased postoperative morbidity1-9. The inadvertent penetration of screws into the hip joint, during the treatment of both complex acetabular fractures and posterior wall pelvic fractures, has been well documented10,11. Successful surgical correction of deformities of the hip joint before the onset of osteoarthritis requires accurate characterization of the anatomic deviations from normal as the first step in the planning of a corrective osteotomy. Pedicle screws inserted with a standard surgical technique have sometimes penetrated the wall or even missed the pedicle12-20. Diagnostic techniques such as radiography, computed tomography, and magnetic resonance imaging provide only two-dimensional images of fractures and may not depict subtle fractures.\u0000\u0000Advances in radiology combined with advances in computer technology have made the three-dimensional representation of anatomic structures in living subjects easily obtainable. With use of modern rapid prototyping techniques, computers can now accurately reproduce three-dimensional models of actual osseous anatomy, which can be invaluable for understanding the characteristics of the fracture, for preoperative contouring of plates, and for selection of screw trajectories. The surgical precision that is possible with use of computer image guidance for placement of screws or pins about the hip joint for the treatment of complex acetabular fractures and for insertion of pedicle screws is impressive1,2,21-27. However, this technology is not yet commonly used by surgeons because of its apparent complexity. Easy fabrication of accurate three-dimensional models of the osseous anatomy, easy …","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77512308","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anthropometric Measurements of the Human Knee: Correlation to the Sizing of Current Knee Arthroplasty Systems","authors":"K. Hitt, John R. Shurman, K. Greene, J. Mccarthy, J. Moskal, T. Hoeman, Michael A. Mont","doi":"10.2106/00004623-200300004-00015","DOIUrl":"https://doi.org/10.2106/00004623-200300004-00015","url":null,"abstract":"Background: There is a paucity of data concerning the morphological dimensions of the distal part of the femur, the proximal part of the tibia, and the patella. The objective of this study was to analyze the exact anatomic data collected from a large group of patients undergoing total knee arthroplasty and to correlate the measurements to the dimensions of current prosthetic systems. Methods: Eight different centers collected morphologic data from the distal part of the femur, the proximal part of the tibia, and the patella from 337 knees during total knee arthroplasty. Microcaliper measurements from templates and measuring guides were used to decrease intraobserver variation. The study included 188 women (209 knees) and 107 men (128 knees) who had a mean age of sixty-nine years. A characterization of the aspect ratio (the medial-lateral to anterior-posterior dimensions) was made for the proximal aspect of the tibia and the distal part of the femur. Known dimensions from six prosthetic knee systems were compared with the morphologic data. Results: A wide variation in the aspect ratio for the femoral component was seen among the six different prosthetic systems. For women, there was a significant association between the component size and the amount of medial-lateral overhang, with larger sizes having more overhang (p < 0.0001). Although the femoral aspect ratio for the morphologic data showed higher ratios for smaller knees and proportionally lower ratios for larger knees, the designs showed little change in the aspect ratio. The tibial aspect ratio from the morphologic data showed a higher ratio for smaller knees and a proportionally lower ratio for larger knees. The Duracon component tracked the decline in aspect ratio fairly well, whereas the other brands either did not change with anterior-posterior dimension or actually increased (NexGen). Gender differences in the morphologic data were shown by the variable tibial aspect ratios. A comparison of the bone dimensions from the study data and the dimensions of the implants indicated that the smaller sizes were too small while the larger sizes tended to be too large. The average overall unresected patellar thickness was 23.7 mm. Conclusion: The results of this study will allow manufacturers to make more appropriate determinations of the sizes and aspect ratios of components for use in total knee arthroplasty.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84837322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Recombinant Human Bone Morphogenetic Protein-2: Use in Spinal Fusion Applications","authors":"H. Sandhu, Safdar N. Khan","doi":"10.2106/00004623-200300003-00015","DOIUrl":"https://doi.org/10.2106/00004623-200300003-00015","url":null,"abstract":"It has been several decades since Marshall Urist's discovery of osteoinductive activity within demineralized bone protein extracts. Initially described in Science in 1965 1, Dr. Urist's remarkable discovery, an unexpected byproduct of intended research on the competitive binding of radionucleotides during bone mineralization, suggested that morphogenetic activity resides among certain bone-matrix-derived proteins; this work continued with Urist's later identification of the active molecules as bone morphogenetic proteins 2,3. This was followed, in 1988, by the isolation of an individual protein, BMP-2, from a purified extract and its recombinant production 4. The long-awaited clinical use and commercial availability of bone morphogenetic proteins (BMPs) have only recently approached reality.\u0000\u0000Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been tested for use in spinal fusion in several completed prospective, randomized clinical trials, beginning in 1997. After rhBMP-2 was demonstrated to be equivalent to autogenous iliac bone graft with regard to both fusion rate and clinical outcome 5, a scientific advisory panel convened by the Food and Drug Administration (FDA) advised that rhBMP-2 be approved as the first complete bone-graft substitute for spinal fusion. At this time, rhBMP-2 carried on a type-I collagen sponge is approved for use in conjunction with a tapered, threaded intervertebral fusion cage (LT-Cage; Medtronic Sofamor Danek, Minneapolis, Minnesota) for the clinical treatment of degenerative lumbar disc disease.\u0000\u0000Preclinical proof-of-concept, feasibility, and efficacy studies laid the groundwork that established certain parameters for the clinical use of rhBMP-2. Each successive spinal fusion study contributed to the evolution of the design and dose of the carrier/protein combination. The site-specific characteristics of spinal fusion led to the development of specific carrier/rhBMP-2 combinations.\u0000\u0000This paper documents the preclinical and clinical progress of the development of rhBMP-2 as a viable complete bone-graft substitute and is a tribute to the pioneering …","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91526191","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Uncemented STAR Total Ankle Prostheses: Three to Eight-Year Follow-up of Fifty-one Consecutive Ankles","authors":"T. Anderson, F. Montgomery, Å. Carlsson","doi":"10.2106/00004623-200307000-00019","DOIUrl":"https://doi.org/10.2106/00004623-200307000-00019","url":null,"abstract":"Background: The feasibility of replacing the ankle joint has been a matter of speculation for a long time. In recent years, the designs of ankle prostheses have been improved, and three designs, all used without bone cement, currently dominate the market. However, documentation of the clinical results of the use of these prostheses is sparse. We reviewed the intermediate-term results of fifty-one consecutive Scandinavian Total Ankle Replacements (STAR). Methods: Between 1993 and 1999, fifty-one consecutive ankles were replaced with an uncemented, hydroxyapatite-coated STAR total ankle prosthesis. Clinical examination for the present study was performed by one surgeon who had not taken part in the operations. Standardized radiographs were used. Complications and failures were recorded, and patient satisfaction and functional outcome scores were determined for all patients with an unrevised implant. Results: Twelve ankles had to be revised. Seven were revised because of loosening of at least one of the components; two, because of fracture of the meniscus; and three, for other reasons. A component was exchanged in seven of the twelve revisions, whereas the ankle was successfully fused in the other five. An additional eight ankles had radiographic signs of loosening. The thirty-nine unrevised ankles (thirty-seven patients) were examined after thirty-six to ninety-seven months (median, fifty-two months). The patient was satisfied with the result after thirty-one of the ankle replacements, somewhat satisfied after two, and not satisfied after six. The median Kofoed score increased from 39 points before the surgery to 70 points at the time of the follow-up examination. A median follow-up score of 74 points was recorded when the system described by Mazur et al. and the AOFAS (American Orthopaedic Foot and Ankle Society) system were used. The median range of motion was approximately the same preoperatively and postoperatively. The estimated five-year survival rate, with revision for any reason as the end point, was 0.70. When radiographic loosening of either component was used as the end point, the estimated five-year radiographic survival rate was significantly better for the last thirty-one ankles treated in the series (p = 0.032). Conclusions: Total ankle replacement may be a realistic alternative to arthrodesis, provided that the components are correctly positioned and are of the correct size. However, the risks of loosening and failure are still higher than are such risks after total hip or total knee replacement. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89351698","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"User's Guide to the Surgical Literature: How to Use an Article About a Diagnostic Test","authors":"M. Bhandari, V. Montori, M. Swiontkowski, G. Guyatt","doi":"10.2106/00004623-200306000-00027","DOIUrl":"https://doi.org/10.2106/00004623-200306000-00027","url":null,"abstract":"Clinical Scenario You are an orthopaedic surgeon who is asked to evaluate a sixty-five-year-old woman in the emergency department because of new-onset right hip pain that started one week ago. Seven months previously, the patient had had a right total hip arthroplasty for the treatment of osteoarthritis. The pain radiates to the thigh and buttocks. The patient reports that she slipped on a kitchen floor a few days ago but did not think that she had sustained a serious injury. In addition, she has been recovering from a sinus infection (a viral illness) for the past ten days. She is otherwise healthy except that she takes oral bisphosphonates for the treatment of osteoporosis. On examination, she has a temperature of 39°C. She walks most comfortably with a flexed posture. The range of motion of the right hip is normal. There is no erythema or draining sinus over the right hip and thigh. Anteroposterior radiographs of the pelvis and the right hip reveal a press-fit acetabular component and a cemented femoral stem with no evidence of loosening. Laboratory evaluations show a white blood-cell count of 12.1 cells/μL, of which 85% are neutrophils. Blood cultures are negative. You wonder whether the new onset of hip pain is the result of a soft-tissue injury, back pain radiating to the hip, prosthetic loosening that is not apparent on radiographs, or an infection of the hip joint. If the hip is truly infected, the patient will require an operative procedure for débridement of the wound and removal of the implants. While some of your colleagues would take all such patients to the operating room for exploration of the hip, you have been impressed by the number of cases in which you have found no infection. Because of such concerns, your practice is to routinely aspirate the hip in patients in whom an infection is suspected. Just as you are thinking about placing your patient’s name on the next day’s procedures list for an aspiration, the result of the C-reactive protein test comes back as 8 mg/dL (normal, ≤10 mg/dL). This finding raises some question as to","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77893421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Clinical Practice Guideline for Treatment of Septic Arthritis in Children: Efficacy in Improving Process of Care and Effect on Outcome of Septic Arthritis of the Hip","authors":"M. Kocher, R. Mandiga, Jane Murphy, D. Goldmann, M. Harper, R. Sundel, K. Ecklund, J. Kasser","doi":"10.2106/00004623-200306000-00002","DOIUrl":"https://doi.org/10.2106/00004623-200306000-00002","url":null,"abstract":"Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79400823","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Keratotic Disorders of the Plantar Skin","authors":"R. Mann, J. Mann","doi":"10.2106/00004623-200305000-00027","DOIUrl":"https://doi.org/10.2106/00004623-200305000-00027","url":null,"abstract":"Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2003-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91547102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}