New Perspectives on Ankle Cartilage Pathology and Treatment.

Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Medial Cystic Osteochondral Lesions of the Talus Exhibited Lower Sports Levels, Higher Cyst Presence Rate, and Inferior Radiological Outcomes Compared With Lateral Lesions Following Arthroscopic Bone Marrow Stimulation

Background: Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure. Purpose: To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs. Study Design: Case control study; Level of evidence, 3. Methods: A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years’ follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores. Results: Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions (P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs (P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125). Conclusion: Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

Background: Bone marrow stimulation (BMS) has proven to be the standard treatment for small osteochondral lesions of the talus (OLTs). It has been theorized that bone marrow aspirate concentration (BMAC) has the potential to enhance cartilage repair stimulated by BMS. The aim of this study was to prospectively compare the effect of BMS with BMAC versus BMS alone on patient-reported outcomes after the treatment of OLTs. Methods: This is a single-institution, randomized prospective study. Patients over the age of 18 with OLTs who were proceeding with BMS were included in the study. Patients with multiple OLTs and follow-up period of Results: Nine patients were evaluated in the study. Six patients were in the BMS with BMAC group, and three patients were in the BMS alone group. Average final follow-up was >2 years for both groups. Both groups showed improvements in patient-reported outcome scores from preoperatively to final follow-up. There were no significant differences in final outcome scores or changes in outcome scores from preoperatively to final follow-up between the two groups. Conclusion: Our study found that both BMS alone and BMS with BMAC treatments are effective in improving pain and functional outcomes in patients with OLTs. There were no significant differences between the two modalities of treatment. This is a pilot study and a larger randomized trial is needed to make definitive conclusions.

Few studies reported the long-term clinical outcomes and joint degeneration of patients with chronic lateral ankle instability (CLAI) and small osteochondral lesions of the talus (OLTs) following simultaneous open modified Broström-Gould (MBG) surgery and arthroscopic bone marrow stimulation (BMS). The purpose of this study was to study the long-term results of patients after BMS and BMG surgery, and to further evaluate the potential effect of OLT size on postoperative results. In this retrospective study, 110 CLAI patients were divided into 57 patients with OLTs (including 24 patients having combined small osteochondral lesions of the tibial plafond) receiving simultaneous BMS and MBG surgeries (BMS+MBG group), and 53 patients without OLTs receiving isolated open MBG surgery (MBG group). The OLT size and pre- and postoperative Kellgren-Lawrence grade were assessed. The subjective scores (visual analog scale pain score, Tegner activity, and Karlsson-Peterson scores), surgical complications, and return to sports were also compared pre- and postoperatively. Patients were followed up at a mean of 144.2 ± 14.9 and 145.6 ± 11.4 months for the BMS+MBG and MBG groups, respectively. Subjective scores were significantly improved (P < .001), and no difference was found in subjective scores or surgical complications between the 2 groups (P > .05). Both groups showed progression of osteoarthritis grade (P < .001), but with no significant difference of changes from the preoperative to the final follow-up (BMS+MBG group: 0.84 ± 0.75 to 1.32 ± 0.80; MBG group: 0.32 ± 0.48 to 0.86 ± 0.56, changes: 0.48 ± 0.59 vs 0.55 ± 0.51, P = .575). For sports function, both groups had similar results in Tegner scores (5.8 ± 1.3 vs 6.2 ± 1.3, P = .081). However, in a subgroup analysis, we found that in the BMS+MBG group, patients exceeding the mean size of OLTs (50 mm2) were associated with an average lower postoperative Karlsson-Peterson score (P = .025) and higher postoperative osteoarthritis grade (P = .037), with more changes (P = .017) than those with OLTs <50 mm2. Patients with CLAI and small OLTs following simultaneous open MBG surgery and arthroscopic BMS showed good long-term outcomes and only mild progression of joint degeneration-overall similar to patients treated for CLAI with MBG surgery. Moreover, as OLT size increased, good outcomes were less predictable.

Osteochondral lesions of the talus(OLT) are the most common articular cartilage defects in the ankle and may cause disability as a result of chronic pain and limited weight-bearing capacity. Numerous treatment strategies for symptomatic OLT have advanced significantly over the past decades.OLT are often managed conservatively for an initial stage before the surgical treatment. However, the conservative management determined solely on symptomatology, and not on the physiological healing. A systematic review for the treatment of OLT demonstrated a 45% success rate of non-operative management. Surgical treatment of OLT is reserved for symptomatic focal lesions that fail to respond to conservative treatments. There are three major operative strategies for OLT, reparative, replacement and regenerative manners.For the reparative modality, arthroscopic bone marrow stimulation(BMS) is widely regarded as the first-line treatment for OLT, as it is a technically undemanding, cost-effective, and minimally invasive procedure with low rates of complication and postoperative pain. Small lesion (<15 mm in diameter or <150mm2 in size) is the ideal candidate for BMS supported by several literatures. And a study reported the long-term follow-up study to date at 8-20 years after BMS in which 78% of patients had an excellent or good functional outcome score.As a replacement strategy, autologous osteochondral transplantation(AOT) is often indicated for symptomatic large, cystic lesions, including those that have failed previous reparative procedures, such as BMS. Osteochondral autograft transfer carries the inherent advantage over osteochondral allograft of being from the host with fresh viable cartilage, most commonly harvested from the ipsilateral knee. Clinical studies have found favorable results with osteochondral autograft techniques, including a recent systematic review of clinical outcomes at mid-term follow-up demonstrating excellent or good outcomes in 87% of patients.In recent years, Scaffold-based regenerative techniques are getting more attention. Matrix-associated chondrocyte implantation(MACI) is a 2-step procedure in which culture-expanded autologous chondrocytes are seeded on a scaffold, which is then secured in the OLT. More recently, 1-step procedures have been developed in which scaffolds and/or orthobiologics, including bone marrow aspirate concentrate(BMAC) and platelet-rich plasma(PRP), and hyaluronic acid(HA) have been used to augment microfracture with the intention of overcoming the 2-step procedures while concurrently promoting chondrogenic differentiation of endogenous stem cells. Matrix-augmented BMS is one such technique that has been reported with good results in case series.In the future, an advanced strategy for tissue engineering with gene therapy may influence the quality of integration and longevity in treatment of OLT.

IntroductionLiterature on treatment outcomes in skeletally immature patients with osteochondral lesions of the talus (OLT) is scarce. As the healing of an OLT may be fundamentally different in a skeletally immature patient, more evidence is required focusing on this specific patient group. The primary aim of this study is to assess the conversion to surgery rate after initial non-operative management in skeletally immature patients with an OLT. The secondary aims of the present study are to assess and compare the clinical outcomes and reoperations after both non-operative and surgical treatment strategies at a mid- to long-term follow-up.MethodsAll skeletally immature patients at the moment of initial treatment, treated for their primary or non-primary OLT with a minimum follow-up duration of 2 years, were included in this study. Patients with concomitant injuries were excluded. All patients started with non-operative management. In case of failure of non-operative management, patients converted to Bone Marrow Stimulation (BMS) or fixation. The primary outcome was the conversion to surgery rate after initial non-operative management. Secondary outcomes consist of reoperations at mature and immature age, pain during weight bearing, measured by the numeric rating scale (NRS), NRS of pain during rest, NRS during stair climbing, Berndt and Harty outcome question, Foot and Ankle Outcome Score (FAOS) and Short Form-36 (SF-36) and the patient satisfaction rate regarding the received treatment.ResultsA total of 52 patients, 54% female, mean age of 13.6 years, were included in this study. Median follow-up duration was 81 months (range = 24-265 months). Seventeen patients received non-operative treatment as final treatment. In total, 35 (67%) out of 52 patients required surgical treatment after initial non-operative management, of which 14 underwent BMS and 20 had fixation while skeletally immature, 1 patient that had surgical treatment as an adult was excluded for further analysis. The median NRS of pain during weight bearing was 1 (interquartile range [IQR] = 0-2), 1 (IQR = 0-3), and 0 (IQR = 0-0.5) in the (sustained) non-operative, BMS, and fixation groups, respectively (P < 0.012). No significant differences in clinical outcomes between the different treatment groups could be observed. No complications occurred after surgical treatment. Reoperation rates were 21% and 20% in the BMS and fixation groups, respectively.ConclusionsThe most important finding of this study is that 67% of the patients receiving initial non-operative management for OLTs ultimately required surgery.Level of evidenceLevel III, cross-sectional comparative study.

Osteochondral lesions of the talus (OLT) occur in up to 70% of acute ankle sprains and fractures. OLT have become increasingly recognized with the advancements in cartilage-sensitive diagnostic imaging modalities. Although OLT may be treated nonoperatively, a number of surgical techniques have been described for patients whom surgery is indicated. Traditionally, treatment of symptomatic OLT have included either reparative procedures, such as bone marrow stimulation (BMS), or replacement procedures, such as autologous osteochondral transplantation (AOT). Reparative procedures are generally indicated for OLT < 150 mm2 in area. Replacement strategies are used for large lesions or after failed primary repair procedures. Although short- and medium-term results have been reported, long-term studies on OLT treatment strategies are lacking. Biological augmentation including platelet-rich plasma and concentrated bone marrow aspirate is becoming increasingly popular for the treatment of OLT to enhance the biological environment during healing. In this review, we describe the most up-to-date clinical evidence of surgical outcomes, as well as both the mechanical and biological concerns associated with BMS and AOT. In addition, we will review the recent evidence for biological adjunct therapies that aim to improve outcomes and longevity of both BMS and AOT procedures.

Bone marrow stimulation (BMS) is presently considered first-line surgical treatment for osteochondral lesions of the talus (OLTs); however, some patients still experience pain or dysfunction after surgery, and the reasons for success or failure remain somewhat unclear. This study aimed to investigate the effect of smoking on postoperative outcomes after arthroscopic BMS for OLTs. Consecutive patients with OLTs who underwent BMS between January 2017 and January 2020 were included. Smokers were defined as patients who actively consumed cigarettes before surgery and postoperatively, whereas nonsmokers were patients who never smoked. Visual analog scale (VAS), American Orthopaedic Foot & Ankle Society ankle hindfoot score (AOFAS), Karlsson-Peterson, and Tegner scores were assessed preoperatively and at follow-up. Additionally, a general linear model (GLM) was performed, followed by the interaction analysis to explore the potential influence of smoking. The study enrolled 104 patients with a mean follow-up of 30.91 ± 7.03 months, including 28 smokers and 76 nonsmokers. There were no significant differences in patient age (35.2 ± 10.0 years vs 37.6 ± 9.7 years, P = .282) or OLT area (63.7 ± 38.7 mm2 vs 52.8 ± 37.0 mm2, P = .782). Both univariate analysis and GLM revealed that smoking was associated with worse postoperative pain levels, Karlsson-Peterson, and AOFAS scores (P < .05). The interaction analysis showed a significant interaction between smoking and OLT area for postoperative Karlsson-Peterson scores (general ankle function) (P = .031). Simple main effects analysis revealed that the negative effect of smoking on Tegner score significantly increased among patients >32 years old or with OLT area>50 mm2 (P < .05). Smoking was associated with worse clinical outcomes following BMS of OLTs. As the size of OLTs increased, the difference in general ankle function between smokers and nonsmokers also increased. Furthermore, smokers who were older than 32 years or had larger OLTs were less likely to resume participation in high-level activities.

This article provides a summary of orthopaedic foot and ankle research from September 2021 to September 2022. The included studies were published in The Journal of Bone & Joint Surgery, Foot & Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, the Journal of Orthopaedic Trauma, The American Journal of Sports Medicine, JAMA (Journal of the American Medical Association), The New England Journal of Medicine, The Bone & Joint Journal, and the Journal of the AAOS (American Academy of Orthopaedic Surgeons). Forefoot Minimally invasive techniques involving the lesser metatarsals continue to grow in popularity. Neunteufel et al.1 reported a case series of 30 patients (31 feet) who underwent minimally invasive distal metatarsal metaphyseal osteotomy for metatarsalgia of ≥1 lesser metarsals2–5. All clinical scores (American Orthopaedic Foot & Ankle Society [AOFAS] Forefoot Score, Foot Function Index, Foot and Ankle Outcome Score [FAOS], and visual analog scale [VAS] pain score) improved significantly at a mean follow-up of 15.5 months. Plantar peak pressure at the relevant area was also reduced significantly. The mean metatarsal shortening across all osteotomies was 6.6 mm. Del Vecchio et al.2 reported the results of a sliding distal metatarsal minimally invasive osteotomy for the correction of a bunionette deformity in 57 patients (74 feet). At a minimum follow-up of 30 months, all radiographic and clinical outcome measures improved, with 89.1% of patients rating the procedure as excellent. The overall complication rate was 6.75%. Syndactyly release remains surprisingly problematic. Langlais et al.3 retrospectively reviewed 38 pediatric patients with 68 syndactylies who underwent syndactyly release with a dorsal commissural flap and cutaneous resurfacing. The recurrence rate was 28.1% and the complication rate was 11.7% at a mean follow-up of 6.9 years. Age of >2 years at the time of the surgical procedure was a risk factor for recurrence. Of the patients with simple syndactylies, only one-half were satisfied. Hallux Valgus Further data continue to demonstrate short-term equivalency but not superiority for minimally invasive hallux valgus surgery compared with open techniques. Hernández-Castillejo et al.4 performed a longitudinal, prospective study on 72 patients (72 feet) who underwent open chevron, open scarf, or percutaneous Reverdin-Isham osteotomy for the correction of hallux valgus deformity. At a mean follow-up of 17.7 months, all patient-reported outcome measures, including the VAS pain score and Manchester Oxford Foot Questionnaire (MOXFQ), demonstrated significant improvement independent of the preoperative radiographic parameters and type of surgical procedure. Lewis et al.5 prospectively reported on 106 consecutive feet (78 patients) that underwent third-generation minimally invasive chevron and Akin (MICA) osteotomies for severe hallux valgus. In the 86 feet (81.1%) with a minimum 2-year follow-up, there was significant improvement in all MOXFQ domains. The mean intermetatarsal angle and hallux valgus angle also improved significantly. The authors reported an 18.8% overall complication rate. Mikhail et al.6 retrospectively reviewed 248 patients (274 feet) who underwent MICA osteotomies for hallux valgus correction. At a mean follow-up of 12.9 months, the intermetatarsal angle, hallux valgus angle, and Foot Function Index improved significantly. The overall satisfaction rate was 91.6%, the mean number of 5-mg oxycodone tablets consumed postoperatively was 2.2 tablets, and the complication rate was 8.4%. The Lapidus procedure continues to grow in popularity. A retrospective review comparing Lapidus bunionectomy (73 patients) with scarf bunionectomy (63 patients) found no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function scores between groups, although patients in the scarf group had a 25% lower chance of achieving a normal intermetatarsal angle, at a mean follow-up of 17.8 months7. Veracruz-Galvez et al.8 prospectively followed 82 patients who underwent scarf osteotomy for moderate to severe hallux valgus. Normal postoperative sesamoid position (48 patients) was associated with significantly less pain (VAS), higher Self-Reported Foot and Ankle Score, and higher patient satisfaction (Likert scale) than the group with outlier sesamoid positions (34 patients). In a retrospective study comparing patients with hallux valgus (34 feet) with normal controls (20 feet), Lalevée et al.9 found that the distal metatarsal articular angle was overestimated on conventional radiographs compared with weight-bearing computed tomographic (CT) scans by a mean of 14°. However, even after computerized correction of the first metatarsal rotation and plantar flexion, the valgus alignment of the first metatarsal distal articular surface was 8.6° higher in patients with hallux valgus than in the control patients on weight-bearing CT scans. Hallux Rigidus Cichero et al.10 retrospectively reviewed 280 first metatarsophalangeal arthrodeses. The overall nonunion rate was 7.9% (22 feet). The risk of nonunion was >3 times higher in patients who had a single-construct locking plate with an interfragmentary compression screw inserted through the plate compared with patients who had a locking plate and a lag screw inserted outside of the plate. Hindfoot Tarsal Tunnel Syndrome The results of tarsal tunnel release remain inconsistent. Bouysset et al.11 retrospectively reviewed 73 patients (84 feet) who underwent tarsal tunnel release with follow-up of at least 1 year. The effectiveness of the release, based on patient willingness to repeat the procedure under similar preoperative circumstances, was significantly lower in patients with marked hindfoot varus or valgus and in patients with plantar fasciitis. Patients in only 51% of cases (43 feet) said that they would undergo the procedure again. Plantar Fasciitis Bildik and Kaya12 performed a double-blinded, randomized controlled trial that compared platelet-rich plasma (30 patients) with autologous blood (30 patients) for the treatment of plantar fasciitis. At 6 months after the injection, both groups demonstrated significant and similar improvements in the VAS pain scores and the Foot and Ankle Disability Index health-related quality-of-life scores compared with baseline. Kaiser et al.13 performed a prospective randomized controlled trial comparing a 6-week formal physical therapy program (27 patients) with a 6-week home stretching program (30 patients) for the treatment of plantar fasciitis. At 6 months, both groups significantly and identically improved from baseline in terms of VAS pain scores, Foot and Ankle Ability Measure scores, and Short Form-36 (SF-36) scores, and results were maintained through the 1-year follow-up. Insertional Achilles Tendinitis Arunakul et al.14 compared conventional rehabilitation (18 patients) with accelerated rehabilitation (31 patients) after debridement and reattachment of the Achilles tendon. At 3 months, the mean scores for VAS pain, Foot and Ankle Ability Measure, and SF-36 were significantly better in the accelerated rehabilitation group, but by 6 and 12 months there were no differences. There also were no complications. In a retrospective series of 50 open Zadek osteotomies fixed with a 6-hole lateral plate for treatment of Haglund syndrome, Tourne et al.15 reported significant improvement in the AOFAS Hindfoot scores and the Victorian Institute of Sport Assessment–Achilles scores at a mean follow-up of 7 years. Of 50 patients, 46 (92%) returned to the same or higher level of sports activity. The authors recommended using the Zadek osteotomy for the treatment of Haglund syndrome in the setting of a long calcaneus or when the novel X/Y ratio proposed in the study is <2.5, where X is the length of the calcaneus and Y is the length of the tuberosity on a lateral weight-bearing radiograph. Pes Planus In an attempt to establish the diagnostic reliability of a new classification for progressive collapsing foot deformity, Li et al.16 distributed a survey to current trainees, graduates, and faculty of 13 foot and ankle fellowship programs. For the entire cohort, the diagnostic accuracy rates were 71.0% overall, 78.3% for class, and 81.7% for stage. The misdiagnosis rates for the entire cohort for were 3.3% for class A, 17.5% for class B, 11.1% for class C, 26.0% for class D, and 3.7% for class E. Importantly, this survey used example patients for whom the physical examination findings were provided to the raters. The reliability of the scheme would likely be even lower in a real-world practice situation. The classification scheme for progressive collapsing foot deformity was evaluated with actual patients by Lee et al.17. Three independent observers assessed 92 feet (84 patients). The authors reported very good intraobserver reliability (Cohen kappa, 0.851; p < 0.001) and much worse interobserver reliability (Fleiss kappa, 0.561; p < 0.001). The classification scheme should not be considered reliable until changes result in improved interobserver reliability. The Cotton osteotomy is a dorsally based opening-wedge osteotomy of the medial cuneiform that is utilized to correct the forefoot varus component of adult-acquired flatfoot deformity, but it may not provide lasting results. Abousayed et al.18 reported a mean 8.6-year follow-up for the Cotton osteotomy performed with either allograft wedges (17 feet) or metal wedges (2 feet). Although a significant improvement was noted in the lateral talus-first metatarsal angle from preoperatively to the first postoperative follow-up (p < 0.0001), approximately one-half of the patients lost >50% of that correction at the final follow-up. The lengthened angular shape of the medial cuneiform was maintained, indicating that collapse occurred through surrounding medial column joints. Sports Osteochondral Lesions of the Talus The management of large osteochondral lesions of the talus is challenging. Shi et al.19 retrospectively compared autologous osteoperiosteal transplantation from the iliac crest (23 patients) with autologous osteochondral transplantation from the ipsilateral knee (23 patients) for the treatment of large, cystic, medial osteochondral lesions of the talus. At a mean follow-up of 48 months, there was no difference between the groups in terms of VAS pain scores, AOFAS scores, or Tegner scores. There was significantly less donor site morbidity in the autologous osteoperiosteal transplantation group. Magnetic resonance observation of cartilage repair tissue (MOCART) scores and International Cartilage Regeneration & Joint Preservation Society (ICRS) scores from second-look arthroscopy showed no differences between groups. Fletcher et al.20 reported on a prospective series of 31 patients who underwent fresh structural allograft transplantation for osteochondral lesions of the talar shoulder. At a mean 56.2-month follow-up, significant improvement was found in VAS scores, SF-36 scores, and the Short Musculoskeletal Functional Assessment Bother Index and Function Index compared with the preoperative status. The overall graft survival was 96.8%. Fifteen patients (48.4%) underwent an additional surgical procedure, typically implant removal or arthroscopic debridement. Microfracture for osteochondral lesions of the talus that have previously undergone a surgical procedure (secondary lesions) may not be as beneficial as previously reported. Arshad et al.21 performed a systematic review of 12 studies to assess patient-reported outcomes and pain scores after arthroscopic bone marrow stimulation for secondary talar lesions. No perioperative complications were noted, but, in studies that reported a revision surgical procedure as an end point, 26 (34%) of 77 patients underwent a revision procedure. Overall, patient-reported outcomes such as AOFAS score and VAS pain score showed inconsistent improvements, and many positive changes were less than the minimal clinically important difference (MCID) for these scales. Enthusiasm for subchondroplasty in the talus has waned. Hanselman et al.22 retrospectively reviewed 7 cases of talar osteonecrosis after subchondroplasty for bone marrow lesions. The mean time to radiographic confirmation of osteonecrosis was 23 months. Three of 7 patients had osteonecrosis risk factors (alcoholism and/or chronic corticosteroid use). The authors urged caution with this procedure, especially in patients with osteonecrosis risk factors. Achilles Rupture and Tendinosis Research continues on the optimal management of acute Achilles tendon ruptures. Seow et al.23 performed a meta-analysis to determine complication rates after the treatment of acute Achilles tendon ruptures and included a best-case and worst-case scenario analysis for rerupture rates. The best-case scenario assumed a 0% rerupture rate in those lost to follow-up, and the worst-case scenario assumed a 100% rerupture rate. Surgical treatment significantly reduced the risk of rerupture compared with nonoperative management. The pooled rerupture rate was 3.6% (3.4% best-case scenario, 8.3% worst-case scenario) in the surgical treatment arm and 12.1% (11.7% best-case scenario, 15.0% worst-case scenario) in the nonoperative treatment arm. The rate of complications, excluding reruptures, was significantly lower with nonoperative treatment (pooled complication rate, 7.1%) compared with surgical treatment (pooled complication rate, 18.5%). Percutaneous Achilles repair may be better paired with less aggressive rehabilitation to avoid stretching the repair. Maffulli et al.24 compared a traditional rehabilitation protocol (31 patients) with a slowed-down rehabilitation protocol (29 patients) for patients undergoing percutaneous repair of an acute Achilles tendon rupture. At a 12-month follow-up, the Achilles tendon resting angle and Achilles Tendon Rupture Score were significantly better in the slowed-down rehabilitation protocol group. Additionally, calf circumference and isometric strength were more similar to those in the contralateral, uninjured leg in the slowed-down rehabilitation protocol group. Trauma The Major Extremity Trauma Research Consortium (METRC)25 published a randomized controlled trial comparing a high perioperative FiO2 (fraction of inspired oxygen) of 80% with a standard perioperative FiO2 of 30% and its effect on surgical site infections in patients undergoing a surgical procedure for tibial plateau, tibial pilon, or calcaneal fractures. At 6 months postoperatively, they found a significant difference in overall surgical site infections (superficial and deep) between the groups: 7.0% for the experimental group compared with 10.7% for the control group (relative risk [RR], 0.65; p = 0.03). The difference was driven by fewer superficial infections in the experimental group (1.7%) compared with the control group (4.3%), for which the RR was 0.41 (p = 0.02); there was no difference in the risk of deep infections (5.6% in the experimental group compared with 6.6% in the control group [RR, 0.86; p = 0.5]). Anterior impaction of the tibial plafond has been shown to portend a particularly poor prognosis. Jo et al.26 retrospectively reviewed 50 patients (52 fractures) who underwent open reduction and internal fixation (ORIF) of OTA/AO 43B and C pilon fractures. At a mean follow-up of 25 months, the group with anterior impaction (28 fractures) had significantly higher rates of implant removal for pain, significantly greater anterior subluxation, and significantly worse posttraumatic arthritis than the group without anterior impaction. Noori et al.27 found that the Lawrence and Botte classification of proximal fifth metatarsal fractures has a low level of interrater reliability (an observed agreement of 77% compared with a chance agreement of 33%). Classification at the interface between Zones 2 and 3 was much less reliable than that between Zones 1 and 2. The authors suggested that a new classification system for these fractures is required for both clinical and research purposes. Ankle Fractures Allen et al.28 studied the effect of acute, intermediate, and late-phase synovial fluid fracture hematoma on cartilage discs from fresh allograft human tali. Compared with controls, the cartilage discs cultured in synovial fluid fracture hematoma demonstrated a significantly greater production of inflammatory cytokines, metalloproteinases, and cartilage matrix fragments, suggesting that cartilage-damaging pathways had been activated. The addition of compounds that inhibit inflammation (interleukin 1 receptor antagonist or doxycycline) decreased the pro-inflammatory effect of synovial fluid fracture hematoma on the cartilage tissue. Clinical tests for fracture stability continue to be debated. In a retrospective Level-III study of supination-external rotation 2 (SER-2) ankle fractures, Ali et al.29 reported no difference (p = 0.595) between manual stress views and gravity stress views for determining fracture stability and the need for a surgical procedure. Despite their ability to limit complications in older patients, fibular nails appear to have drawbacks when used in younger patients. Kho et al.30 retrospectively compared young patients (mean age, 41.4 years) who underwent closed reduction and intramedullary fixation (CRIF) with a fibular nail (n = 94) compared with ORIF with a locking plate (n = 110). At a minimum follow-up of 3 years, complications were lower in the CRIF group (9.5% compared with 39%; p < 0.001). However, the CRIF group demonstrated significantly higher rates of posttraumatic arthritis (21.3% compared with 9.1%; p = 0.024) and fair or poor reduction (p < 0.001) on 3-D CT scans. The authors recommended that surgeons consider ORIF in active young patients, especially for more complex fracture patterns. Stupay et al.31 performed a retrospective cohort study to identify risk factors for aseptic revision of operatively treated ankle fractures. Using multivariable logistic regression modeling, the authors reported that falls in the early postoperative period, movement-altering disorders, a nonanatomic mortise (medial clear space was greater than superior clear space) on initial postoperative imaging, more severe initial fracture displacement, substance abuse, and polytrauma are independent risk factors for aseptic revision after ankle ORIF. Identifying these risk factors may help surgeons to counsel patients and improve safety and outcomes after ankle fracture surgery. Syndesmotic Injuries Bhimani et al.32 retrospectively reviewed preoperative bilateral weight-bearing CT scans in patients with unilateral Weber B fibular fractures and a symmetric medial clear space who did (n = 23) and did not (n = 18) have intraoperatively confirmed syndesmosis instability. The authors found that weight-bearing CT was able to distinguish a stable from an unstable syndesmosis even in the presence of a Weber B fibular fracture. Syndesmotic volume measured to a height of 5 cm proximal to the tibial plafond was the best measurement for diagnosing syndesmosis instability. Wong et al.33 utilized 4-D CT scans to characterize the of ankle of on The authors found significant medial and rotation of the ankle plantar but no in with in There was no difference in between in The authors that reduction in the setting of an ankle fracture be from the uninjured ankle the ankle position is The same used 4-D CT scans to at 12 months after syndesmosis fixation (n = and syndesmosis fixation (n = Although the patient were with initial fixation demonstrated significantly reduced syndesmosis of in of 5 measures (p < when compared with the uninjured No differences in syndesmosis of between and uninjured were observed in the group with Lee et retrospectively reviewed patients with a minimum follow-up after surgical fixation of the syndesmosis in the setting of an ankle fracture. patients had chronic syndesmosis as pain with a and >2 of syndesmosis compared with the ankle on bilateral CT scans at 5 years analysis a of (p = and the presence of a fracture (p = as risk factors for chronic syndesmosis instability. et performed a study the as the of the syndesmosis on a mortise of the The authors a 12 from the which that utilized to fractures are not in the syndesmosis and not the tendon. Ankle and outcomes of 3-D and for ankle and hindfoot have been reported. In a of ankle cases with and 25 cases with standard et found no difference between the techniques for component position or of the surgical procedure. All cases were performed by a In a study of cases that utilized 3-D for of the hindfoot and/or et found that of cases required secondary and of cases required removal of the implant for or aseptic outcomes are at least similar to or better than findings using allograft for these in the of was associated with the need for a secondary procedure ratio p = 0.03). and follow-up of ankle has been including of the first Using the et found of metal to be at 5 years and at years. age, and low volume for the procedure were independent of The first data for ankle were reported by et who reviewed the cases performed by the of the Of the for the were with the in at the follow-up or at the time of The authors proposed as a for and third-generation have compared the results of ankle with those of revision ankle an important the of when a et performed a cohort study of patients with ankle and 23 patients with revision ankle No were There was significantly greater improvement (p = 0.024) in the overall MOXFQ scores for ankle compared with revision deformity for ankle or is less than previously but In an et found at follow-up of 2 to 3 years, patients with deformity of who underwent either or from the procedure. No difference between the 2 be using the SF-36 and the Musculoskeletal Functional but the results as a were to those of a control cohort without deformity. ankle is an to the more anterior procedure. rates using this procedure have to be reported. et reported radiographic in of 86 cases at a mean follow-up of months. Using more CT imaging, et reported lesions in of cases at a mean follow-up of months. rates of are similar to those observed for The to the lateral are to by the same on the same cohort of patients found a rate of early complications and in The results of may be In a retrospective review of patients who underwent hindfoot with an intramedullary et reported an overall hindfoot rate at a mean follow-up of months. A greater nail ratio (p = and hindfoot compression (p = were associated with a higher rate. medial was nonunion (p = and hindfoot (p = and clinical factors including age, and did not rates. and retrospectively reviewed patients (23 feet) who underwent with internal fixation for and At a mean follow-up, the authors reported a 100% rate of with of 23 patients weight-bearing There were 6 The authors for a a and and the of in the Although is as a risk factor for is a of patients age, was associated with a of to and a of The risk was in patients with ratio p = followed by chronic and p < The study the need for improved early and for patients with Orthopaedics The of reviewed a large number of published studies to the system that a higher of In addition to in this relevant to foot and ankle surgery are to this review after the standard with a article to help in an in this Orthopaedics of corticosteroid to therapy for Achilles a randomized clinical JAMA In a randomized controlled trial on the treatment of Achilles et compared corticosteroid and physical therapy with and physical were and were in the tissue anterior to the of the tendon than in the tendon At 6 months, the corticosteroid group had significantly greater improvement in the Victorian Institute of Sport Assessment–Achilles score compared with the group. There was no of improvement at the 2-year follow-up. There were no infections and no ruptures in either group. Although traditional corticosteroid for the treatment of Achilles of corticosteroid the anterior tissue to be a and to physical therapy when Achilles or surgical treatment of acute tendon rupture. In this large randomized controlled et compared open and minimally invasive surgical treatment of acute Achilles tendon ruptures. This is by the study of the The authors reported no significant difference between groups in the mean in the Achilles Tendon Rupture Score from the baseline to and 12 months Although was not reported by the the study was for a of rerupture rates. The rate of rerupture was significantly higher in the nonoperative treatment group of patients) compared with the groups of patients in the open repair group and 1 of patients in the repair were reported in the group, and 5 were reported in the open repair group. Although this study suggested that there was no difference in patient-reported between and operatively treated acute Achilles tendon ruptures at 1 it is important to that the results may have been by the to Achilles Tendon Rupture of patients who a as in the protocol This the likely results from the nonoperative group. A study without data that patient-reported outcomes through the entire of of complications, be required to more the for a surgical procedure. Patients a surgical procedure to an Achilles should be that they similar results for nonoperative management and management as long as they not a but the risk of rerupture is higher with nonoperative management. A, of platelet-rich plasma on ankle and in patients with ankle a randomized clinical 2021 clinical improvement of ankle arthritis after platelet-rich plasma has been by and case et found no to platelet-rich plasma at 26 in a randomized Although the outcome was the AOFAS Hindfoot Score, which has a and is not an patient-reported secondary outcome also their Patients should be that there is no for platelet-rich plasma in ankle C, blood with treatment for chronic plantar a randomized controlled Foot Ankle This double-blinded, randomized controlled trial compared autologous blood patients) and patients) for the treatment of chronic plantar fasciitis. The mean pain scores both groups improved by at a final follow-up. There were no differences in patient-reported or pain scores at time plantar should patients that there is no clear to autologous blood to

Category:Ankle; ArthroscopyIntroduction/Purpose:Osteochondral lesions of the talus (OLT) are commonly seen in patients with lateral ankle instability. If left undiagnosed, OLTs can cause significant ankle pain, progressive osteoarthritis, and contribute to increased morbidity after an ankle sprain. Arthroscopy has long been the gold standard for OLT diagnosis. While MRI is a useful imaging modality for pre- operative evaluation and planning, prior research on the diagnostic utility of pre-operative MRI for OLTs observes low detection rates. With 3-T scanners replacing 1.5-T scanners, long considered the clinical standard, there is potential that 3-T MRIs may improve MRI's diagnostic efficacy. The purpose of this study is to assess the efficacy of 3-T MRI and 1.5-T MRI in diagnosing OLTs in patients undergoing Broström Gould procedure for lateral ankle instability.Methods:Following institutional review board approval, a database was obtained for all patients from 2/11/2015 to 1/21/2019 who underwent a Broström Gould procedure for lateral ankle instability in addition to diagnostic arthroscopy of the tibiotalar joint. Additionally, patients required a pre-operative MRI for inclusion in the study. Patients who underwent the Broström Gould procedure, but did not have a diagnostic arthroscopy or did not have a pre-operative MRI were excluded from the study. Patient charts were then reviewed to determine the field strength of the preoperative MRIs, and the efficacy of 3-T MRIs and 1.5-T MRIs in correctly identifying the presence or absence of OLTs using diagnostic arthroscopy as a reference standard. Patients with pre- operative MRIs where the field strength was either unlabeled or could not be determined, as they were conducted at outside institutions, were excluded from analysis.Results:Forty (49.4%) out of 81 patients were identified of having preoperative MRI with identifiable field strength, Broström Gould procedure for lateral ankle instability, and diagnostic arthroscopy of the tibiotalar joint. The average age was 37.3 +- 14.2 years. Twenty-four (60.0%) patients were female and 16 (40.0%) were male. Nineteen (47.5%) patients had OLTs identified via diagnostic arthroscopy. Twenty-one patients had a preoperative 3-T MRI, and 19 patients had a preoperative 1.5-T MRI (Table 1). The sensitivity and specificity of 3-T MRI was 75% and 100%; the sensitivity and specificity of 1.5-T M was 72.7% and 87.5%, respectively. For 3-T MRI, six patients were correctly identified as having OLTs, and 13 patients were correctly identified as not having OLTs. For 1.5-T MRI, eight patients were correctly identified as having OLTs, and seven patients were correctly identified as not having OLTs.Conclusion:Three-Tesla MRI appears to be superior to 1.5-T MRI in diagnosing OLTs in patients undergoing Broström Gould procedure for lateral ankle instability. Three-Tesla MRI demonstrates a sensitivity and specificity of 75.0% and 100%, respectively, whereas 1.5-T MRI is associated with a sensitivity and specificity of 72.7% and 87.5%. Three-Tesla MRI's low false positive rate provides support for the efficacy of this imaging modality to rule in OLTs and prompt arthroscopic surgery with subsequent OLT treatment. This suggests that 3-T MRIs may prove useful in clinical decision making regarding OLTs in patients undergoing Broström Gould procedure for lateral ankle instability.

BackgroundThe aim of this study is to analyse the re-operation rate after surgical treatment of osteochondral lesions of the talus (OCLTs) in children and adolescents.MethodsBetween 2009 and 2019, 27 consecutive patients with a solitary OCLT (10 male, 17 female; mean age 16.9 ± 2.2 years; 8 idiopathic vs. 19 traumatic) received primary operative treatment (arthroscopy + bone marrow stimulation [BMS], n = 8; arthroscopy + retrograde drilling, n = 8; autologous chondrocyte implantation [ACI]/autologous bone grafting, n = 9; arthroscopy + BMS + retrograde drilling; n = 1; flake fixation, n = 1). Seventeen OCLTs were located at the medial and ten at the lateral talus.‘Re-operation’ as the outcome measure was evaluated after a median follow-up of 42 months (range 6–117 months). Patients were further subdivided into groups A (re-operation, n = 7) and B (no re-operation, n = 20). Groups A and B were compared with respect to epidemiological, lesion- and therapy-related variables.ResultsSeven of 27 patients needed a re-operation (re-operation rate 25.9% after a median interval of 31 months [range 13–61 months]). The following operative techniques were initially used in these seven patients: arthroscopy + BMS n = 2, arthroscopy + retrograde drilling n = 4, ACI + autologous bone grafting n = 1. A comparison of group A with group B revealed different OCLT characteristics between both groups. The intraoperative findings according to the International Cartilage Repair Society (ICRS) classification revealed significantly more advanced cartilage damage in group B than in group A (p = 0.001).ConclusionsWe detected a re-operation rate of 25.9% after primary surgical OCLT treatment. Patients with re-operation had significantly lower ICRS classification stages compared to patients without re-operation.

Concomitant Subchondral Bone Cysts Negatively Affect Clinical Outcomes Following Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus

High incidence of osteoarthritic changes in patients with osteochondral lesions of the talus without chronic lateral ankle instability

Background: Uncontained osteochondral lesions of the talar shoulder are associated with an increased risk of clinical failure in patients treated with current cylindrical osteochondral autograft techniques. Whether the same holds true in patients undergoing arthroscopic treatment is unknown. Purpose: To determine the relative prognostic significance of the containment (shoulder vs nonshoulder type) and location (medial vs lateral) of an osteochondral lesion of the talus (OLT). Hypothesis: Arthroscopic treatment may not be ideal for uncontained lesions of the talar shoulder due to a lack of structural support. Study Design: Cohort study; Level of evidence, 3. Methods: Arthroscopic treatment for OLT was performed on the ankles of 399 patients between 2001 and 2009. Analyses were performed by grouping the patients according to type of containment (shoulder, n = 181; nonshoulder, n = 218), location (medial, n = 274; lateral, n = 125), and both type of containment and location (medial shoulder, n = 129; medial nonshoulder, n = 145; lateral shoulder, n = 52; lateral nonshoulder, n = 73). To evaluate the role of containment and location independently of OLT size, patients were grouped according to quartile of defect size, and outcomes were analyzed within each group. Results: Patients with shoulder-type OLT had a substantially worse clinical outcome than did those with nonshoulder-type OLT, even after adjustment for OLT size (P < .05). However, there was no significant difference in clinical outcome between patients with medial OLT and those with lateral OLT, and the clinical failure rates of the 2 groups were similar (P > .05). A Cox proportional hazards regression model demonstrated that OLT containment, but not location, exerted an independent prognostic effect. Conclusion: Patients with uncontained OLT of the talar shoulder experienced a more complicated clinical outcome than did those with contained, nonshoulder-type OLT even after adjustment for OLT size and regardless of location.