Faculty Bibliography

BACKGROUND:Assessing patient's risk of infection is fundamental for prevention of periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA). The Mayo Prosthetic Joint Infection Risk Score (Mayo Score) is based on data from total hip and knee arthroplasty and has not been validated for application for TAA. METHODS:A total of 405 consecutive TAA cases were followed for 6 months for PJI. Individual patients' Mayo Scores were calculated and analyzed with logistic regression and receiver operating characteristic (ROC) for predictability for PJI. A critical cut-off Mayo Score for patients at high risk of PJI was determined by best Youden index. Among the Mayo Score-defined high-risk patients, the contribution of different risk factors were compared between the PJI and non-PJI patients. RESULTS: < .001). Logistic regression showed that the probability of PJI increased with higher Mayo Scores (odds ratio 1.48, 95% CI 1.23-1.78). All but 1 PJI patients had a Mayo Score >5. The sensitivity and specificity were 90.0% and 84.3%, respectively, when a Mayo Score >5 was used as a criterion for high risk of PJI. CONCLUSION:This study demonstrated that the Mayo Score could similarly predict PJI risk after TAA as in total hip and knee arthroplasty. Data analysis suggests that a Mayo Score >5 could be a criterion for identifying high-risk patients for PJI, although further validation with a large number of PJI cases is necessary. LEVEL OF EVIDENCE:Level II, developing diagnositic criteria with consecutive cases.

Orthopedic surgeons frequently use fluoroscopy and flat plate X-ray in the operating room. As the length of surgeons' careers gets longer, the risk of potential for harm from radiation exposure also grows. Knowledge of the background and science of radiation, the C-arm, and various ways that surgeons can protect themselves is fundamental and should be incorporated into residency education for orthopedic surgery. This review provides information that we hope will better prepare residents in orthopedic surgery to use fluoroscopy and X-rays and protect themselves from radiation risks.

BACKGROUND:The decision regarding total ankle replacement (TAR) is challenging in patients with inflammatory arthritis (IA) regarding more inferior bone quality, large bone cysts, and increased risk of infections. This systematic review and meta-analysis aimed to compare the functional outcome, revision rate, complication rate, and survival rate of TAR between IA (including rheumatoid arthritis [RA]) and noninflammatory arthritis (NIA) (primary and posttraumatic). METHODS:After reviewing the full texts, 30 articles fulfilled all inclusion criteria from 1985 until 2021, comparing TAR results. The eligible studies included 5508 patients, of whom 1565 patients had IA and 3943 patients had NIA. At the time of surgery, the average age was 58 years in the IA group and 63 in the NIA group. The average follow-up was 67.2 months in the IA group and 67 months in the NIA group. The outcome measures were the American Orthopaedic Foot and Ankle Society (AOFAS) score and the rate of complications, revisions, and survival. RESULTS:The mean final AOFAS score was 82 (95% confidence interval [CI]: 78-86) in the IA group and 83 (95% CI: 78-88) in the NIA group, with no significant difference. There was no significant difference in the mean preoperative to postoperative AOFAS score change between the IA and the NIA. The complication rate was 16% (95% CI: 9%-27%) in the IA group and 15% (95% CI: 8%-27%) in the NIA group with no significant difference. The revision rate was 12% (95% CI: 10%-15%) in the IA group and 13% (95% CI: 10%-18%) in the NIA group, which was significant (P = .04). There was no significant difference in the survival rate between IA and NIA. CONCLUSION/CONCLUSIONS:Total ankle replacement is a safe procedure in inflammatory ankle arthritis, specifically in RA patients with relatively minor and major complications close to other reasons for ankle replacement. LEVELS OF EVIDENCE/UNASSIGNED:Level IV: prognostic.

OBJECTIVE:Joint destruction in Charcot neuroarthropathy (CNA) is accompanied with abundant hyperplastic synovium. This study aimed to characterize the expression patterns of a group of neuropeptides in the CNA synovium. METHODS:Synovial specimens were collected during surgery from the CNA (n = 6) and non-CNA joints (n = 14). Tissue samples were processed for protein extraction and western blot for vasoactive intestinal peptide (VIP), galanin, and calcitonin gene-related peptide (CGRP). Immunohistochemistry was performed to localize CGRP in the CNA synovium. Additionally, CGRP was applied to fibroblast-like synoviocytes (FLS) isolated from CNA synovium for its effects on cell proliferation and collagenolysis in vitro. RESULTS:Western blot detected light bands of VIP in the CNA samples but abundant galanin in both CNA and non-CNA samples. Most of the CNA samples (5/6) increased expression of CGRP, with an average band density about 2 times that in the non-CNA group (p < .05). Immunohistochemistry of CGRP demonstrated intense staining in the intimal layer of the CNA synovium. In tissue culture, adding CGRP (10 nM) in the medium promoted FLS proliferation. In combination with TNF-α, CGRP enhanced FLS-mediated collagenolysis in vitro. CONCLUSION:This study revealed an increased expression of CGRP in the CNA synovium and demonstrated that CGRP regulates FLS proliferation and collagenolytic activity, suggesting CGRP may contribute to the bone and cartilage destruction in CNA.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS:A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

OBJECTIVE:The aim of this study was to evaluate the association between 4-dimensional computed tomography (4DCT)-derived measurements of tibiofibular syndesmosis during active dorsiflexion-plantarflexion motion and the presence of tibiotalar osteoarthritis (OA). METHODS:Sixteen ankle joints underwent 4DCT imaging during active dorsiflexion-plantarflexion. Syndesmotic anterior distance (SAD) and syndesmotic translation (ST) were obtained by a foot-and-ankle surgeon. We used Kellgren-Lawrence (KL) grading to determine tibiotalar OA. RESULTS:Of 16 scanned ankles, 12 ankles had KL ≥2 at the tibiotalar joint. In these ankles, SAD (-0.4, P = 0.02) and ST (-0.9, P = 0.006) measurements significantly changed during the dorsiflexion-plantarflexion motion. Changes in SAD measurements were significantly correlated with the KL grades (correlation coefficient: -0.688, P = 0.003); however, the changes in ST measurements were not significantly correlated with the KL grade. CONCLUSIONS:Our exploratory cross-sectional analysis shows that SAD measurement changes during motion using 4DCT are correlated with the tibiotalar OA grading. This measurement may be used but requires confirmation in larger studies including patients with actual syndesmotic injuries.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%. RESULTS:A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.

OBJECTIVE:Biologics are increasingly used for cartilage repair and osteoarthritis (OA) treatment. This study aimed to provide an overview of the clinical trials conducted on this subject. DESIGN:Two-word combinations of two sets of key words "cartilage"; "joint"; "osteoarthritis" and "biologics"; "stem cells"; "cell implantation" were used to search the database of ClinicalTrials.gov and supplemented with searches of PubMed and EMbase. The registered trials were analyzed for clinical conditions, completion status, phases, and investigated biologics. Recently completed trials with posted/published results were summarized. RESULTS:From 2000 to 2022, a total of 365 clinical trials were registered at ClinicalTrials.gov to use biologics for cartilage repair and OA treatment. Since 2006, the number of registered trials accelerated at an annual rate of 16.4%. Of the 265 trials designated with a phase, 72% were early Phase 1, Phase 1, and Phase 2. Chondrocytes and platelet-rich plasma (PRP) were studied in nearly equal number of early- and late-stage trials. Mesenchymal stem/stromal cells (MSCs) were the most commonly investigated biologics (38%) and mostly derived from bone marrow and adipose tissue (70%). In last 5 years, 32 of the 72 completed trials posted/published results, among which seven Phase 3 trials investigated chondrocytes, PRP, bone marrow aspirate concentrate, hyaluronic acid, collagen membrane, and albumin. CONCLUSIONS:There was a rapid increase in the number of registered clinical trials in recent years, using a variety of biologics for cartilage repair and OA treatment. Majority of the biologics still require late-stage trials to validate their clinical effectiveness.

BACKGROUND:An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS:A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION:These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE:Level V, mechanism-based reasoning.