Faculty Bibliography

BackgroundThe management of osteochondral lesions of the talus (OLT) is challenging, with 2 main options being conservative and surgical management. Orthobiologic therapies come to bridge the gap between these 2 options; however, inconsistencies in indication, composition, and heterogeneous evidence limit clinical decision-making. To address these challenges, 3 International Congress Meetings on Cartilage Repair of the Ankle were convened in Pittsburgh, USA (2017), Dublin, Ireland (2019), and New York, USA (2025) to establish agreement on the role of conservative management and injectable orthobiologic strategies in the treatment of OLT.MethodsSeventy-five multidisciplinary experts from over 25 countries and 1 territory participated in a structured Delphi-based consensus process. Blinded surveys, structured questionnaires, and in-person discussions were used to develop and refine statements, supported by literature review and graded evidence (A1-E). Consensus strength was defined as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%)ResultsIn total, 29 consensus statements were achieved across the 3 meetings. Strong agreement was reached regarding indications and expected outcomes of conservative management, including the role of immobilization and appropriate timing for surgical intervention. Orthobiologic injections, including platelet-rich plasma, concentrated bone marrow aspirate, and hyaluronic acid, were considered appropriate in select patients with persistent symptoms, although no superiority was demonstrated among formulations, preparation methods, or injection strategies. When used as adjuncts to surgical procedures, orthobiologics may improve radiological outcomes, with limited evidence for improvement in clinical outcomes. Technical considerations, including preferred harvest sites and a lack of standardized preparation protocols, were identified, along with key principles for patient counselingConclusionThese international consensus statements establish a standardized framework for the conservative management and use of injectable orthobiologic therapies in OLT. By clarifying indications, technical considerations, and current limitations, this work aims to improve consistency in clinical practice, guide treatment decision-making, and inform future research.

BackgroundThe management of osteochondral lesions of the talus (OLT) is challenging, with 2 main options being conservative and surgical management. Orthobiologic therapies come to bridge the gap between these 2 options; however, inconsistencies in indication, composition, and heterogeneous evidence limit clinical decision-making. To address these challenges, 3 International Congress Meetings on Cartilage Repair of the Ankle were convened in Pittsburgh, USA (2017), Dublin, Ireland (2019), and New York, USA (2025) to establish agreement on the role of conservative management and injectable orthobiologic strategies in the treatment of OLT.MethodsSeventy-five multidisciplinary experts from over 25 countries and 1 territory participated in a structured Delphi-based consensus process. Blinded surveys, structured questionnaires, and in-person discussions were used to develop and refine statements, supported by literature review and graded evidence (A1-E). Consensus strength was defined as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%)ResultsIn total, 29 consensus statements were achieved across the 3 meetings. Strong agreement was reached regarding indications and expected outcomes of conservative management, including the role of immobilization and appropriate timing for surgical intervention. Orthobiologic injections, including platelet-rich plasma, concentrated bone marrow aspirate, and hyaluronic acid, were considered appropriate in select patients with persistent symptoms, although no superiority was demonstrated among formulations, preparation methods, or injection strategies. When used as adjuncts to surgical procedures, orthobiologics may improve radiological outcomes, with limited evidence for improvement in clinical outcomes. Technical considerations, including preferred harvest sites and a lack of standardized preparation protocols, were identified, along with key principles for patient counselingConclusionThese international consensus statements establish a standardized framework for the conservative management and use of injectable orthobiologic therapies in OLT. By clarifying indications, technical considerations, and current limitations, this work aims to improve consistency in clinical practice, guide treatment decision-making, and inform future research.

BackgroundOsteochondral lesions of the tibial plafond (OLTPs) are considerably less common than osteochondral lesions of the talus (OLT), and the terminology, prognostic factors, and treatment strategies for these lesions remain poorly characterized.MethodsExperts participated in a structured Delphi-based consensus process during the International Consensus Meeting on Cartilage Repair of the Ankle (ICCRA) meeting held in 2019. Blinded surveys, structured questionnaires, literature review, and in-person discussions were used to develop and refine statements. Consensus strength was defined as consensus (51-74%), strong consensus (75-99%), or unanimous (100%).ResultsA total of 11 consensus statements were developed addressing terminology, prognostic factors, and management of OLTP, all of which achieved strong consensus. Unanimous agreement was reached on the terminology "osteochondral lesion of the tibial plafond." Key prognostic factors included lesion characteristics, cystic changes, kissing lesions, and hindfoot alignment. Nonoperative treatment may be considered in asymptomatic or nondisplaced lesions, whereas surgical treatment may be indicated for symptomatic or progressive lesions. Bone marrow stimulation was recommended for small, non-cystic lesions; osteochondral transplantation was supported for larger or cystic lesions. Associated pathology such as kissing lesions and malalignment should be addressed concurrently, and salvage procedures may be considered in advanced cases.ConclusionThese international consensus statements establish practical guidance for the assessment and management of OLTP by integrating current evidence with expert opinion. By outlining key prognostic considerations and treatment pathways, these recommendations aim to reduce variability in clinical practice and provide a foundation for future investigation in this challenging pathology.Level of Evidence:V, expert consensus.

BackgroundManagement of moderate-to-large (1-2.9 cm²) osteochondral lesions of the talus (OLT) remains challenging due to the transition from reparative to replacement surgical strategies and the absence of high-level comparative evidence guiding treatment selection.MethodsAn international panel of experts participated in a modified Delphi consensus process during the International Congress on Cartilage Repair of the Ankle (ICCRA) meetings held in 2017 and 2025. Survey rounds and structured discussions were used to generate and refine consensus statements. Consensus strength was categorized as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%), and levels of evidence were graded according to established criteria.ResultsConsensus statements were developed for autologous osteochondral transplantation (AOT), osteochondral allograft transplantation (OCA), scaffold-based cartilage restoration techniques, and emerging extracellular matrix and juvenile cartilage allograft strategies. Autologous osteochondral transplantation was supported as a primary treatment option for cystic, uncontained, and revision lesions, with emphasis on graft continuity and appropriate depth. Osteochondral allograft transplantation was recommended for larger or uncontained lesions and in cases where autograft is contraindicated, with preference for fresh, size-matched grafts used within 28 days. Scaffold-based techniques were identified as viable alternatives in select primary and revision settings, although not superior to AOT for larger lesions. Extracellular matrix cartilage allograft (ECMA) and particulate juvenile cartilage allograft transplantation (PJCAT) potentially enhance cartilage restoration.ConclusionThe ICCRA consensus provides a structured, evidence-informed framework for the surgical management of moderate-to-large OLT. Although multiple treatment strategies demonstrate clinical utility, the current literature remains heterogeneous with limited high-level evidence. Further prospective and comparative studies are warranted to better define optimal indications and long-term outcomes for each approach.Level of Evidence:V, Expert consensus.

BACKGROUND:Total ankle arthroplasty (TAA), traditionally performed through an anterior approach, has generally been reserved for older patients. A lateral transfibular approach requires minimal osseous resection and permits implantation into denser bone, which may make it a durable option for younger candidates. This study compared midterm implant survivorship and clinical and radiographic outcomes following primary transfibular TAA in patients younger and older than 55 years. METHODS:Patients who underwent primary transfibular TAA and had a minimum follow-up of 5 years were included. Patient-reported outcome measures (PROMs) included the 12-Item Short-Form Health Survey (SF-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) for pain. Radiographic alignment, range of motion, and periprosthetic cysts (radiolucency of >2 mm) were assessed. Adverse events and reoperations were reported. Outcomes in younger (<55 years old) and older (≥55 years old) patients were compared using multivariable linear regression and linear mixed models. RESULTS:Two hundred and fifty-one ankles (in 236 patients; 86% White) were included. The younger group included 72 ankles (in 70 patients, mean age of 45.4 years [95% confidence interval (CI), 43.7 to 47.1] years) with a mean of 6.9 (6.2 to 7.5) years of follow-up; the older group included 179 ankles (in 166 patients, mean age of 65.7 years [64.7 to 66.7] years) with a mean of 7.0 (6.7 to 7.3) years of follow-up. The younger group more commonly had a primary diagnosis of posttraumatic arthritis (83% versus 61%) and a history of ankle fracture fixation (84% versus 68%) (both p < 0.05). There were no significant differences between the younger and older groups in the rate of adverse events (40.3% versus 33.0%), time to reoperation (21.7 versus 27.4 months), implant revision (1.4% versus 0%), or periprosthetic cysts (5.6% versus 2.8%). In analyses controlling for confounding variables, age did not demonstrate significant associations with pre- or postoperative PROMs, alignment, or range of motion (all p > 0.05). CONCLUSIONS:Although this study was not designed to determine equivalence between the age groups, favorable midterm outcomes were observed in both younger and older patients. These results suggest that transfibular TAA may be a viable treatment option for end-stage ankle arthritis across a wide age range, but longer-term follow-up is needed. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:series. METHODS:Retrospective review was performed of all transfibular TAA performed by a single surgeon from 2012 to 2022, and patients with minimum 2-year radiographic follow-up were included. Fibular osteotomy fixation was achieved with a lateral locked plate. Weightbearing ankle radiographs were analyzed at 3, 6, 12, and 24 months postoperatively for evidence of healing based on mature bridging bone across the osteotomy. Secondary analyses at 3 and 6 months were performed based on patient age (<55 vs 55 ≥ years old), history of diabetes, and smoking status. RESULTS:> .05). Four (1.0%) nonunions were observed in total: 2 cases were symptomatic and healed following revision fixation with bone grafting. CONCLUSION/CONCLUSIONS:In this large series of consecutive transfibular TAA, most patients had healed their fibular osteotomy by 3 months. There was no association between osteotomy healing and patient age, smoking status, or diabetes at 3 and 6 months postoperatively, and the overall incidence of fibular nonunion was 1%. These results should be reassuring to surgeons concerned about this potential complication when considering transfibular approach for TAA. LEVEL OF EVIDENCE/METHODS:Level IV, case series.

BACKGROUND:Patient-specific instrumentation (PSI) has been proposed to improve accuracy and efficiency in total ankle arthroplasty (TAA). Although cadaveric studies suggest improved precision, the clinical value of PSI over standard instrumentation (SI) remains uncertain. METHODS:A systematic review and meta-analysis following PRISMA guidelines was performed using PubMed, Embase, and Cochrane databases through July 2025. Comparative studies evaluating PSI vs SI in TAA were included. Outcomes analyzed included patient-reported outcome measures (PROMs), radiologic alignment, intraoperative efficiency, complication and revision rates, and cost. Random effects models were used to pool standardized or mean differences (MDs) or risk ratios with 95% CIs. RESULTS: < .001). No statistically significant differences were detected in complication and revision rates. Cost analysis produced conflicting results, with one study suggesting potential savings and another finding PSI more expensive after accounting for preoperative imaging. CONCLUSION/CONCLUSIONS:PSI in TAA reduces fluoroscopy time but does not appear to enhance functional outcomes, complication rates, or revision risk compared with SI in the short term. PSI may result in greater deviation from sagittal alignment, and its cost-effectiveness remains uncertain. High-quality prospective studies with long-term follow-up are needed to clarify its role in routine and complex cases.

BACKGROUND:Total ankle arthroplasty (TAA) provides pain relief and motion preservation for end-stage ankle arthritis, yet outcomes and utilization vary widely. Social determinants of health (SDOHs) such as socioeconomic, demographic, and behavioral factors may contribute to these disparities, but their influence on TAA has not been systematically evaluated. METHODS:A systematic review was registered on PROSPERO (CRD420251156933) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PROGRESS-Plus framework to identify studies examining the impact of SDOH on TAA utilization and outcomes. PubMed, Embase, and Scopus were searched through 2025. Study quality was assessed with the Risk Of Bias In Nonrandomized Studies of Interventions tool, and certainty of evidence for each domain was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Data were synthesized narratively with random-effects meta-analysis where feasible. RESULTS:Forty-four studies including more than 200,000 patients were analyzed. Social determinants were found to influence both access to TAA and postoperative outcomes. Men demonstrated slightly better postoperative function, whereas women reported more pain and higher rates of nonhome discharge. Older patients experienced more perioperative complications but achieved similar long-term implant survival compared with younger cohorts. Patients from minority racial and ethnic groups had higher complication rates and were less likely to receive TAA compared with arthrodesis. Lower income, public insurance, and treatment in rural or lower-volume hospitals were consistently linked with reduced access to TAA, longer hospital stays, and greater healthcare costs. Behavioral factors such as smoking and preoperative opioid use were strongly associated with wound complications, prolonged hospitalization, and poorer recovery. CONCLUSION/CONCLUSIONS:SDOH significantly shape access to surgery, complication risk, and recovery after TAA. Recognition of these influences and targeted strategies such as preoperative optimization, equitable referral pathways, and improved access to rehabilitation may help reduce disparities and improve outcomes in ankle arthroplasty. LEVEL OF EVIDENCE/METHODS:Level III, systematic review of predominantly Level III studies.

Graphical Abstract.

Stenosing tenosynovitis/tendinitis of the flexor hallucis longus (FHL) tendon is a relatively common occurrence in dancers. When nonoperative management fails, surgical tenolysis/tenosynovectomy has been shown to successfully reduce pain and restore function. In this study, we present the case of a professional contemporary dancer with FHL stenosing tenosynovitis/tendinitis who underwent a z-lengthening of the FHL proximal to the intact tendon sheath which resulted in a rupture of the FHL upon return to dance. He subsequently underwent a FHL reconstruction with tendon allograft. He returned to unrestricted professional dance at 11 months postoperative, which has been maintained at 4-year clinical and MRI follow-up.Level of evidence: V.