Faculty Bibliography

This manuscript presents the perspective of the International Society of Cartilage Repair of the Ankle (ICCRA) regarding a recent English High Court ruling that challenges established principles of evidence-based sports orthopaedic care. Following a legal case involving a professional footballer and the surgical management of an ankle fracture with concomitant arthroscopy, the authors highlight significant discrepancies between the legal conclusions and the current scientific literature. The ruling suggests that arthroscopic intervention contributed to the development of ankle arthritis and premature termination of the athlete's career. However, substantial evidence demonstrates that posttraumatic ankle arthritis is a well-recognised sequela of ankle fractures, particularly in the presence of prior injury and syndesmotic instability. Arthroscopy at the time of fracture fixation is widely regarded as the standard of care for identifying and managing intraarticular pathology. The judgement is critiqued for disregarding expert orthopaedic testimony, misinterpreting scientific evidence and endorsing unsupported theoretical mechanisms linking routine arthroscopic procedures to accelerated joint degeneration. The authors emphasise that such conclusions contradict accepted surgical practice and risk establishing harmful precedents that may deter appropriate management of similar injuries. This ICCRA statement highlights the need for alignment between medico-legal reasoning and scientific evidence to safeguard patient care and uphold the integrity of orthopaedic decision-making. LEVEL OF EVIDENCE: NA.

BackgroundOsteochondral lesions of the talus (OLT) remain challenging to evaluate and report because of historically inconsistent terminology and nonspecific clinical findings. The 2017 and 2019 International Consensus Meetings on Cartilage Repair of the Ankle addressed complementary aspects of OLT evaluation, including history, physical examination, and terminology. The purpose of this proceedings article is to integrate these consensus statements into a concise framework for clinicians and researchers.MethodsSelected statements from the 2017 and 2019 International Consensus Meetings were reviewed and synthesized. Both meetings used a modified Delphi consensus process involving international experts in ankle cartilage repair. Statements were developed through blinded electronic surveys, structured questionnaires, literature review, in-person discussion, and final anonymous voting. Consensus strength was defined as consensus, strong consensus, or unanimous agreement according to predefined voting thresholds.ResultsConsensus statements supported standardized terminology distinguishing subchondral bone lesions, chondral lesions, and OLT. Bone marrow stimulation was endorsed as an umbrella term for marrow-access procedures, and standardized terminology was recommended for autologous and allograft osteochondral transplantation. The panel also supported consistent reporting of subchondral edema, subchondral cysts, lesion area, diameter, depth, and injury chronicity. For clinical assessment, consensus supported documentation of activity level, symptom duration, trauma history, pain localization, mechanical symptoms, prior treatment, swelling, alignment, ankle range of motion, stability, and tenderness to palpation. Deep activity-related ankle pain, with or without swelling, was identified as the most important clinical feature suggesting a symptomatic ankle cartilage lesion.ConclusionThis proceedings article integrates terminology, history, and physical examination recommendations from the 2017 and 2019 International Consensus Meetings on Cartilage Repair of the Ankle. Standardized use of these definitions and clinical assessment elements may improve clinical communication, documentation, and consistency in research reporting.

BACKGROUND:Total ankle arthroplasty (TAA) utilization has rapidly increased over the last decade despite relatively unknown long-term survivorship of fourth-generation implants. The purpose of this study was to determine the long-term survivorship of the trabecular metal (TM) transfibular TAA and report relevant interval changes. METHODS:Retrospective review was performed of prospectively followed patients who underwent primary transfibular TAA by a single surgeon from October 2012 to February 2016, including patients with minimum 10-year clinical and radiographic follow-up. Patient-reported outcomes measures (PROMs) included 12-item Short Form Health Survey physical (SF-12 PCS) and mental (SF-12 MCS) component summary scores, Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS). Radiographic outcomes included alignment, motion, presence of periprosthetic lucencies. Adverse events and reoperations were reported using the Canadian Orthopaedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). RESULTS:Seventy-one ankles (68 patients) were included out of 79 TAAs (89.9%) with mean age of 61 (range, 28-80) years. Mean follow-up was 11.0 years (IQR, 1.5). There was 1 metal component revision (MCR) for periprosthetic joint infection requiring below-knee amputation (CROCS 11). Twenty-nine (40.8%) ankles underwent reoperations, with no ankles requiring more than 3 reoperations. The most common indication for reoperation was gutter debridement (n = 12; CROCS 4). Five cysts were detected in 4 ankles (7%) at final follow-up. Postoperative PROMs, radiographic alignment and motion were stable between 5- and ≥10-year time points. CONCLUSION/CONCLUSIONS:This single surgeon cohort demonstrated 98.6% implant survivorship of the TM transfibular TAA at a mean 11-year follow-up. Radiographic evaluation showed stable alignment and range of motion between midterm and long-term follow-up, and low rates of periprosthetic lucencies with minimal interval osteolysis between 5- and 10-year evaluations. Overall, these results support transfibular TAA as a durable long-term treatment for ankle arthritis. LEVEL OF EVIDENCE/METHODS:Level IV, case series.

BackgroundThe evaluation of osteochondral lesions of the talus (OLT) has long been limited by variability in imaging protocols, lesion measurement techniques, and clinical utility of radiographic classification systems. 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 work-up, diagnostic imaging, and radiographic classification systems for 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, 19 consensus statements were achieved across the 3 meetings. Strong agreement was reached for first-line use of weight-bearing radiographs and complementary use of magnetic resonance imaging (MRI) and computed tomography for lesion characterization. Standardized assessment of lesion size in 3 planes and localization using a 9-zone grid were endorsed. Diagnostic arthroscopy was considered to have limited routine value in the setting of advanced imaging. Post-treatment imaging recommendations clarified indications for radiographs and cross-sectional imaging and emphasized the limited correlation between imaging findings and clinical function. Computed tomography-based classification systems were considered more useful for guiding treatment decisions than plain radiographic or MRI-based systems.ConclusionThese international consensus statements establish a standardized imaging-based framework for the evaluation and classification of OLT, improving consistency in diagnosis, treatment planning, and clinical reporting.

BACKGROUND:The aim of this study is to present early outcomes following revision of failed TAA using a low-profile, transfibular TAA prosthesis. METHODS:This was a retrospective review of 11 ankles (11 patients; average 72.1 years-old) who underwent revision TAA using the transfibular trabecular metal (TM) prosthesis. Modes of failure included aseptic loosening/subsidence (n = 7) and periprosthetic joint infection (PJI, n = 4). Demographic, radiographic, and patient-reported outcomes were analyzed at minimum 2-years. RESULTS:Average time to revision TM TAA was 9 years (range, 2-22), All 4 cases with PJI were successfully treated with two-stage revision. There was significant improvement in VAS and AOS Pain (both p < 0.05). Mean coronal (90.7°) and sagittal (86.1°) alignment were within normal limits. There was 1 (9%) revision, 4 (36%) reoperations. CONCLUSION/CONCLUSIONS:In select patients with failed TAA who wish to avoid fusion or amputation, revision arthroplasty using a transfibular approach may be a possible alternative. LEVEL OF EVIDENCE/METHODS:IV, Case-Series.

BACKGROUND/UNASSIGNED:There are limited results about total ankle arthroplasty (TAA) in the setting of severe malalignment. The aim of this study was to compare midterm patient-reported and radiographic outcomes in patients with severe varus or valgus tibiotalar deformity treated with primary transfibular TAA at a minimum of 5-year follow-up. METHODS/UNASSIGNED:Retrospective review was performed of all primary transfibular TAA by a single surgeon from October 2012 to January 2020 and grouped based on preoperative coronal talar tilt angle. Severe preoperative deformity included cases with ≥10° of varus (n = 36) or valgus (n = 33), while cases within 5° of neutral coronal alignment (n = 140) served as a control group. PROMs included 12-item Short-Form Health Survey physical and mental component scores, Ankle Osteoarthritis Scale, and Visual Analog Scale. Alignment and periprosthetic cysts (>2 mm) were assessed on postoperative radiographs. Adverse events and reoperations were reported using the Canadian Orthopaedic Foot and Ankle Society Reoperation Coding System. RESULTS/UNASSIGNED:Aside from age (Neutral vs. Valgus, 58.1 vs. 64.2 years; p = 0.01), there were no significant differences in demographics, preoperative, or postoperative PROMs among the 3 groups. The median preoperative talar tilt was -15.1° (interquartile range [IQR], -17.8° to -13.1°) in the Varus and 16.0° (IQR, 12.0° to 19.5°) in the Valgus groups; there were no significant differences in median tibiotalar alignment between the 3 groups postoperatively. In the Neutral group, 1 patient had postoperative varus, and 2 patients had postoperative valgus deformity. In the Varus group, 1 patient had recurrent varus, and 1 patient progressed to valgus. Seven ankles had periprosthetic cysts. Overall reoperation rates were similar (Neutral, 34%; Varus, 33%; Valgus, 36%) with no implant revisions. CONCLUSION/UNASSIGNED:Transfibular TAA is capable of correcting severe coronal tibiotalar malalignment in the primary treatment of end-stage ankle arthritis. Patients with ≥10° varus or valgus deformity demonstrated postoperative patient-reported and radiographic outcomes similar to those with neutral ankle alignment at midterm follow-up, without an increased risk of reoperations. LEVEL OF EVIDENCE/UNASSIGNED:Level III. See Instructions for Authors for a complete description of levels of evidence.

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.