Faculty Bibliography

BACKGROUND/UNASSIGNED:Lateral ankle sprains are the most common lower extremity injury in athletes, most often involving the anterior talofibular ligament (ATFL). Although ATFL repair outcomes are well studied, optimal management for patients with generalized ligamentous laxity (GLL) remains less understood. PURPOSE/UNASSIGNED:To (1) evaluate the radiographic findings, clinical measures, and complications in patients with GLL undergoing modified Broström-Gould repair and to (2) assess the role of suture augmentation in optimizing outcomes. STUDY DESIGN/UNASSIGNED:Systematic review; Level of evidence, 4. METHODS/UNASSIGNED:During July 2025, the PubMed, EMBASE, and Cochrane library databases were systematically searched to identify studies examining outcomes and complications in GLL patients who underwent modified Broström-Gould repair. RESULTS/UNASSIGNED:= .03). When suture augmentation was performed, no significant difference in complication rates existed between cohorts. CONCLUSION/UNASSIGNED:Patients with GLL experienced significantly higher rates of complication and failure following modified Broström-Gould repair compared with patients without ligamentous laxity. Suture augmentation may lower complication rates in GLL patients, but its effect on failure rates remains undetermined, as no studies directly compared augmented and nonaugmented GLL patients. Importantly, both GLL patients and patients without ligamentous laxity experienced clinical improvements from the modified Broström-Gould repair. While GLL increases the risk of mechanical complications, it should not be considered a contraindication to undergoing the modified Broström-Gould procedure. However, suture augmentation may be beneficial for GLL patients to reduce the risk of complications after undergoing ATFL repair. REGISTRATION/UNASSIGNED:CRD420251182303 (PROSPERO identifier).

BACKGROUND:The Hospital Frailty Risk Score (HFRS) is associated with adverse events after joint replacement, but outcomes following total ankle arthroplasty (TAA) remain unclear. METHODS:The National Readmissions Database (2017-2019) identified patients undergoing primary TAA, classified as frail or non-frail using HFRS. Thirty-day readmission rates, length of hospital stay (LOS), and hospitalization costs were compared between cohorts. Univariate analysis was used to compare 30-day complication rates, reoperation rates, and disposition designation. RESULTS:From a total of 6147 patients who underwent TAA, frail patients had longer LOS (2.4 vs. 1.6 days, p < 0.01), higher costs ($27,181 versus $24,777; p < 0.01), and more discharge to higher-level care (44.0 % versus 26.0 %; p < 0.01). Frailty was associated with longer LOS (IRR 1.36; p < 0.001) and increased costs (IRR 1.07; p < 0.001), but not associated with 30-day readmissions, complications, or reoperations. CONCLUSION/CONCLUSIONS:Frailty was associated with longer LOS, higher costs, and increased discharge to higher-level care in patients undergoing TAA. LEVEL OF EVIDENCE/METHODS:IV.

BACKGROUND/UNASSIGNED:Knee ligament injuries are common in elite rugby union players and are associated with performance limitations. However, comparative data on long-term performance and career patterns after isolated anterior cruciate ligament (ACL) versus medial collateral ligament (MCL) injuries remain limited. METHODS/UNASSIGNED:A retrospective review of elite rugby union players who sustained an isolated partial or complete ACL or MCL tear from 2013 to 2025 was performed. Data were collected from rugby databases and media reports, and included player demographics, injury characteristics, and performance metrics. A Wilcoxon signed rank test was used to compare pre-injury and post-injury performance metrics, with a p value < 0.05 determined as statistically significant. RESULTS/UNASSIGNED:Twenty-eight players sustained ACL injuries and 23 sustained MCL injuries. At 9.8 ± 3.1 months, 96.4% of ACL-injured players returned to sport, while 100% of MCL-injured players returned at 1.9 ± 2.1 months. ACL-injured players demonstrated significant declines in games played, tries, and points scored in the season following injury. Over time, performance largely stabilized, but total seasons played decreased. Players with MCL injuries demonstrated short-term performance declines but played a. similar number of seasons before and after injury. Re-injury occurred in 17.9% of ACL cases and 13.0% of MCL cases, with greater re-injury frequency and shorter intervals between injuries in the ACL cohort. CONCLUSION/UNASSIGNED:ACL injuries in elite rugby union players were associated with longer return to sport (RTS) times and fewer post-injury seasons despite recovery of performance metrics. MCL injuries allowed faster RTS and preserved career length but were associated with decreased performance. Re-injury led to further performance decline in both cohorts. These findings highlight distinct patterns of career and performance impact following ACL versus MCL injury in elite rugby union players. LEVEL OF EVIDENCE/UNASSIGNED:IV.

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:This systematic review and meta-analysis aimed to evaluate the outcomes of intra-articular hyaluronic acid (HA) injections for the treatment of ankle osteoarthritis (OA). METHODS:A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was conducted in February 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data extracted included patient demographics, injection protocols, subjective clinical outcomes, ankle range of motion, complications, and failures. RESULTS:Six randomized controlled trials (RCTs) were included, comprising 145 patients (149 ankles) who received intra-articular HA injections and 129 patients (138 ankles) in the control cohorts. The weighted mean follow-up was 5.2 ± 3 months for the HA group. There were no significant differences between HA and control groups in terms of visual analog scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, and ankle osteoarthritis scale (AOS) scores. Complication rates were similar between groups, with transient injection site pain being the most common complication. CONCLUSION/CONCLUSIONS:: I, meta-analysis of randomized controlled trials.

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.

BACKGROUND/UNASSIGNED:Spring ligament disruption is a primary contributor to the development of progressive collapsing flatfoot deformity (PCFD). The purpose of this systematic review is to evaluate the radiographic findings, clinical outcomes, complications, and failures following spring ligament repair with and without augmentation. METHODS/UNASSIGNED:During December 2025, the PubMed, Cochrane, and EMBASE library databases were systematically searched to identify studies examining radiographic findings, clinical outcomes, complications, and failures in patients who underwent spring ligament repair with and without augmentation. RESULTS/UNASSIGNED:Nine studies including 209 patients (212 feet) with spring ligament injuries were analyzed. Patients who underwent spring ligament repair with and without augmentation were evaluated. Both treatment approaches were associated with clinically meaningful improvements in radiographic alignment, with mean talo-first metatarsal angle (TFMA) correction of 12.9° following isolated repair and 11.0° following repair with augmentation. Clinical outcomes also improved, with mean increases in American Orthopaedic Foot and Ankle Society (AOFAS) scores of 24.1 and 29.8 points for isolated repair and repair with augmentation, respectively. Complication rates were low for both isolated repair (4.5 %) and repair with augmentation (6.7 %), with corresponding failure rates of 1.3 % and 3.3 %, respectively. CONCLUSION/UNASSIGNED:Spring ligament repair with and without augmentation is associated with meaningful improvements in radiographic alignment and clinical outcomes in patients with PCFD. Across the included studies, both treatment approaches also demonstrated low complication and failure rates. While suture augmentation may provide additional mechanical support in select patients, the available evidence precludes direct comparative conclusions regarding the superiority of the technique over isolated spring ligament repair. Further high-quality, comparative studies are warranted to definitively establish the optimal surgical method for managing spring ligament injuries. LEVEL OF EVIDENCE/UNASSIGNED:IV.

Freiberg's disease is a condition characterized by progressive flattening and eventual collapse of a metatarsal head. Core decompression, metatarsophalangeal joint (MTPJ) debridement, metatarsal osteotomies, autologous osteochondral transplantation (AOT), interpositional arthroplasties, and synthetic implant hemiarthroplasties comprise the surgical management options for patients with Freiberg's disease. Although autografts harvested from the iliac crest have been utilized for the treatment of various osteochondral pathologies of the lower extremity, their use for Freiberg's disease has not been reported to date. We present the case of a novel technique of metatarsal osteoperiostic grafting from the iliac crest (MetOPIC) to the second metatarsal head with injection of concentrated bone marrow aspirate (cBMA) in a 28-year-old former collegiate cheerleader with a longstanding history of chronic pain due to Freiberg's disease. The patient was able to return to her normal activities and participate in sporting activity 8 weeks following the operation. To the authors' knowledge, this is the first report of the use of the MetOPIC procedure to surgically correct Freiberg's disease.Levels of Evidence: V, Case report.

BACKGROUND/UNASSIGNED:Peroneal tendon disorders span tendinopathy, tenosynovitis, intrasheath subluxation, stenosis, and tears, and may be challenging to diagnose accurately with clinical examination and MRI alone. Peroneal tendoscopy offers a minimally invasive, diagnostic-therapeutic option. We systematically reviewed clinical indications, intraoperative findings, procedures, imaging accuracy, complications, and patient-reported outcomes following peroneal tendoscopy. METHODS/UNASSIGNED:Eight studies (190 patients; 195 ankles) were reviewed. Data on demographics, indications, procedures, PROMs, return to sport (RTS), complications/failures, and imaging-tendoscopy agreement were extracted and pooled when constructs aligned. Random-effects meta-analyses generated pooled means or proportions with 95 % CIs (Hartung-Knapp adjustment). Where applicable, diagnostic performance of preoperative assessment was compared with tendoscopy as reference. RESULTS/UNASSIGNED:Across 190 patients (195 ankles), pooled mean age was 32 years (95 % CI 25.0-39.0), follow-up 30.3 months (95 % CI 20.8-39.8); 71 % of ankles had traumatic aetiologies. Indications were broad, with recurrent subluxation/dislocation, intrasheath subluxation, and refractory lateral ankle pain common. Frequently performed procedures included synovectomy/debridement (94 ankles), groove deepening (34 ankles), excision of space occupying lesions (65 ankles; predominantly low-lying muscle bellies [LLMB] and peroneus quartus), tendon repair/tubularization (23 ankles), and tendoscopic retinacular repair (14 ankles). Six studies reported validated PROMS with four reporting AOFAS suitable for pooling. Postoperative AOFAS averaged 96.6 (95 % CI 94.3-99.0) with a pooled mean gain of +19.8 (95 % CI 18.5-21.2); JSSF, FAOS and SF-12 improved significantly. RTS occurred at a pooled 13.3 weeks (95 % CI 10.6-16.0), with RTS of 12.2 ± 0.6 weeks after tendoscopic retinacular stabilization and 14.8 ± 2.0 weeks after groove deepening. Overall complications were 7.6 % (13 events) and mainly consisted of persistent ankle pain and minor wound issues. Failure rate was 1.5 % and two revision surgeries (1.0 %) were reported. Diagnostic agreement was high at the aggregate level (MRI overall sensitivity 0.90, specificity 0.72), but lesion-level performance varied: MRI was strong for tears and tenosynovitis, weaker for stenosis. Composite preoperative diagnosis in a large series showed high specificity (0.97) but only moderate sensitivity (0.76), with LLMB frequently under-recognized preoperatively. CONCLUSIONS/UNASSIGNED:Peroneal tendoscopy provides meaningful functional gains, timely RTS, and a low adverse-event burden across a wide indication spectrum, and it complements imaging by clarifying dynamic/space-conflict pathology. Longer, prospective comparative studies are warranted.

BACKGROUND:Freiberg's disease is a rare osteochondrosis of the metatarsal head that can cause progressive pain, deformity, and loss of function. The two most widely used joint-preserving surgical options for advanced disease are dorsiflexion closing wedge metatarsal osteotomy (DCWMO) and autologous osteochondral transplantation (AOT). To date, no meta-analysis has directly compared these procedures. This systematic review and meta-analysis aimed to evaluate functional, radiographic, and complication outcomes of AOT versus DCWMO in Freiberg's disease. METHODS:A systematic search of PubMed, Embase, and Cochrane Library was conducted in August 2025 according to PRISMA guidelines. Inclusion criteria were clinical studies comparing or reporting outcomes of AOT or DCWMO in Freiberg's disease. Risk of bias was assessed using JBI Critical Appraisal Tools. Pairwise meta-analyses were performed for comparative studies evaluating American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analogue scale (VAS) pain, range of motion (ROM), and complications. Single-arm pooled analyses were conducted for AOT and DCWMO separately to provide context for within-group improvements and complication rates. Random-effects models were applied throughout. RESULTS:Sixteen studies involving 259 toes were included: 62 treated with AOT and 197 with DCWMO. Three comparative studies (n = 70) demonstrated significantly greater functional gain with AOT (AOFAS mean difference [MD] 7.15, 95 % CI 4.29-10.02; I²=0 %) and superior dorsiflexion both postoperatively (MD 7.85°, 95 % CI 4.40-11.29; I²=0 %) and in terms of gain from baseline (MD 7.46°, 95 % CI 3.77-11.14; I²=0 %). Absolute postoperative AOFAS and VAS pain scores were similar between groups, as were improvements in plantarflexion. DCWMO consistently shortened the metatarsal head (pooled mean 1.76 mm), whereas AOT preserved or slightly increased length (-0.20 mm). Complications were significantly lower with AOT (risk difference -0.20, 95 % CI -0.35 to -0.04; risk ratio 0.23, 95 % CI 0.05-0.96). Single-arm pooled analyses confirmed large improvements in AOFAS (∼25 points) and VAS (∼5 points) for both groups, with pooled complication rates of 1 % for AOT and 6 % for DCWMO. CONCLUSION/CONCLUSIONS:Both AOT and DCWMO provide meaningful pain relief and functional improvement in advanced Freiberg's disease. However, AOT demonstrated superior functional gains, greater preservation of motion and metatarsal length, and fewer complications, suggesting it may represent the preferred joint-preserving option, particularly for Smillie stage III-IV disease. Future prospective comparative trials with standardized outcome reporting and exploration of lower-morbidity donor graft sources are warranted to refine surgical decision-making. LEVEL OF EVIDENCE/METHODS:Level II, systematic review and meta-analysis.