Faculty Bibliography

A systematic literature search was performed using the PubMed, MEDLINE, and the Cochrane Library databases according to the Preferred Reporting Items for Systematic review and Meta-Analyses guidelines on May 20, 2019. The keywords used were: ankle, distal tibia, distal fibula, fracture, arthroscopic, cartilage, and chondral. The objective of this study is to systematically review the characterization of intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following ankle fracture. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures within any timeframe were included. The incidence of intra-articular chondral lesions was recorded, the location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. Fifteen studies with 1355 ankle fractures were included. About 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL). We compared incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < .05 was considered statistically significant. We found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy.

OBJECTIVE:To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries. DESIGN/METHODS:A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions. RESULTS:Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies. CONCLUSIONS:This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome. PROSPERO REGISTRATION NUMBER/UNASSIGNED:CRD42020176641.

Purpose/UNASSIGNED:To investigate the short-term clinical outcomes and satisfaction for the first set of patients at our institution receiving in-office needle arthroscopy (IONA) for the treatment of posterior ankle impingement syndrome (PAIS). Methods/UNASSIGNED:A retrospective cohort study was conducted to evaluate patients who underwent IONA for PAIS between January 2019 and January 2021. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and Patient-Reported Outcomes Measurement Information System Pain Interference, and Pain Intensity scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale. The Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores. Results/UNASSIGNED:Ten patients (4 male and 6 female) with a mean age of 41.9 ± 15.5 years (range, 24-66 years) were included in the study. The mean follow-up time was 13.3 ± 2.9 months (range, 11-17 months). All mean preoperative FAOS scores demonstrated improvement after IONA, including FAOS symptoms (71.48 ± 10.3 to 80.3 ± 12.6), pain (69.3 ± 11.0 to 78.2 ± 13.9), activities of daily living (61.7 ± 8.8 to 77.93 ± 11.4), sports activities (55.6 ± 12.7 to 76.0 ± 13.6), and quality of life (46.6 ± 9.2 to 71.1 ± 12.1). There were 7 patients who participated in sports activities before the IONA procedure. Within this group, all patients returned to play at a median time of 4.1 weeks (range, 1-14 weeks). The median time to return to work was 3.4 ± 5.3 days. Patients reported an overall positive IONA experience with a mean rating scale of 9.5 ± 1.5 (range, 5-10). Conclusions/UNASSIGNED:The current study demonstrates that IONA treatment of PAIS results in significant pain reduction, a low complication rate, and excellent patient-reported outcomes. In addition, IONA for PAIS leads to high patient satisfaction with a significant willingness to undergo the same procedure again. Level of Evidence/UNASSIGNED:IV, therapeutic case series.

The anterior talofibular ligament (ATFL) is the most frequently injured lateral ligament of the ankle, and up to 20% of patients with ankle sprains may require surgical intervention to correct chronic lateral ankle instability. There has been increased interest in arthroscopic lateral ankle ligament repair techniques to minimize postoperative pain and expedite recovery. Additionally, the use of suture-tape augmentation may allow for improved recovery in those with ATFL reconstruction. The goal of this Technical Note is to describe the steps to performing in-office needle arthroscopy using suture tape as an internal brace for an ATFL deficient ankle. We also include an accompanying discussion on indications and opportunities afforded by an in-office procedure over the traditional operating room suite.

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.

PURPOSE/OBJECTIVE:To evaluate the clinical outcomes of in-office needle arthroscopy (IONA) for the treatment of anterior ankle impingement in the office setting and also evaluate patient experience of the IONA procedure. METHODS:A prospectively collected database of 31 patients undergoing IONA for the treatment of anterior ankle impingement between January 2019 and January 2021 was retrospectively reviewed. Inclusion criteria for this study were patients ≥18 years of age, clinical history, physical examination, radiographic imaging, and magnetic resonance imaging findings consistent with anterior ankle impingement for which each patient underwent IONA and had a minimum of 12-month follow-up. Clinical outcomes were evaluated using the following methods preoperatively and at final follow-up: the Foot and Ankle Outcome Scores (FAOS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity domains. A 5-point Likert scale regarding patient satisfaction with their IONA procedure was evaluated at final follow-up. Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores. RESULTS:In total, 31 patients were included in this study, including 18 male and 13 female, with a mean age of 41.7 ± 15.5 years (range, 17-69 years) and mean body mass index of 27.3 ± 5.7 (range, 19.37-41.5). The mean follow-up time was 15.5 ± 4.9 months. The mean postoperative FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 79.4 ± 11.9, 82.9 ± 15.3, 83.5 ± 15.4, 71.9 ± 18.5 and 64.3 ± 21.4 at final follow-up respectively. Minimal clinically important difference was achieved by 84% of patients for FAOS pain, 77% for FAOS symptoms, 75% for FAOS Quality of Life, 74% for FAOS sports, 65% for PROMIS Pain Interference, 61% for FAOS Activities of Daily Living, and 42% for PROMIS Pain Intensity. Lastly, 29 patients (94 %) expressed willingness to undergo the same procedure again. CONCLUSIONS:The current study demonstrates that IONA treatment of anterior ankle impingement results in significant pain reduction, a low complication rate and excellent patient reported outcomes with high rates of return to work/sport. Additionally, IONA for anterior ankle impingement leads to high patient satisfaction with a significant willingness to undergo the same procedure again. LEVEL OF EVIDENCE/METHODS:IV, Case series study.

Achilles tendinopathy is a common inflammatory condition of the Achilles tendon prevalent in the athletic population in which patients present with pain, swelling, and reduced performance exacerbated by physical activity. Operative intervention using either open or percutaneous approaches has traditionally been performed after failure of nonoperative treatment, but less invasive modalities that include endoscopic approaches have been increasingly used. This Technical Note highlights our technique for Achilles paratenon needle tendoscopy in the wide-awake office setting, with accompanying indications for use, advantages, and technical pearls.

Tendoscopy has been recognized to be a useful technique in the diagnosis and treatment of early tibialis posterior tendon (TPT) dysfunction. Although open surgical procedures for advanced TPT disease have led to excellent outcomes, disagreement persists concerning the correct management algorithm for early TPT dysfunction. Recent developments in needle tendoscopy have provided a minimally invasive option for direct evaluation and intervention throughout the forefoot, midfoot, and hindfoot. The goal of this manuscript is to describe the technique for performing in-office needle tendoscopy targeting the TPT with a discussion of indications and opportunities afforded by an in-office procedure over the traditional operating room suite.

Anterior ankle impingement is a common cause of chronic ankle pain characterized by altered joint mechanics with considerable deficits in range of motion. The benefits of in-office nano arthroscopy (IONA) include the ability to diagnosis and treat anterior ankle impingement, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office nano arthroscopy for anterior ankle impingement, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-office needle tendoscopy (IONT) can be used for the diagnosis and treatment of several peroneal tendon pathologies including peroneal tendon tendinopathy, tears, and instability. Benefits of IONT for peroneal tendon disorders include the ability to dynamically evaluate peroneal tendon stability, quicker patient recovery, reduced cost, and improved patient satisfaction. Several studies have suggested that tendoscopic treatment may avoid several complications related to open treatment of peroneal tendon pathologies, including scar formation and groove stenosis. The purpose of the present report is to describe the technique for performing IONT for common peroneal tendon pathologies. This Technical Note describes the techniques for obtaining adequate anesthesia and performing IONT, indications, and advantages of performing these procedures in the office rather than in the operating room.