Faculty Bibliography

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.

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.

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.

BACKGROUND:Bedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents. Accuracy and tolerability of this approach in the clinical setting-including patients with end-stage ankle pathology and/or a history of prior surgery-is not known. AIM/OBJECTIVE:To assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint. METHODS:This was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space. Secondary outcome measures included a patient-reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up. Complications were monitored from inclusion up to a 2-wk control visit. RESULTS:< 0.01). Infections or other complications were not encountered. CONCLUSION/CONCLUSIONS:Clinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent. Accuracy was 100% in patients without total ventral joint obliteration.

Hallux rigidus is the most common arthritic condition of the foot. Interpositional arthroplasty (IPA) is indicated for advanced-stage hallux rigidus and attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, the data evaluating the effectiveness of IPA are limited. The purpose of this study was to systematically review the outcomes of IPA in the treatment of hallux rigidus. MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed based on the preferred reporting items for systematic reviews and meta-analyses guidelines. Outcomes collected and analyzed included: American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (HMI) score, visual analogue scale score, short-form 36 score, range of motion (ROM), radiographic parameters, and postoperative complications. The level and quality of clinical evidence were recorded and assessed. Sixteen studies with a total of 428 patients met inclusion/exclusion criteria. The mean AOFAS-HMI score improved from 51.6 ± 10.1 (range 35.0-64.2) preoperatively to 86.0 ± 7.7 (range 71.6-95.4) postoperatively (p ≤ .001) at weighted mean follow-up of 58.0 ± 34.5 (range 16.5-135.6) months. The preoperative weighted mean total ROM was 39.3° ± 9.6° (range 24.2-49.9) and the postoperative weighted mean total ROM was 61.5° ± 4.8° (range 54.0-66.5) (p ≤ .001). The complication rate was 21.5% with metatarsalgia as the most commonly reported complication. One study was level 3 and 15 studies were level 4 clinical evidence. This systematic review demonstrates improvement in functional and ROM outcomes following IPA procedure at mid-term follow-up. The procedure however has a moderate complication rate. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data.

BACKGROUND:The negative effects of bullying, discrimination, harassment, and sexual harassment (BDHS) on well-being and productivity of surgical residents in training have been well documented. Despite this, little has changed over the past decade and these behaviors continue. The purpose of this study was to determine the prevalence of each abusive behavior experienced by residents, identify the perpetrators, and examine the reporting tendency. METHODS:A systematic review of articles published between 2010 and 2020 in the MEDLINE, EMBASE, and Cochrane databases was performed following PRISMA guidelines. The following search terms were used: bullying, harassment, sexual harassment, discrimination, abuse, residency, surgery, orthopedic surgery, general surgery, otolaryngology, obstetrics, gynecology, urology, plastic surgery, and training. RESULTS:Twenty-five studies with 29,980 surgical residents were included. Sixty-three percent, 43, 29, and 27% of surgical residents experienced BDHS, respectively. Female residents reported experiencing all BDHS behaviors more often. Thirty-seven percent of resident respondents reported burnout, and 33% reported anxiety/depression. Attending surgeons, followed by senior co-residents, were the most common perpetrators. Seventy-one percent did not report the behavior to their institution. Fifty-one percent stated this was due to fear of retaliation. Of those who reported their experiences, 56% stated they had a negative experience reporting. CONCLUSION/CONCLUSIONS:Our review demonstrates high prevalence rates of BDHS experienced by residents during surgical training, which have been associated with burnout, anxiety, and depression. The majority of residents did not report BDHS due to fear of retaliation. Residency programs need to devise methods to have a platform for residents to safely voice their complaints.

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.

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.

Concentrated bone marrow aspirate (CBMA) offers an alternative to sesamoid resection in end stage sesamoid pathology. CBMA potentiates the anti-inflammatory effect, stimulates local tissue regeneration and osteogenesis, when injected into bone. The purpose of this study is to evaluate the functional outcomes in a cohort of athletes following CBMA injection for the treatment of hallux sesamoid disorders. A retrospective case series of consecutive patients treated with CBMA injection for hallux sesamoid disorders were identified. Radiographs, Foot and Ankle Outcome Scores (FAOS), and Visual Analogue Scale (VAS) score were collected pre- and postinjections. Descriptive statistics were presented as the mean and standard deviation for continuous variables and frequency as percentages for categorical variables. Fifteen consecutive patients with were included with a mean follow-up time of 20.1 (range 12-34) months. Significant improvement in all scoring subscales of the FAOS and VAS score was noted preinjection compared to final follow-up postinjection (p < .001). Eight of 11 patients that were involved in sports prior to the CBMA injection returned to play, with 7 successfully returning to preinjury level status. Three patients required further treatment (20%). The case series suggests that CBMA injection is a safe and effective treatment option for hallux sesamoid disorders with a high rate of return to play.

A 65-year-old female with 18 months of left ankle pain after a traumatic injury underwent nano arthroscopy of her left ankle with identification and removal of a loose osseous body annealed to her tibiotalar joint not seen on advanced imaging. The arrival of nano arthroscopy has provided foot and ankle surgeons with the necessary tools to now locate sources of pain and dysfunction not necessarily observed on advanced imaging and directly intervene on these disorders in the office setting. This case report describes one of the first patients treated with an innovative nano arthroscopy device.
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