Faculty Bibliography

Articular cartilage is a highly specialised connective tissue that serves to lubricate joint surfaces and distribute loads across the joint. Injury to articular cartilage is a significant cause of pain and dysfunction that may eventually lead to osteoarthritis or degenerative arthrosis. Management of these injuries is complicated by the complex architecture and poor vascularity of this tissue. The field of articular cartilage restoration has evolved rapidly over the past several decades and current techniques offer promising results. However, despite the fast pace of progress in the treatment and repair of articular cartilage injury, a clear gold standard in management has yet to emerge. Current techniques for managing cartilage injuries discussed in this review include bone marrow stimulation, osteochondral transplantation, chondrocyte implantation, cell-based transplantation, biological augmentation and scaffold-based therapies. Heterogeneity in study design, including surgical procedures, lesion and patient characteristics, cell collection, biologics preparation protocols and outcome measures limits interpretation of results presented in the literature. Therefore, standardisation across research protocols and collaboration among centres will be necessary. This state-of-the-art review' presents the indications and techniques for managing ankle articular cartilage lesions, as well as future directions and geographical differences in management.
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Ankle sprains are common musculoskeletal injuries, with approximately 27,000 occurring every day in the U.S. alone. The anterior talofibular ligament (ATFL) is the most commonly injured ligament. Although most acute lateral ankle sprains can be treated conservatively, up to 20% of these injuries result in chronic lateral ankle instability and may require surgical stabilization. Recently, an arthroscopic lateral ankle ligament repair technique has become increasingly popular. This minimally invasive procedure is expected to reduce postoperative pain and promote faster recovery. The current article presents an ATFL repair using a 2-portal, non-distraction arthroscopic technique. Chronic lateral ankle instability refractory to physical therapy for 3 to 6 months is the main indication for surgical treatment, and sufficient quality of ligament tissue remnant is required for arthroscopic repair. Compared with an open procedure, equivalent clinical results and earlier recovery following arthroscopic ATFL repair have been reported. The major steps of the procedure, demonstrated in this video article, are (1) placement of portals for the arthroscopic procedure, (2) suture anchor insertion into the distal aspect of the fibula, (3) needle insertion into the ATFL remnant, (4) a lasso-loop stitch using a suture relay technique, (5) reattachment of the ATFL remnant, and (6) postoperative protocol. Complications are rare, and earlier return to daily activities compared with a standard open technique can be achieved.

Ankle arthroscopy is a diagnostic and therapeutic surgical procedure which was first attempted on cadavers by Dr Burman in 1931 and first successfully described in patients by Dr Takagi in 1939. Two general approaches to ankle arthroscopy currently exist: (1) anterior ankle arthroscopy and (2) posterior ankle arthroscopy. The indications for ankle arthroscopy have expanded as increased experience has been obtained treating various pathologic entities and as the surgical results have been reported in the literature. There has been significant progress in ankle arthroscopic surgery over the past decades, notably allowing surgical procedures to be performed with fewer complications and with quicker return to work and play. We anticipate that expanding indications for arthroscopic ankle surgical procedures combined with further development of biomedical devices to enhance these procedures will result in improved patient outcomes in the future.

BACKGROUND:/UNASSIGNED:Operative treatment is indicated for unstable syndesmosis injuries, and approximately 20% of all ankle fractures require operative fixation for syndesmosis injuries. PURPOSE:/UNASSIGNED:To perform a meta-analysis of randomized controlled trials evaluating clinical outcomes between suture button (SB) and syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. STUDY DESIGN:/UNASSIGNED:Meta-analysis. METHODS:/UNASSIGNED:A literature search was performed according to the PRISMA guidelines to identify randomized controlled trials comparing the SB and SS techniques for syndesmosis injuries. Level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine. Statistical analysis was performed with RevMan, and a P value ≤.05 was considered statistically significant. RESULTS:/UNASSIGNED:Five clinical studies were identified, allowing comparison of 143 patients in the SB group with 142 patients in the SS group. Patients treated with the SB technique had a higher postoperative American Orthopaedic Foot & Ankle Society score at a mean 20.8 months (95.3 vs 86.7, P < .001). The SB group resulted in a lower rate of broken implants (0.0% vs 25.4%, P < .001), implant removal (6.0% vs 22.4%, P = .01), and joint malreduction (0.8% vs 11.5%, P = .05) as compared with the SS group. CONCLUSION:/UNASSIGNED:The SB technique results in improved functional outcomes as well as lower rates of broken implant and joint malreduction. Based on the findings of this meta-analysis, the SB technique warrants a grade A recommendation by comparison with the SS technique for the treatment of syndesmosis injuries.

BACKGROUND:There is a paucity of clinical studies that compare the efficacy of autograft and allograft in osteochondral transplantation for treatment of osteochondral lesions of the talus (OLT). The purpose of the present study was to compare the clinical and radiographic outcomes following osteochondral transplantation with autograft or allograft for OLT. METHODS:A retrospective analysis comparing patients treated with autograft or allograft for OLT was performed. Clinical outcomes were evaluated with use of the Foot and Ankle Outcome Score (FAOS) and the Short Form-12 (SF-12) score. Magnetic resonance imaging (MRI) was evaluated with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. The rates of cyst occurrence, graft degradation, graft failure, and revision surgeries were also evaluated. RESULTS:Twenty-five nonrandomized patients with autograft and 16 with allograft were included, with a mean follow-up of 26 months in the autograft group and 22 months in the allograft group. There were no significant differences among all demographic variables between the autograft and allograft groups. The mean postoperative FAOS was significantly higher in the autograft group (81.9; 95% confidence interval [CI]: 78.6 to 85.2) than in the allograft group (70.1; 95% CI: 63.7 to 76.5; p = 0.006). Similarly, the mean postoperative SF-12 scores were significantly higher in the autograft group (74.7; 95% CI: 71.0 to 78.4) than in the allograft group (66.1; 95% CI: 61.2 to 71.0; p = 0.021). MOCART scores were significantly better in the autograft group (87.1) than in the allograft group (75.5; p = 0.005). The rate of chondral wear on MRI was higher in the allograft group (53%) than in the autograft group (4%; p < 0.001). Cyst formation in the graft itself was more likely to occur in the allograft group (47%) than in the autograft group (8%; p = 0.017). The rate of secondary procedures for the graft was higher in the allograft group (25%) than in the autograft group (0%; p = 0.009). CONCLUSIONS:In this small nonrandomized cohort study, the procedures performed with use of an autograft provided better clinical and MRI outcomes than the allograft procedures. The rate of chondral wear on MRI was higher with allograft than with autograft, and allograft-treated patients had a higher rate of clinical failure. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:The purpose of this systematic review is to evaluate the effects of adipose derived mesenchymal stem cells (ADSCs) in the treatment of osteoarthritis (OA) in the clinical setting. METHODS:A literature search was performed in the MEDLINE, EMBASE, and The Cochrane Library Database up to January 2017 for inclusion and exclusion criteria. Criteria for inclusion were clinical studies demonstrating the effects of ADSCs on OA, and written in English. The following variables were analyzed: donor site, volume of adipose tissue, preparation of ADSCs, clinical outcomes, and complication rate. RESULTS:Sixteen studies (knee: 14 studies, multiple joints: 1 study, ankle: 1 study) were included in this systematic review. All of the studies prepared ADSCs in the form of the stromal vascular fraction (SVF). Inconsistencies between studies were found with regards to reported clinical variability, donor sites of SVF, and reported clinical outcomes. Nine studies used either platelet-rich plasma (PRP) (7/16) or fibrin (4/16) or both PRP and Fibrin (1/16), as an adjunct at time of SVF injection. All of the studies reported an improvement in clinical outcomes with the use of SVF. Five studies reported a 90% satisfaction rate, and no study reported any complications with liposuction. Five studies reported on complications, with a 5% incidence of swelling and pain. CONCLUSIONS:This systematic review demonstrated that ADSCs are currently used in the form of SVF. While SVF may produce favorable clinical outcomes with minimal risk of side effects on osteoarthritis, the variability in the data and the use of biological adjuvants have confounded the effectiveness of ADSCs. This study will help surgeons understand the limitations in the literature on ADSCs. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of level IV studies.

Studies have shown that sesamoidectomy provides good clinical outcomes; however, concern exists regarding complications occurring after resection of 1 or both sesamoid bones. The purpose of the present systematic review was to evaluate the current evidence on sesamoidectomy for the treatment of hallux sesamoid disorders. A systematic search of the MEDLINE, Embase, and Cochrane Library databases was performed during October 2017. The included studies were evaluated for the level of evidence and quality of evidence using the Coleman Methodology Score. Variable reporting outcomes data, clinical outcomes, and percentage of patients returning to sports at their previous level were evaluated. Ten studies, totaling 196 feet, were included. The weighted mean patient age was 36.6 ± 11.0 years, and the weighted mean follow-up duration was 45.1 ± 19.3 months. The mean visual analog scale score improved from 6.5 ± 0.3 to 1.2 ± 0.5. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 92.7 ± 2.7. Six studies demonstrated that 94.4% of patients returned to sports, with 90.0% returning to their previous level, at a mean of 11.8 ± 1.8 weeks. The mean hallux valgus angle increased from 13.1° ± 2.1° preoperatively to 14.8° ± 3.7° postoperatively (p = .470), and the mean intermetatarsal angle increased from 8.7° ± 0.8° to 9.7° ± 0.8° (p = .180). Overall complication rate was 22.5% and the revision rate was 3.0%. The present systematic review has demonstrated that sesamoidectomy for hallux sesamoids disorders yields good clinical outcomes and a high rate of return to sports in the short term, albeit with a high complication rate of 22.5%.

Unfortunately, the spelling of the names Daniel Haverkamp and Ákos Kynsburg were incorrect in the original online publication of the article.

INTRODUCTION/BACKGROUND:Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies. PURPOSE/OBJECTIVE:The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies. METHODS:Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached. CONCLUSION/CONCLUSIONS:This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature. LEVEL OF EVIDENCE/METHODS:V.