Faculty Bibliography

OBJECTIVE:To evaluate the effect of intra-articular injection of autologous micronized adipose tissue (MAT) with ankle arthroscopic debridement in patients with advanced-stage posttraumatic osteoarthritis (PTOA) of ankle. DESIGN/METHODS:A retrospective cohort study investigating patients treated with arthroscopic debridement and autologous MAT injection for ankle PTOA was performed. Patients with Kellgren-Lawrence (KL) grade 3 to 4 were included. Visual analogue scale (VAS), Foot and Ankle Outcome Scores (FAOS), and patient satisfaction were evaluated. RESULTS:= 0.048). CONCLUSIONS:Autologous MAT injection is a safe and potentially beneficial procedure for advanced-stage ankle PTOA as an adjunct to arthroscopic debridement, although more than one-third of patients were unsatisfied with the procedure. This procedure may be more beneficial for KL grade 3 patients than grade 4 patients. However, future investigations are necessary to define the role of MAT for ankle PTOA.

BACKGROUND/UNASSIGNED:Hamstring injuries are common and account for considerable time lost to play in athletes. Platelet-rich plasma has potential as a means to accelerate healing of these injuries. PURPOSE/UNASSIGNED:(1) To present the evidence of platelet-rich plasma injection in the treatment of hamstring injuries, (2) evaluate the "best-case scenario" in dichotomous outcomes, and (3) evaluate the "worst-case scenario" in dichotomous outcomes. STUDY DESIGN/UNASSIGNED:Systematic review and meta-analysis. METHODS/UNASSIGNED:values <.05 were considered statistically significant. RESULTS/UNASSIGNED:A total of 10 studies were included with 207 hamstring injuries in the platelet-rich plasma group and 149 in the control group. The fixed effects model for mean time to return to play, which compared platelet-rich plasma + physical therapy and physical therapy alone, significantly favored platelet-rich plasma + physical therapy (mean difference, -5.70 days). The fixed effects model for reinjury rates, which also compared platelet-rich plasma + physical therapy with physical therapy alone insignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.88). The best-case scenario fixed effects model for reinjury rates insignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.82). The worst-case scenario fixed effects model for reinjury rates insignificantly favored physical therapy alone (risk ratio, 1.13). The mean ± SD complication rate for either postinjection discomfort, pain, or sciatic nerve irritation was 5.2% ± 2.9% (range, 2.7% to 9.1%). CONCLUSION/UNASSIGNED:There has been statistically nonsignificant evidence to suggest that PRP injection ± PT reduced mean time to RTP or reinjury rates compared to no treatment or PT alone for hamstring injuries in a short-term follow-up. The complication profiles were favorable. Further studies of high quality and large cohorts are needed to better support or disprove the consensus of the systematic review and meta-analysis.

Background/UNASSIGNED:Plantar fasciitis is the most common cause of plantar heel pain. Several recent randomized control trials (RCTs) have been published comparing the use of platelet-rich plasma (PRP) and corticosteroids (CSs) for the treatment of plantar fasciitis. Purpose/UNASSIGNED:To perform a systematic review of RCTs to compare whether PRP or CS injections result in decreased pain levels and improved patient outcomes in the treatment of plantar fasciitis. Study Design/UNASSIGNED:Systematic review; Level of evidence, 1. Methods/UNASSIGNED:< .05 was considered to be statistically significant. Results/UNASSIGNED:< .00001, respectively). Conclusion/UNASSIGNED:In patients with chronic plantar fasciitis, the current clinical evidence suggests that PRP may lead to a greater improvement in pain and functional outcome over CS injections.

BACKGROUND/UNASSIGNED:Treatment for post-traumatic osteoarthritis (PTOA) of the ankle remains challenging. Distraction arthroplasty (DA) is an alternative for patients who are averse to or poor candidates for arthrodesis or joint replacement. The purpose of this study was to examine the role of microfracture (MFX) and concentrated bone marrow aspirate (CBMA) on the outcome of patients undergoing DA for end-stage PTOA of the ankle joint. METHODS/UNASSIGNED:Ninety-five patients who underwent DA for the treatment of end stage PTOA from 2009 to 2014 were selected from the hospital ankle registry. Demographic data, functional activity levels, complications, and radiographs taken at 6, 12, 24, and 36 months postoperatively were reviewed. Foot and Ankle Outcome Scores (FAOS) were obtained at the same time intervals. A total of 78 patients were included in this study. Interventions were divided into 4 groups for comparison: DA+MFX (n = 8), DA+MFX+CBMA (n = 35), DA+CBMA (n = 22), and DA alone (n = 13). RESULTS/UNASSIGNED:= .01). The use of MFX was associated with significantly lower FAOS scores. CONCLUSION/UNASSIGNED:The current study showed no benefit from MFX when combined with DA in the treatment of PTOA. CBMA may have helped mitigate the adverse effect of MFX but conferred no benefit when used with DA alone. DA remains a useful alternative to ankle arthrodesis and arthroplasty in patients with PTOA. However, MFX and biologic augmentation using CBMA appeared to have no additional benefit. LEVEL OF EVIDENCE/UNASSIGNED:Level III, comparative study.

Turf toe is hyperextension injury of the plantar plate at the first metatarsophalangeal joint. Etiologies have often included sports/activities with excessive forefoot axial loading and/or violent pivotal movements. The purpose of the systematic review was to systematically review and present an overview for the current evidence-based treatment options of turf toe. Both authors systematically reviewed the PubMed and EMBASE databases from inception to April 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The level of evidence and quality of evidence were assessed by using the Level of Evidence for Primary Research Question of the Journal of Bone and Joint Surgery, and the quality of evidence was assessed with use of the Newcastle-Ottawa scale. Data were collected and categorized into: case reports and case series. Eight studies (16 turf toes) met the aforementioned criteria and were included. Five case reports and 3 case series reported various treatment options for turf toe. Specifically, 3 studies reported solely conservative treatment (n = 5), 1 study reported solely surgical treatment (n = 1), and 4 studies involved patients in conservative and/or surgical treatments (n = 10). All studies were of level of clinical evidence 4 and quality of clinical evidence score 2 (poor quality). Conservative treatment included closed reduction and immobilization, and surgical treatment included plantar plate tenodesis. Restricted dorsiflexion was the most common complication reported. Turf toe is an underreported injury with no evidence-based treatment guideline to date. Future studies of higher level and quality of evidence with a specific classification system (Jahss or Anderson) consistently reported are warranted for the development of an optimal guideline to determine the most appropriate treatment for each specific severity in injury.

BACKGROUND:Identifying preoperative patient characteristics that correlate with an increased risk of periprosthetic joint infection (PJI) following total ankle replacement (TAR) is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR. METHODS:Utilizing the terms "(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)" we searched the PubMed/MEDLINE electronic databases. The quality of the included studies was then assessed using the AAOS Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence. RESULTS:Eight studies met the inclusion criteria. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age less than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery. CONCLUSIONS:Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.

PURPOSE/OBJECTIVE:The purpose of this meta-analysis was to analyze the current comparative studies of arthroscopic and open techniques for lateral ankle ligament repair to treat chronic lateral ankle instability. METHODS:A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed during February 2018. Included studies were evaluated with regard to level of evidence and quality of evidence using the Modified Coleman Methodology Score. Total number of patients, patient age, follow-up time, gender ratio, surgical technique, surgical complications, complication rate, recurrent instability or revision rate, clinical outcome measures and percentage of patients who returned to sport at previous level were also evaluated. Statistical analysis was performed using RevMan, and a p value of < 0.05 was considered to be statistically significant. RESULTS: = 0%, n.s.). There was no statistically significant difference in total, nerve, or wound complications. CONCLUSIONS:The current meta-analysis found that short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. There was no significant difference between arthroscopic and open repair with regards to Karlsson functional outcome score, total complication rate, or the nerve and wound complication subsets with the included studies with at least 12 months of follow-up. However, the current evidence is still limited, and further prospective trials with longer follow-up are needed. LEVEL OF EVIDENCE/METHODS:III.

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.