Faculty Bibliography

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are 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 "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS:A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus. LEVEL OF EVIDENCE:Level V, expert opinion.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are 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 was to report on the consensus statements on "Revision and Salvage Management" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS:A total of 8 statements on revision and salvage management reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with revision and salvage management in the cartilage repair of the ankle.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are 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 "Conservative Management and Biological Treatment Strategies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS:A total of 12 statements on Conservative Management and Biological Treatment Strategies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Ten statements reached strong consensus (greater than 75% agreement), and 2 achieved consensus. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with conservative management and biological treatment strategies for osteochondral lesions of the talus.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are 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 Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS:A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement. CONCLUSIONS:The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle.

PURPOSE/OBJECTIVE:The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability. METHODS:A systematic search of MEDLINE, EMBASE, and Cochrane Library databases was performed during August 2017. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated. RESULTS:Eight studies for a total of 269 ankles were included; 87.5% of studies were LOE III or IV, and the QOE in all studies was of poor or fair quality. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores ranged from 41.2 to 69.9, and postoperative AOFAS scores ranged from 90.2 to 98. All studies using AOFAS score showed an increase in postoperative outcome score of 22.8 to 54.2 at a mean follow-up of 17.1 months. Five studies used Karlsson-Peterson scores with mean postoperative score of 88.5 (range, 76.2-93.6) at a mean follow-up of 21.2 months. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 11.6% in the included studies. The overall rate of return to sport was 100%. CONCLUSIONS:The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. However, there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure, and there are no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate (11.5%) associated with the arthroscopic procedures, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of Level I, III, and IV studies.

PURPOSE/OBJECTIVE:Autologous osteochondral transplantation is an established treatment for large-sized osteochondral lesions of the talus (OLT) with excellent short term outcomes. However, few studies assess the outcomes of autologous osteochondral transplantation at mid-term follow-up. The purpose of the current systematic review was to evaluate the clinical outcomes of the autologous osteochondral transplantation procedure in the treatment of OLT at mid-term and long-term follow-up. METHODS:A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in October 2017 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Clinical outcomes, and complications were also evaluated. RESULTS:Eleven studies, with 500 ankles were included at a mean 62.8 months follow-up. Seven studies used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.1 ± 6.1, and the postoperative score was 86.2 ± 4.5, with 87.4% of patients (132 of 151) being reported as excellent or good results. In total, 53 of the 500 patients (10.6%) had complications. The most common complication was donor site morbidity with 18 patients (3.6%) at final follow-up. Thirty-one patients (6.2%) underwent reoperations, and 5 ankles (1.0%) were regarded as failed autologous osteochondral transplantation. CONCLUSION/CONCLUSIONS:The current systematic review demonstrated that good clinical and functional outcomes can be expected following autologous osteochondral transplantation for the treatment of OLT, with a low failure rate. The results from this study show patients can be reasonably counselled to expect good clinical outcomes in the mid-term. MRI and radiographs showed restoration of articular surface as well as a minimal presence of osteoarthritis at mid-term follow-up. However, as low level and quality of evidence and the variability of the data may confound the data, further well-designed studies are necessary to determine the effectiveness of autologous osteochondral transplantation in the treatment for OLT. LEVEL OF EVIDENCE/METHODS:IV.

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.

Background/UNASSIGNED:The incidence of coexisting osteochondral lesions (OCLs) of the tibia and talus has been negatively correlated with successful clinical outcomes, yet these lesions have not been extensively characterized. Purpose/UNASSIGNED:To determine the incidence of coexisting tibial and talar OCLs, assess the morphologic characteristics of these lesions, and evaluate whether these characteristics are predictive of outcome. Study Design/UNASSIGNED:Case series; Level of evidence, 4. Methods/UNASSIGNED:A total of 83 patients who underwent surgery for a talar OCL were evaluated for coexisting OCLs of the distal tibia with preoperative magnetic resonance images. Size, location, containment, International Cartilage Repair Society (ICRS) grade, patient age, and patient sex were analyzed for predictors of coexisting lesions or patient outcome. The talar and tibial surfaces were each divided into 9 zones, with 1 corresponding to the most anteromedial region and proceeding laterally and then posteriorly. The Foot and Ankle Outcome Score (FAOS) was evaluated pre- and postoperatively. Results/UNASSIGNED:= .043). There was no difference in OCL size or containment between kissing and nonkissing coexisting OCLs. Conclusion/UNASSIGNED:The incidence of coexisting talar and tibial OCLs may be more prevalent than what previous reports have suggested, with older patients being more likely to present with this pathology. The location of a talar OCL correlates with the incidence of a coexisting tibial OCL.

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.