Faculty Bibliography

UNLABELLED:Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive. LEVEL OF EVIDENCE/METHODS:Therapeutic study, Level V.

BACKGROUND:The purpose of this study was to report trends associated with concurrent ankle arthroscopy at the time of operative treatment of ankle fracture. METHOD/METHODS:The current procedural terminology (CPT) billing codes were used to search the PearlDiver Patient Record Database and identify all patients who were treated for acute ankle fracture in the United States. The Medicare Standard Analytic Files were searchable between 2005 and 2011 and the United Healthcare Orthopedic Dataset from 2007 to 2011. Annual trends were expressed only between 2007 and 2011, as it was the common time period among both databases. Demographic factors were identified for all procedures as well as the cost aspect using the Medicare data set. RESULTS:In total, 32 307 patients underwent open reduction internal fixation (ORIF) of an ankle fracture, of whom 313 (1.0%) had an ankle arthroscopy performed simultaneously. Of those 313 cases, 70 (22.4%) patients received microfracture treatment. Between 2005 and 2011, 85 203 patients were treated for an ankle fracture whether via ORIF or closed treatment. Of these, a total of 566 patients underwent arthroscopic treatment within 7 years. The prevalence of arthroscopy after ankle fracture decreased significantly by 45% from 2007 to 2011 (P< .0001). When ORIF and microfracture were performed concurrently, the total average charge for both procedures drops to $4253.00 and average reimbursement to $818.00 compared with approximately $4964.00 and $1069.00, respectively, when they were performed subsequently. CONCLUSION/CONCLUSIONS:Despite good evidence in favor of arthroscopy at the time of ankle fracture treatment, it appears that only a small proportion of surgeons in the United States perform these procedures concurrently. LEVELS OF EVIDENCE/METHODS:Therapeutic, Level IV: Retrospective.

PURPOSE/OBJECTIVE:The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures. METHODS:A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included. RESULTS:Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5% at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022). CONCLUSIONS:Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of level IV studies.

BACKGROUND:Autologous osteochondral transplantation (AOT) is used to treat osteochondral lesions (OCLs) of the talus, typically reserved for lesions greater than 150 mm(2). Few studies exist examining the functional and magnetic resonance imaging (MRI) outcomes following this procedure. The purpose of this study was to investigate functional and MRI outcomes, including quantitative T2 mapping following AOT. METHODS:Eighty-five consecutive patients who underwent AOT were identified. Functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. Quantitative T2 MRI relaxation time of graft tissue and adjacent normal cartilage values were recorded in a subset of 61 patients. The mean clinical follow-up was 47.2 months, with mean MRI follow-up of 24.8 months. RESULTS:Mean FAOS improved pre- to postoperatively from 50 to 81 (P < .001). The mean MOCART score was 85.8. Lesion size was negatively correlated with MOCART score (r = -0.36, P = .004). Superficial T2 values in graft tissue were higher than control tissue (42.0 vs 35.8, P < .001). Deep T2 values in graft tissue were similar to the control values (30.9 vs 30.0, P = .305). Functional outcomes were similar in patients irrespective of whether they had previous microfracture or concomitant procedures. CONCLUSION/CONCLUSIONS:AOT was an effective treatment for large OCLs of the talus in the current study. MOCART scoring indicated good structural integrity of the graft. Quantitative T2 mapping suggests that graft tissue may not always mirror native hyaline cartilage. The long-term implications of this are not yet known. LEVEL OF EVIDENCE/METHODS:Level IV, case series.

PURPOSE/OBJECTIVE:The purpose of this systematic review was to report the effects of gastrocnemius recession on ankle dorsiflexion range of motion, function, and push-off power. METHODS:The MEDLINE and EMBASE databases were reviewed with terms "gastrocnemius recession". The inclusion criteria were: (1) clinical studies, (2) published in a peer-reviewed journal within the past 10 years, and (3) published in English. Excluded were: (1) review articles, (2) cadaveric studies, (3) studies including patients under the age of 18 years, (4) studies evaluating a neurologic condition, (5) level of evidence 5, and (6) Quality of Evidence Score <3. Data were then extracted and analysed for trends. The PearlDiver Database was also used to review de-identified patient information retrospectively between 2007 and 2011. RESULTS:Full-text review yielded 23 articles that fit the inclusion criteria. Twenty-one of 23 (91%) and 2/23 (9%) studies were level of evidence 4 and 3, respectively. Twelve of 23 (52%) studies reported follow-up assessment between 12 and 36 months, and no studies reported longer-term follow-up. Twelve of 12 (100%) studies reported improved dorsiflexion range of motion 9/9 (100%) reported improved AOFAS, and 11/11 (100%) reported improved VAS. Five of 23 (22%) studies reported strength in a measured and controlled fashion with variable results, but of these, no study reported a return to normal power. The mean complication rate was 14%. CONCLUSION/CONCLUSIONS:The available evidence supports that GR improves functional outcomes and increases dorsiflexion range of motion. Furthermore, GR affects gait kinematics, which may cause compensatory effects at the knee, ankle, and subtalar joints. Evidence has shown that power does not return to normal levels. Clinicians may utilize these data clinically to determine whether patients may benefit from GR or not. LEVEL OF EVIDENCE/METHODS:IV.

BACKGROUND:While successful subtalar joint arthrodesis provides pain relief, resultant alterations in ankle biomechanics need to be considered, as this procedure may predispose the remaining hindfoot and tibiotalar joint to accelerated degenerative changes. However, the biomechanical consequences of isolated subtalar joint arthrodesis and additive fusions of the Chopart's joints on tibiotalar joint biomechanics remain poorly understood. QUESTIONS/PURPOSES/OBJECTIVE:We asked: What is the effect of isolated subtalar fusion and sequential Chopart's joint fusions of the talonavicular and calcaneocuboid joints on tibiotalar joint (1) mechanics and (2) kinematics during loading for neutral, inverted, and everted orientations of the foot? METHODS:We evaluated the total force, contact area, and the magnitude and distribution of the contact stress on the articular surface of the talar dome, while simultaneously tracking the position of the talus relative to the tibia during loading in seven fresh-frozen cadaver feet. Each foot was loaded in the unfused, intact control condition followed by three randomized simulated hindfoot arthrodesis modalities: subtalar, double (subtalar and talonavicular), and triple (subtalar, talonavicular, and calcaneocuboid) arthrodesis. The intact and arthrodesis conditions were tested in three alignments using a metallic wedge insert: neutral (flat), 10° inverted, and 10° everted. RESULTS:Tibiotalar mechanics (total force and contact area) and kinematics (external rotation) differed owing to hindfoot arthrodeses. After subtalar arthrodesis, there were decreases in total force (445 ± 142 N, 95% CI, 340-550 N, versus 588 ± 118 N, 95% CI, 500-676 N; p < 0.001) and contact area (282 mm(2), 95% CI, 222-342 mm(2), versus 336 ± 96 mm(2), 95% CI, 265-407 mm(2); p < 0.026) detected during loading in the neutral position; these changes also were seen in the everted foot position. Hindfoot arthrodesis also was associated with increased external rotation of the tibiotalar joint during loading: subtalar arthrodesis in the neutral loading position (3.3° ± 1.6°; 95% CI, 2°-4.6°; p = 0.004) and everted loading position (4.8° ± 2.6°; 95% CI, 2.7°-6.8°; p = 0.043); double arthrodesis in neutral (4.4° ± 2°; 95% CI, 2.8°-6°; p = 0.003) and inverted positions (5.8° ± 2.6°; 95% CI, 3.7°-7.9°; p = 0.002), and triple arthrodesis in all loaded orientations including neutral (4.5° ± 1.8°; 95% CI, 3.1°-5.9°; p = 0.002), inverted (6.4° ± 3.5°; 95% CI, 3.6°-9.2°; p = 0.009), and everted (3.6° ± 2°; 95% CI, 2°-5.2°; p = 0.053) positions. Finally, after subtalar arthrodesis, additive fusions at Chopart's joints did not appear to result in additional observed differences in tibiotalar contact mechanics or kinematics with the number of specimens available. CONCLUSIONS:Using a cadaveric biomechanical model, we identified some predictable trends in ankle biomechanics during loading after hindfoot fusion. In our tested specimens, fusion of the subtalar joint appeared to exert a dominant influence over ankle loading. CLINICAL RELEVANCE/CONCLUSIONS:A loss or deficit in function of the subtalar joint may be sufficient to alter ankle loading. These findings warrant consideration in the treatment of the arthritic hindfoot and also toward defining biomechanical goals for ankle arthroplasty in the setting of concomitant hindfoot degeneration or arthrodesis.

PURPOSE/OBJECTIVE:The primary purpose of this study was to evaluate clinical outcomes following peroneal tendoscopy for the treatment of peroneal pathology. Correlation between pre-operative magnetic resonance imaging (MRI) and peroneal tendoscopic diagnostic findings was also assessed. METHODS:Twenty-three patients with a mean age of 34 ± 8.8 years undergoing peroneal tendoscopy were pre- and post-operatively assessed with the foot and ankle outcome score (FAOS) and the Short Form-12 (SF-12) outcome questionnaires. Follow-up was over 24 months in all patients. The sensitivity and specificity of MRI were calculated in comparison with peroneal tendoscopy, including the positive predictive value (PPV). RESULTS:Both the FAOS and the SF-12 improved significantly (p < 0.05) at a mean follow-up of 33 ± 7.3 months significantly. MRI showed an overall sensitivity of 0.90 (95% confidence interval (CI) = 0.82-0.95) and specificity of 0.72 (95% CI 0.62-0.80). The PPV for MRI diagnosis of peroneal tendon pathology was 0.76 (95% CI 0.68-0.83). CONCLUSIONS:The current study found good clinical outcomes in patients with peroneal tendon disorders, treated with peroneal tendoscopy. Although a relatively small number of patients were included, the study suggests good correlation between tendoscopic findings and pre-operative MRI findings of peroneal tendon pathology, supporting the use of MRI as a useful diagnostic modality for suspected peroneal tendon disorders. LEVEL OF EVIDENCE/METHODS:Level IV, retrospective case series.

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

PURPOSE/OBJECTIVE:This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. METHODS:Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. RESULTS:The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively). CONCLUSIONS:BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.