Faculty Bibliography

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: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.

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.

PURPOSE/OBJECTIVE:Over 50 % of the patients with chronic lateral ankle instability present with some degree of intra-articular pathology. To date, no consensus regarding the concomitant ankle arthroscopy procedures along with ankle ligament procedures has been reached. The purpose of current study was to investigate reoperation rates and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures. METHODS:Reoperations and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures were investigated using the PearlDiver Patient Record Database (PearlDiver Technologies, Inc.; Fort Wayne, IN, USA) between 2007 and 2011. Ankle ligament procedures, including ligament repair and reconstruction, and ankle arthroscopic procedures were investigated as primary surgery. Subsequently, the reoperation procedures, including ankle ligament procedures, arthroscopic procedures, autologous osteochondral transplantation, and ankle arthrodesis, as well as wound complications and nerve injury following primary ankle ligament procedures were identified. RESULTS:In 8014 patients receiving ligament repair, the arthroscopic group had a significantly higher reoperation rate in comparison with the non-arthroscopic group (8.8 vs. 6.5 %, odds ratio: 1.1, [p < 0.01], 95 % confidence interval (CI) 1.2-1.7). However, the non-arthroscopic group included 29 open arthrodesis procedures following the primary surgery, whereas arthroscopic group had none. Of the 8055 patients who received a ligament reconstruction, there was no significant difference in reoperation rate between the groups (5.9 vs. 5.9 %, odds ratio: 1.0, [n.s], 95 % CI 0.8-1.2). As seen in the ligament repair group, the non-arthroscopic group had a 4.9 % rate of ankle arthrodesis as a secondary procedure. Arthroscopic group had a significantly lower rate of wound dehiscence following ankle ligament procedures than non-arthroscopic group. CONCLUSION/CONCLUSIONS:Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation. However, there was a lower incidence of ankle arthrodesis and a lower rate of wound complications in the arthroscopic group when compared to those in non-arthroscopic group. Based on the results of the study, which analysed 16.069 patients, concomitant ankle arthroscopy is recommended. LEVEL OF EVIDENCE/METHODS:IV.

The diagnosis of ankle osteoarthritis (OA) is increasing as a result of advancements in non-invasive imaging modalities such as magnetic resonance imaging, improved arthroscopic surgical technology and heightened awareness among clinicians. Unlike OA of the knee, primary or age-related ankle OA is rare, with the majority of ankle OA classified as post-traumatic (PTOA). Ankle trauma, more specifically ankle sprain, is the single most common athletic injury, and no effective therapies are available to prevent or slow progression of PTOA. Despite the high incidence of ankle trauma and OA, ankle-related OA research is sparse, with the majority of clinical and basic studies pertaining to the knee joint. Fundamental differences exist between joints including their structure and molecular composition, response to trauma, susceptibility to OA, clinical manifestations of disease, and response to treatment. Considerable evidence suggests that research findings from knee should not be extrapolated to the ankle, however few ankle-specific preclinical models of PTOA are currently available. The objective of this article is to review the current state of ankle OA investigation, highlighting important differences between the ankle and knee that may limit the extent to which research findings from knee models are applicable to the ankle joint. Considerations for the development of new ankle-specific, clinically relevant animal models are discussed. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:440-453, 2017.

BACKGROUND:in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs. PURPOSE/OBJECTIVE:To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs. STUDY DESIGN/METHODS:Systematic review. METHODS:A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes. RESULTS:. The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies. CONCLUSION/CONCLUSIONS:in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

PURPOSE:Early stage adult acquired flatfoot deformity (AAFD) is traditionally treated with osteotomy and tendon transfer. Despite a high success rate, the long recovery time and associated morbidity are not sufficient. This study aims to evaluate the functional and radiological outcomes following the use of the arthroereisis screw with tendoscopic delivered PRP for early stage AAFD. METHODS:Patients with stage IIa AAFD who underwent the use of the arthroereisis screw with tendoscopic delivered PRP with a minimum follow-up time of 24 months were retrospectively evaluated. Clinical outcomes for pain were evaluated with the Foot and Ankle Outcomes Score (FAOS) and Visual Analog Score (VAS). Radiographic deformity correction was assessed using weight-bearing imaging. RESULTS:Thirteen patients (13 feet) with mean follow-up of 29.5 months were included. The mean age was 37.3 years (range, 28-65 years). FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life significantly improved from 52.1, 42.6, 57.6, 35.7, and 15.4 pre-operatively to 78.5, 68.2, 83.3, 65.0, and 49.6 post-operatively, respectively (p < 0.05). Statistically significant radiographic improvements (lateral talus first metatarsal angle, calcaneal pitch, and cuneiform to ground distance) were also observed between the pre- and post-operative images. CONCLUSIONS:This study elucidates the successful implementation of a less invasive approach to stage IIa AAFD. Through the use of a subtalar arthroereisis screw, PTT tendoscopy, and PRP injection, clinical and radiographic outcomes were improved.

OBJECTIVE:Numerous basic science articles have published evidence supporting the use of biologic augmentation in the treatment of osteochondral lesions of the talus (OLT). However, a comprehensive evaluation of the clinical outcomes of those treatment modalities in OLT has yet to be published. The purpose of this review is to provide an evidence-based overview of clinical outcomes following biologic augmentation to surgical treatments for OLT. DESIGN/METHODS:A comprehensive literature review was performed. Two commonly used surgical techniques for the treatment of OLT-bone marrow stimulation and osteochondral autograft transfer-are first introduced. The review describes the operative indications, step-by- step operative procedure, clinical outcomes, and concerns associated with each treatment. A review of the currently published basic science and clinical evidence on biologic augmentation in the surgical treatments for OLT, including platelet-rich plasma, concentrated bone marrow aspirate, and scaffold-based therapy follows. RESULTS:Biologic agents and scaffold-based therapies appear to be promising agents, capable of improving both clinical and radiological outcomes in OLT. Nevertheless, variable production methods of these biologic augmentations confound the interpretation of clinical outcomes of cases treated with these agents. CONCLUSIONS:Current clinical evidence supports the use of biologic agents in OLT cases. Nonetheless, well-designed clinical trials with patient-specific, validated and objective outcome measurements are warranted to develop standardized clinical guidelines for the use of biologic augmentation for the treatment of OLT in clinical practice.

Osteochondral lesions of the talus (OLT) occur in up to 70% of acute ankle sprains and fractures. OLT have become increasingly recognized with the advancements in cartilage-sensitive diagnostic imaging modalities. Although OLT may be treated nonoperatively, a number of surgical techniques have been described for patients whom surgery is indicated. Traditionally, treatment of symptomatic OLT have included either reparative procedures, such as bone marrow stimulation (BMS), or replacement procedures, such as autologous osteochondral transplantation (AOT). Reparative procedures are generally indicated for OLT < 150 mm² in area. Replacement strategies are used for large lesions or after failed primary repair procedures. Although short- and medium-term results have been reported, long-term studies on OLT treatment strategies are lacking. Biological augmentation including platelet-rich plasma and concentrated bone marrow aspirate is becoming increasingly popular for the treatment of OLT to enhance the biological environment during healing. In this review, we describe the most up-to-date clinical evidence of surgical outcomes, as well as both the mechanical and biological concerns associated with BMS and AOT. In addition, we will review the recent evidence for biological adjunct therapies that aim to improve outcomes and longevity of both BMS and AOT procedures.

Anterior ankle impingement is a common cause of chronic ankle pain, particularly in athletic populations. Morris and McMurray provided the earliest descriptions of anterior impingement, coining the condition as "athlete's ankle" or "footballer's ankle". The pathology has since been a topic of considerable investigation and has been re-termed "anterior ankle impingement syndrome". Treatment with open surgery has provided good results historically, but at the price of significant complications. Advancements in ankle arthroscopy have decreased the risk of complication drastically and evidence in the literature indicates that anterior arthroscopy is an effective approach to treating osseous and soft tissue impingement. Effective clinical diagnosis and diagnostic imaging are critical for pre-surgical planning. Preoperative detection of anterior osteophytes has been correlated with outcomes. Factors such as joint space narrowing and large osteophytes may also influence outcomes. Therefore, a comprehensive understanding of diagnosis and surgical technique can influence patient outcomes, and patient expectations can be managed around prognostic indicators such as the presence of osteoarthritis. The purpose of this review is to discuss the etiology, clinical presentation, diagnosis, surgical technique, and postoperative rehabilitation of anteromedial and anterolateral anterior ankle impingement syndrome and to evaluate the evidence-based outcomes of arthroscopic management.