Faculty Bibliography

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.

PURPOSE OF REVIEW/OBJECTIVE:Osteochondral lesions of the talus (OLT) are common injuries in athletes. The purpose of this study is to comprehensively review the clinical results and return to sport capacity in athletes following treatment for OLT. RECENT FINDINGS/RESULTS:Reparative procedures, such as bone marrow stimulation, and replacement procedures, such as autologous osteochondral transplantation, provide good clinical outcomes in short- and mid-term follow-up in the athlete. Recently, biological augmentation and scaffold-based therapies have been shown to improve clinical and radiological outcomes in OLT in both the general population and athletes. Most studies are of a low level of evidence. Studies analyzing the return to sport capability in athletes are further lacking. High-level evidence and well-designed clinical trials are required to establish the most effective treatment protocol.

Introduction. Disorders of the Achilles tendon can be broadly classified into acute and chronic entities. Few studies have established chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy. Methods. The United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-9 codes for Achilles rupture and/or Achilles tendinopathy. The number of patients with acute rupture, chronic tendinopathy, and rupture following a prior diagnosis of tendinopathy was assessed. Results. Four percent of patients with an underlying diagnosis of Achilles tendinopathy went on to sustain a rupture (7,232 patients). Older patients with tendinopathy were most vulnerable to subsequent rupture. Conclusions. The current study demonstrates that 4.0% of patients who were previously diagnosed with Achilles tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable. These findings are important as they can help clinicians more objectively council patients with Achilles tendinopathy.

Objective Despite the mechanical and biological roles of subchondral bone (SCB) in articular cartilage health, there remains no consensus on the postoperative morphological status of SCB following bone marrow stimulation (BMS). The purpose of this systematic review was to clarify the morphology of SCB following BMS in preclinical, translational animal models. Design The MEDLINE and EMBASE databases were systematically reviewed using specific search terms on April 19, 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The morphology of the SCB was assessed using of microcomputed tomography (bone density) and histology (microscopic architecture). Results Seventeen animal studies with 520 chondral lesions were included. The morphology of SCB did not recover following BMS. Compared with untreated chondral defects, BMS resulted in superior morphology of superficial SCB and cartilage but inferior morphology (specifically bone density, P < 0.05) of the deep SCB. Overall, the use of biological adjuvants during BMS resulted in the superior postoperative morphology of SCB. Conclusions Alterations in the SCB following BMS were confirmed. Biologics adjuvants may improve the postoperative morphology of both SCB and articular cartilage. Refinements of BMS techniques should incorporate consideration of SCB damage and restoration. Investigations to optimize BMS techniques incorporating both minimally invasive approaches and biologically augmented platforms are further warranted.

AIM/OBJECTIVE:To clarify the effectiveness of scaffold-based therapy for osteochondral lesions of the talus (OLT). METHODS:A systematic search of MEDLINE and EMBASE databases was performed during August 2016 and updated in January 2017. Included studies were evaluated with regard to the level of evidence (LOE) and quality of evidence (QOE) using the Modified Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and the percentage of patients who returned to sport at previous level were also evaluated. RESULTS:Twenty-eight studies for a total of 897 ankles were included; 96% were either LOE III or IV. Studies were designated as either of poor or fair quality. There were 30 treatment groups reporting six different scaffold repair techniques: 13 matrix-induced autologous chondrocyte transplantation (MACT), nine bone marrow derived cell transplantation (BMDCT), four autologous matrix-induced chondrogeneis (AMIC), and four studies of other techniques. The categories of general demographics (93%) and patient-reported outcome data (85%) were well reported. Study design (73%), imaging data (73%), clinical variables (49%), and patient history (30%) were also included. The weighted mean American Orthopaedic Foot and Ankle Society (AOFAS) score at final follow-up was: 86.7 in MACT, 88.2 in BMDCT, and 82.3 in AMIC. Eight studies reported that a weighted mean of 68.3% of patients returned to a previous level of sport activity. CONCLUSION/CONCLUSIONS:Scaffold-based therapy for OLT may produce favorable clinical outcomes, but low LOE, poor QOE, and variability of the data have confounded the effectiveness of this treatment.

AIM/OBJECTIVE:To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT). METHODS:Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score. RESULTS:This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality. CONCLUSION/CONCLUSIONS:The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.