Faculty Bibliography

Metatarsalgia is one of the most common forefoot pain presentations seen in orthopedics. Surgical management has often been suboptimal with more than 20 surgical methods reported, differing in indication, technique, fixation, and postoperative mobilization.The literature has not yet recorded a definitive surgical solution to this problem. Outcome parameters including patient satisfaction, pedobarographic, and radiologic measurements have indicated the relative success of the different surgical techniques and their adverse outcome trends.The current authors present their experience with the Weil, chevron, and oblique sliding diaphyseal techniques in the context of their indications, techniques, and outcomes, and review their success in the literature

BACKGROUND:Ossification of the Achilles tendon is rare with most cases of ossification or calcification consisting of small, focal lesions. This pathology is usually predisposed by surgery, trauma, or other factors. CASE DESCRIPTION/METHODS:A case of extensive Achilles ossification and calcification, without prior surgery or trauma, is reported. Following removal of one of the largest ossific masses reported in the literature, measuring 11.0cm×2.5cm×2.0cm with additional 6.5cm calcifications, surgical reconstruction was required. PURPOSE AND CLINICAL RELEVANCE/CONCLUSIONS:The objective of this report was to describe an unusual case of Achilles tendon ossification and calcification that occurred without the presence of predisposing factors. When a large gap is present after removal of the ossification, direct repair may be impossible and V-Y lengthening plus flexor hallucis longus (FHL) transfer is a viable option for pain relief and return to function.

Midfoot sprains in the National Football League (NFL) are uncommon. There are few studies on midfoot sprains in professional athletes, as most studies focus on severe traumatic injuries resulting in Lisfranc fracture-dislocations. We conducted a study to evaluate midfoot sprains in NFL players to allow for better identification and management of these injuries. All midfoot sprains from a single NFL team database were reviewed over a 15-year period, and 32 NFL team physicians completed a questionnaire detailing their management approach. A comparative analysis was performed analyzing several variables, including diagnosis, treatment methods, and time lost from participation. Fifteen NFL players sustained midfoot sprains. Most injuries occurred during games as opposed to practice, and the injury typically resulted from direct impact rather than torsion. Twelve players had nonoperative treatment, and 3 had operative treatment. Nonoperative management resulted in a mean of 11.7 days of time lost from participation. However, there was a significant (P=.047) difference in mean (SD) time lost between the grade 1 sprain group, 3.1 (1.9) days, and the grade 2 sprain group, 36 (26.1) days. Of the 3 operative grade 3 patients, 1 returned in 73 days, and 2 were injured late in the season and returned the next season. Eleven (92%) of the 12 players who had nonoperative treatment had a successful return to play, and 10 (83%) of the 12 played more games and seasons after their midfoot injury. Depending on the diastasis category, NFL team physicians vary treatment: no diastasis (84% cam walker), latent diastasis (47% surgery, 34% cam walker), and frank diastasis (94% surgery). In the NFL, midfoot sprains can be a source of significant disability. Successful return to play can be achieved with nonoperative management for grade 1 injuries within 1 week and grade 2 injuries within 5 weeks. However, severe injuries with frank diastasis that require operative management will necessitate a more significant delay in return to play. Either way, most NFL athletes will have a successful NFL career after their midfoot sprain injury.

BACKGROUND:Osteochondral lesions of the distal tibial plafond are uncommon compared with talar lesions. The objective of this study was to assess functional and magnetic resonance imaging (MRI) outcomes following microfracture for tibial osteochondral lesions. METHODS:Thirty-one tibial osteochondral lesions in thirty-one ankles underwent arthroscopic microfracture. The Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire were used to obtain patient-reported functional outcome scores preoperatively and postoperatively. MRI scans were assessed postoperatively with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for twenty-three ankles. RESULTS:The average age was thirty-seven years (range, fifteen to sixty-eight years), and the average lesion area was 38 mm(2) (range, 7.1 to 113 mm(2)). Twelve ankles had a kissing lesion on the opposing surface of the talus, and two ankles had a concomitant osteochondral lesion elsewhere on the talus. FAOS and SF-12 scores were significantly improved (p < 0.01) at the time of follow-up, at an average of forty-four months. The average postoperative MOCART score was 69.4 (range, 10 to 95), with a lower score in the ankles with kissing lesions (62.8) than in the ankles with an isolated lesion (73.6). Increasing age negatively impacted improvement in SF-12 (p < 0.01) and MOCART (p = 0.04) scores. Increasing lesion area was negatively correlated with MOCART scores (p = 0.04) but was not associated with FAOS or SF-12 scores. Lesion location and the presence of kissing lesions showed no association with functional or MRI outcomes. CONCLUSIONS:Arthroscopic microfracture provided functional improvements, but the optimal treatment strategy for tibial osteochondral lesions remains unclear. The repair tissue assessed on MRI was inferior to normal hyaline cartilage. The MRI outcomes appeared to deteriorate with increasing lesion area, and both functional and MRI outcomes appeared to deteriorate with increasing age. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

UNLABELLED:The purpose of this study was to evaluate a series of patients undergoing a single platelet-rich plasma (PRP) injection for the treatment of chronic midsubstance Achilles tendinopathy, in whom conservative treatment had failed. Thirty-two patients underwent a single PRP injection for the treatment of chronic midsubstance Achilles tendinopathy and were evaluated at a 6-month final follow-up using the Foot and Ankle Outcome Score and Short Form 12 general health questionnaire. Magnetic resonance imaging was performed on all patients prior to and 6 months after injection. Twenty-five of 32 patients (78%) reported that they were asymptomatic at the 6-month follow-up visit and were able to participate in their respective sports and daily activities. The remaining 7 patients (22%) who reported symptoms that did not improve after 6 months ultimately required surgery. Four patients went on to have an Achilles tendoscopy, while the other 3 had an open debridement via a tendon splitting approach. A retrospective evaluation of patients receiving a single PRP injection for chronic midsubstance Achilles tendinopathy revealed that 78% had experienced clinical improvement and had avoided surgical intervention at 6-month follow-up. LEVELS OF EVIDENCE/METHODS:Therapeutic, Level IV: Retrospective case series.

UNLABELLED:Osteochondral lesions of the talar dome are increasingly diagnosed and are a difficult pathology to treat. Conservative treatment yields best results in pediatric patients, often leaving surgical options for adult populations. There is a paucity of long-term data and comparisons of treatment options. Arthroscopic bone marrow stimulation is a common first-line treatment for smaller lesions. Despite promising short to medium term clinical results, bone marrow stimulation results in fibrocartilagenous tissue that incurs differing mechanical and biological properties compared with normal cartilage. Autologous osteochondral transplantation has demonstrated promising clinical results in the short to medium term for larger, cystic lesions and can restore the contact pressure of the joint. However, concerns remain over postoperative cyst formation and donor site morbidity. Recent developments have emphasized the usefulness of biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate, as well as particulate juvenile cartilage, in augmenting reparative and replacement strategies in osteochondral lesion treatment. The purpose of this article is to review diagnosis and treatment of talar osteochondral lesions so that current practice guidelines can be more efficiently used given the available treatment strategies. A treatment paradigm based on current evidence is described. LEVELS OF EVIDENCE/METHODS:Therapeutic, Level V, Expert Opinion.

OBJECTIVES/OBJECTIVE:To evaluate the efficacy of 3 commercially available systems: the Harvest SmartPReP 2 BMAC, Biomet BioCUE, and Arteriocyte Magellan systems. We compared the number and concentration of progenitor cells achieved both before and after centrifugation and the percentage of progenitor cells salvaged after centrifugation. METHODS:Forty patients, mean age 47 ± 18 years (range: 18-92 years, 19 male/21 female) were prospectively consented for bilateral iliac crest aspiration. The first 20 aspirations compared the Harvest and Biomet systems, and based on those results, the second 20 compared the Harvest and Arteriocyte systems. One system was randomly assigned to each iliac crest. Each system's unique marrow acquisition process and centrifugation mechanism was followed. Samples for analysis were taken both immediately before the marrow was put into the centrifugation system (after acquisition), and after centrifugation. The number of progenitor cells in each sample was estimated by counting the connective tissue progenitors (CTPs). RESULTS:The Harvest system achieved a significantly greater number and concentration of CTPs both before and after centrifugation when compared to the Biomet system. There was no difference in the percent yield of CTPs after centrifugation. There was no significant difference in the number and concentration of CTPs between the Harvest and Arteriocyte systems before centrifugation, but the Harvest system had a significantly greater number and concentration of CTPs after centrifugation. The Harvest system also had a significantly higher percent yield of CTPs after centrifugation compared with the Arteriocyte system. CONCLUSIONS:The Harvest system resulted in a greater CTP number and concentration after centrifugation when compared with the Biomet and Arteriocyte systems and may thus provide increased osteogenic and chondrogenic capacity.

BACKGROUND:Traditional treatment of talonavicular osteochondral lesions (OCLs) requires an open procedure. Arthroscopic microfracture of talonavicular OCLs may provide a viable, minimally invasive approach. The purpose of this study was to describe an arthroscopic approach for treatment of talonavicular OCLs, describe the proximity of arthroscopic portals to important structures in cadaver specimens, and report magnetic resonance imaging (MRI) findings and clinical outcomes of this technique. METHODS:Five cadaver specimens were dissected so proximity of portals to adjacent tendons and neurovascular structures could be assessed. Subsequently, 3 athletic patients with OCLs of the talonavicular joint were treated with arthroscopic debridement and microfracture. Patient records and imaging studies were retrospectively reviewed. RESULTS:In the cadaver specimens, the mean distance between the neurovascular bundle and the medial border of the extensor hallucis longus (EHL) was 9.0 (range, 8 to 10) mm. The saphenous nerve was located a mean of 6.8 (range, 6 to 7) mm from the medial border of the tibialis anterior tendon. Therefore, portals were placed just medial to the EHL and tibialis anterior tendon to avoid the neurovascular bundle and saphenous nerve, respectively. In all patients, access, identification of the OCL, debridement, and microfracture were successfully performed. All patients demonstrated improvements in Foot and Ankle Outcome Scores and Short Form-12 scores and began gradual return to activity within 12 weeks following the operation. No significant complications occurred. MRI indicated signal consistent with reparative fibrocartilage in all patients. CONCLUSION/CONCLUSIONS:Talonavicular arthroscopy allowed visualization, curettage, synovectomy, loose body removal, and microfracture of OCLs that would have otherwise required an open approach. At early follow-up, all patients had returned to their previous activity levels. Arthroscopy of the talonavicular joint was a viable approach for microfracture of OCLs. LEVEL OF EVIDENCE/METHODS:Level IV, case series.

BACKGROUND: Autologous osteochondral transplantation (AOT) is used for large (>100-150 mm2) or cystic osteochondral lesions (OCLs) of the talus. Larger lesions may require using more than 1 graft to fill the defect. While patients with larger OCLs treated with microfracture exhibit inferior clinical outcomes, there is little evidence regarding the effect of lesion size and number of grafts required on clinical and radiological outcomes after AOT. HYPOTHESIS: Larger OCLs of the talar dome treated by double-plug AOT (dp-AOT) have inferior clinical and radiological MRI outcomes compared with smaller OCLs requiring single-plug AOT (sp-AOT). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Fourteen consecutive patients with a large OCL (mean, 208 +/- 54 mm2) treated using dp-AOT with a minimum 5-year follow-up were matched by age and sex to a control cohort of 28 patients who underwent sp-AOT for a smaller OCL (mean, 74 +/- 26 mm2) over the same period. Functional outcomes were assessed both pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Mean follow-up was 85 months (range, 65-118 months). Latest postoperative MRI was evaluated with modified magnetic resonance observation of cartilage repair tissue (MOCART) score. RESULTS: There was no significant difference between groups demographically (P > .05). All patients with dp-AOT and sp-AOT showed a significant pre- to postoperative increase in FAOS and SF-12 scores (P < .001). When comparing preoperative scores for both groups, there was no statistical significance between sp-AOT and dp-AOT scores (FAOS, P = .719; SF-12, P = .947). There was no significant difference in functional scores between the 2 groups postoperatively for both FAOS (P = .883) and SF-12 (P = .246). Mean MOCART scores did not exhibit any statistically significant difference between groups (P = .475). Two patients complained of knee donor site stiffness (4.8%), which later resolved. CONCLUSION: Patients with large OCLs treated using a dp-AOT procedure did not show inferior clinical or radiological outcomes compared with those treated with sp-AOT at a minimum 5-year follow-up. The dp-AOT procedure is as effective as sp-AOT in treating larger OCLs of the talar dome in the intermediate term, with similar high postoperative clinical and radiological outcomes.

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.