Faculty Bibliography

Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.

Platelet-rich plasma (PRP) has become an increasingly utilized biological adjunct in orthopedics, particularly in sports medicine. Cartilage repair is one such application for which PRP has been utilized. Osteochondral lesions of the talus are common athletic injuries, and they present a difficult clinical problem in part because of the poor biological environment of cartilage healing. The current authors' are investigating the use of PRP with reparative and restorative techniques, including arthroscopic bone marrow stimulation and autologous osteochondral transplantation, respectively. The hypothesis is that the bioactive molecules and growth factors contained within PRP will stimulate a healing response for the differentiation of fibrocartilage such that it resembles a more hyaline-like microstructure, in addition to enhancing bony incorpoaration. In addition to these anabolic pathways, there is also recent evidence to suggest that PRP may inhibit the catabolic processes of arthritis. This article presents the indications and treatment strategy for using PRP in the surgical treatment of osteochondral lesions of the talus

BACKGROUND:Autologous osteochondral transplantation procedures provide hyaline cartilage to the site of cartilage repair. It remains unknown whether these procedures restore native contact mechanics of the ankle joint. PURPOSE/OBJECTIVE:This study was undertaken to characterize the regional and local contact mechanics after autologous osteochondral transplantation of the talus. STUDY DESIGN/METHODS:Controlled laboratory study. METHODS:Ten fresh-frozen cadaveric lower limb specimens were used for this study. Specimens were loaded using a 6 degrees of freedom robotic arm with 4.5 N·m of inversion and a 300-N axial compressive load in a neutral plantar/dorsiflexion. An osteochondral defect was created at the centromedial aspect of the talar dome and an autologous osteochondral graft from the ipsilateral knee was subsequently transplanted to the defect site. Regional contact mechanics were analyzed across the talar dome as a function of the defect and repair conditions and compared with those in the intact ankle. Local contact mechanics at the peripheral rim of the defect and at the graft site were also analyzed and compared with the intact condition. A 3-dimensional laser scanning system was used to determine the graft height differences relative to the native talus. RESULTS:The creation of an osteochondral defect caused a significant decrease in force, mean pressure, and peak pressure on the medial region of the talus (P = .037). Implanting an osteochondral graft restored the force, mean pressure, and peak pressure on the medial region of the talus to intact levels (P = .05). The anterior portion of the graft carried less force, while mean and peak pressures were decreased relative to intact (P = .05). The mean difference in graft height relative to the surrounding host cartilage for the overall population was -0.2 ± 0.3 mm (range, -1.00 to 0.40 mm). Under these conditions, there was no correlation between height and pressure when the graft was sunken, flush, or proud. CONCLUSION/CLINICAL RELEVANCE/CONCLUSIONS:Placement of the osteochondral graft in the most congruent position possible partially restored contact mechanics of the ankle joint. Persistent deficits in contact mechanics may be due to additional factors besides graft congruence, including structural differences in the donor cartilage when compared with the native tissue.

OBJECTIVE:To present the functional results after autologous osteochondral transplantation with bone marrow aspirate concentrate in 72 patients, while placing an emphasis on the surgical technique. METHODS:Between 2005 and 2009, 72 patients underwent autologous osteochondral transplantation under the care of the senior author. The mean patient age at the time of surgery was 34.19 years (range, 16-85 years). All patients were followed for a minimum of 1 year after surgery. The mean follow-up time was 28.02 months (range, 12-64 months). Patient-reported outcome measures were taken preoperatively and at final follow-up using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Identical questionnaires were used in all instances. RESULTS:The mean FAOS scores improved from 52.67 points preoperatively to 86.19 points postoperatively (range, 71-100 points). The mean SF-12 scores also improved from 59.40 points preoperatively to 88.63 points postoperatively (range, 52-98 points). Three patients reported donor site knee pain after surgery, and one patient required the decompression of a cyst that developed beneath the graft site approximately 2 years after the index procedure. CONCLUSION/CONCLUSIONS:Autologous osteochondral transplantation is a reproducible and primary treatment strategy for large osteochondral lesions of the talus.

BACKGROUND:Internal fixation is a popular first-line treatment method for proximal fifth metatarsal Jones fractures in athletes; however, nonunions and screw breakage can occur, in part because of nonspecific fixation hardware and poor blood supply. PURPOSE/OBJECTIVE:To report the results from 26 patients who underwent percutaneous internal fixation with a specialized screw system of a proximal fifth metatarsal Jones fracture (zones II and III) and bone marrow aspirate concentrate. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:Percutaneous internal fixation for a proximal fifth metatarsal Jones fracture (zones II and III) was performed on 26 athletic patients (mean age, 27.47 years; range, 18-47). All patients were competing at some level of sport and were assessed preoperatively and postoperatively using the Foot and Ankle Outcome Score and SF-12 outcome scores. The mean follow-up time was 20.62 months (range, 12-28). Of the 26 fractures, 17 were traditional zone II Jones fractures, and the remaining 9 were zone III proximal diaphyseal fractures. RESULTS:The mean Foot and Ankle Outcome Score significantly increased, from 51.15 points preoperatively (range, 14-69) to 90.91 at final follow-up (range, 71-100; P < .01). The mean physical component of the SF-12 score significantly improved, from 25.69 points preoperatively (range, 6-39) to 54.62 at final follow-up (range, 32-62; P < .01). The mean mental component of the SF-12 score also significantly improved, from 28.20 points preoperatively (range, 14-45) to 58.41 at final follow-up (range, 36-67; P < .01). The mean time to fracture healing on standard radiographs was 5 weeks after surgery (range, 4-24). Two patients did not return to their previous levels of sporting activity. One patient experienced a delayed union, and 1 healed but later refractured. CONCLUSION/CONCLUSIONS:Percutaneous internal fixation of proximal fifth metatarsal Jones fractures, with a Charlotte Carolina screw and bone marrow aspirate concentrate, provides more predictable results while permitting athletes a return to sport at their previous levels of competition, with few complications.

BACKGROUND:The traditional scarf osteotomy has been associated with complication rates between 1.1% and 45%. We have modified the traditional technique with a rotational osteotomy to reduce these complications. QUESTIONS/PURPOSES/OBJECTIVE:We determined whether a modified rotational scarf osteotomy improves functional outcome scores, allows correction of a wide degree of an intermetatarsal (IM) angle deformity, has a low incidence of troughing, and maintains normal ROM postoperatively in the treatment of symptomatic hallux valgus (HV). PATIENTS AND METHODS/METHODS:We retrospectively reviewed 140 patients: 38 men and 102 women with a mean age of 54 years (range, 35-66 years) who underwent surgery for HV and had a minimum followup of 24 months (mean, 41 months; range, 24-68 months). All patients had preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot and Short Form (SF)-36 V2 outcome scores recorded. RESULTS:The mean AOFAS score improved from 52 points preoperatively to 92 points (range, 71-96 points) at followup. The mean SF-36 V2 score improved from 69 points preoperatively to 94 points (range, 67-98 points) at followup. The IM angle improved from a preoperative mean of 18° (range, 9°-23°) to a mean of 8° (range, 6°-12°). Eleven patients experienced a complication. CONCLUSIONS:The modified rotational scarf osteotomy has a low complication rate (9%) and apparently reduces the risk of troughing. This procedure can reduce a high degree of IM angle deformity while restoring function to the forefoot. LEVEL OF EVIDENCE/METHODS:Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Osteochondral lesions of the talus are common injuries, particularly in athletes. Traditional surgical treatment paradigms for osteochondral lesions include reparative and restorative techniques. The concern with reparative techniques (ie, microfracture and drilling) is that the fibrocartilaginous infill may ultimately fail over time, thereby causing recurrence in symptoms and a progression of arthritis. The current authors have developed a treatment algorithm whereby reparative techniques are reserved for lesions ≤8 mm in diameter, beyond which replacement strategies (ie, autologous osteochondral plug transplantation) comprise the preferred treatment strategy. In an effort to address the concerns of fibrocartilage degradation over time, the authors are currently studying the use of bone marrow aspirate concentrate (BMAC) as a means of improving the tissue quality and collagen fiber architecture of the differentiated repair cartilage. When used as an adjunct to the autologous osteochondral plug transplantation procedure, BMAC may facilitate infill of the graft-host bone and cartilage, thereby reducing the theoretical potential of synovial fluid inflow under normal joint hydrostatics, which could undermine the graft over an extended period. This article will evaluate the use of BMAC in the surgical treatment of osteochondral lesions of the talus

Athletes and their physicians are constantly searching for ways to heal injuries faster and allow for a quicker return to activity and sport. However, reliable and effective means of treating foot and ankle tendon/ligament disorders as well as fracture nonunions, and osteochondral lesions of the talus are limited. In the past, rest/immobilization, corticosteroids/nonsteroidal anti-inflammatory drugs, and rehabilitation were the mainstays of nonoperative treatment. However, results were inconsistent. In addition, anti-inflammatory medications and corticosteroids have been associated with potentially serious side effects. Recently, platelet-rich plasma (PRP) has been heralded as a safe, new therapy with potential for treating both soft and mineralized tissue injuries throughout the body, including the foot and ankle. PRP is a concentrated solution of platelets and other buffy coat elements in plasma that can be activated by collagen or thrombin and calcium. Platelets are known to be rich in growth factors and cytokines that are involved in the healing response, such as platelet-derived growth factor, vascular endothelial growth factor, insulin-like growth factor-1, and transforming growth factor-β. Early reports showed positive results leading to increasingly greater interest. Currently, we recommend using PRP only for injuries/lesions of the foot and ankle that have failed standard therapies. Before use, a thorough history and physical examination should be performed, including a detailed history of allergies and blood disorders. For maximum benefit with minimal risk of complications, injections should be performed under image guidance. Despite the great potential associated with it, evidence regarding the efficacy of PRP has been primarily limited to small case series and anecdotal reports. More rigorous analyses, preferably randomized controlled studies, are needed before PRP may be adopted as a standard therapeutic modality