Faculty Bibliography

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

BACKGROUND:Ankle sprains may damage both the lateral ligaments of the hindfoot and the osteochondral tissue of the ankle joint. When nonoperative treatment fails, operative approaches are indicated to restore both native motion patterns at the hindfoot and ankle joint contact mechanics. The goal of the present study was to determine the effect of lateral ligament injury, repair, and reconstruction on ankle joint contact mechanics and hindfoot motion patterns. METHODS:Eight cadaveric specimens were tested with use of robotic technology to apply combined compressive (200-N) and inversion (4.5-Nm) loads to the hindfoot at 0° and 20° of plantar flexion. Contact mechanics at the ankle joint were simultaneously measured. A repeated-measures experiment was designed with use of the intact condition as control, with the other conditions including sectioned anterior talofibular and calcaneofibular ligaments, the Broström and Broström-Gould repairs, and graft reconstruction. RESULTS:Ligament sectioning decreased contact area and caused a medial and anterior shift in the center of pressure with inversion loads relative to those with the intact condition. There were no significant differences in inversion or coupled axial rotation with inversion between the Broström repair and the intact condition; however, medial translation of the center of pressure remained elevated after the Broström repair relative to the intact condition. The Gould modification of the Broström procedure provided additional support to the hindfoot relative to the Broström repair, reducing inversion and axial rotation with inversion beyond that of intact ligaments. There were no significant differences in center-of-pressure excursion patterns between the Broström-Gould repair and the intact ligament condition, but this repair increased contact area beyond that with the ligaments intact. Graft reconstruction more closely restored inversion motion than did the Broström-Gould repair at 20° of plantar flexion but limited coupled axial rotation. Graft reconstruction also increased contact areas beyond the lateral ligament-deficient conditions but altered center-of-pressure excursion patterns relative to the intact condition. CONCLUSIONS:No lateral ankle ligament reconstruction completely restored native contact mechanics of the ankle joint and hindfoot motion patterns.

BACKGROUND:Arthroscopic debridement is a well-accepted method of removing osseous and/or soft tissue impingement from the ankle joint. To the best of the authors' knowledge, this is the first case series reporting the outcomes following arthroscopic resection of anteromedial impingement. PURPOSE/OBJECTIVE:The authors report the results at a minimum 2-year follow-up of 41 patients who underwent arthroscopic resection for anteromedial impingement. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:Arthroscopic surgery for anteromedial impingement was performed on 43 patients under the care of the senior surgeon between January 2005 and July 2007; 41 patients were included in the present study. All patients were assessed preoperatively and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and Short Form 36 (SF-36v2) outcome scores. The mean patient age at the time of surgery was 31.12 years (range, 13-57 years). The mean follow-up time was 34.41 months (range, 24-52 months). Thirty-four patients (83%) were competing at some level of athletic sport. RESULTS:Thirty-eight patients (93%) were satisfied with the procedure. The AOFAS scores improved from 62.83 points preoperatively to 91.17 points postoperatively (range, 61-100 points) (P < .001). The SF-36v2 scores improved from 61.54 points preoperatively to 92.21 points postoperatively (range, 58-100 points) (P = .002). All but 1 patient returned to their prior level of sporting activity. Three patients (7%) reported a complication. CONCLUSION/CONCLUSIONS:Arthroscopic resection for anteromedial impingement provides excellent functional outcomes, thereby allowing the athlete an expedited return to sport at previous levels of competition.

Osteochondral lesions of the talus are common injuries following acute and chronic ankle sprains. Numerous surgical treatment strategies have been employed for treating these lesions; arthroscopic bone marrow stimulation is recognized as the first-line technique to provide fibrocartilage infill of the defect site. While the short- and medium-term outcomes of this technique are good, the long-term outcomes are not yet known. An increasing number of studies, however, show a cause for concern in employing this technique, including declining outcome scores over time. The current authors have therefore developed a treatment strategy based on previously established guidelines in addition to morphological cartilage-sensitive fast spin echo techniques and quantitative T2 mapping magnetic resonance imaging (MRI). Accordingly, the authors advocate arthroscopic bone marrow stimulation in lesion sizes up to 8 mm in diameter and osteochondral autograft transplant (OATS) in lesion sizes greater than 8 mm in diameter. In the absence of long-term studies, confining the use of arthroscopic bone marrow stimulation to smaller lesions may support prolonged joint life by decreasing the rate at which the fibrocartilage ultimately degenerates over time. Employing the OATS procedure in larger lesions has the advantage of replacing "like with like." The current review examines the role of arthroscopic bone marrow stimulation techniques of the talus.

Osteochondral lesions (OCLs) are rare joint disorders, typically found in the larger joints of the body and less so in smaller joints (J Bone Joint Surg Am 41-A:988-1020, 1959; Arthroscopy 6(3):190-197, 1990; Clin Orthop Relat Res 148:245-253, 1980). Although their specific cause is subject to frequent debate, they are often caused by trauma with subsequent compromise of the articular cartilage (Arthroscopy 6(3):190-197, 1990; J Bone Joint Surg Am 78(3):439-456, 1996). Symptoms are typically attributable to a mechanical defect, either of the bony defect or a flap of cartilage. The current case report describes an osteochondral lesion of the head of the fifth metatarsal which is a heretofore unreported location. Magnetic resonance imaging (MRI) of the lesion revealed a notable subchondral bone signal change, indicating a possible synovial fluid pressure phenomenon rather than a mechanical defect.

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.