Faculty Bibliography

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.

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.

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.

Fractures of the medial tubercle of the posterior process of the talus are rare injuries. They are often misdiagnosed, resulting in increased morbidity and symptoms of chronic ankle pain and instability. When undetected, these fractures may become displaced, with potential additional injuries such as to the flexor hallucis longus tendon which may become interposed between the fracture fragments. We report a case of a clinically unsuspected fracture of the medial tubercle of the posterior process of the talus seen on magnetic resonance imaging, treated conservatively, with interval satisfactory healing of the fracture at 6 weeks follow-up.

Ankle stability is integral to normal motion and to minimizing the risk of ankle sprain during participation in sport activities. The ability of the dynamic and static stabilizers of the ankle joint to maintain their structural integrity is a major component of the normal gait cycle. In sports, this quality assumes even greater importance given the range of movement and stresses imposed on the ankle during various sporting disciplines. In the general population, the incidence of ankle sprain is very high. In several studies, injuries to the lateral ankle ligaments have been shown to be the most common sports-related injuries, accounting for approximately 25% of all sports-related injuries. Furthermore, up to 80% of all ankle sprains involve the lateral ligament complex. Other studies have estimated their incidence as approximately 5000 injuries per day in the United Kingdom and 23 000 in the United States. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries among athletes, both professional and "weekend warriors" alike.

BACKGROUND:Limited open repairs of acutely ruptured Achilles tendon, using the Achillon device, are becoming a frequently used method of treatment. To date there are no biomechanical studies comparing the strength of the Achillon repair to the Krackow repair. This study provides a direct comparison of the strength of these two repair techniques. METHODS:Using 10 paired cadaveric Achilles tendon specimens; repairs were performed using a Krackow technique on one specimen and a repair with the Achillon Suture System on the contralateral specimen. All repairs were made with identical suture material. Specimens were tested for ultimate strength using a servo-hydraulic testing device. FINDINGS/RESULTS:The mean load to failure of the control group (Krackow suture) was 276N (standard deviation 87.0), and for the experimental group (Achillon suture) was 342N (standard deviation 92.8). Using a Wilcoxon test this result was found to be statically significant (P=0.03). INTERPRETATION/CONCLUSIONS:The current study has demonstrated that the Achillon repair is stronger in a cadaveric biomechanical study than the Krackow repair using identical sutures. This provides biomechanical evidence to support the continued use of the limited open repair as opposed to the traditional open repair.

Ankle inversion injuries are the most common traumatic injuries in dancers. Ankle stability is integral to normal mobilization and to minimizing the risk for ankle sprain. The ability of the dynamic and static stabilizers of the ankle joint to maintain their structural integrity is a major component of the normal gait cycle. In the world of dance, this quality assumes even greater importance given the range of movement and stresses imposed on the ankle during various dance routines.