Faculty Bibliography

Osteochondral lesions of the ankle joint are typically associated with a traumatic etiology and present with ankle pain and swelling. Conservative management yields unsatisfactory results because of the poor healing capacity of the articular cartilage. Smaller lesions (<100 mm² or <10 mm) can be treated with less invasive procedures such as arthroscopic debridement, anterograde drilling, scaffold-based therapies, and augmentation with biological adjuvants. For patients with large lesions (>100 mm² or >10 mm), cystic lesions, uncontained lesions, or patients who have failed prior bone marrow stimulation, management with autologous osteochondral transplantation is indicated.

BACKGROUND This article presents a rare case of an intra-tendinous ganglion cyst of the peroneus tertius. Ganglion cysts are benign lesions frequently seen in hand pathologies, but they are rarely seen in the foot and ankle. This article discusses the present case and similar previously reported cases in the English literature. CASE REPORT We present a case of a 58-year-old man with a 3-year history of right foot pain caused by a mass located at the dorso-lateral aspect of the midfoot. Preoperative MRI demonstrated a ganglion cyst arising from the peroneus tertius tendon sheath. The lesion was successfully decompressed in the office; however, it recurred 7 months later. As it was symptomatic, we elected to proceed with surgical resection. During dissection, it became apparent that the cyst was arising from an intrasubstance tear of the peroneus tertius tendon, and a branch of the superficial peroneal nerve was noted to be adherent to the pseudo-capsule. Following excision of the lesion and its expansile pseudo-capsule, the tear was repaired with tubularization of the tendon and external neurolysis of the nerve was performed. At 6 months after surgery, there was no recurrence of the lesion, and the patient was pain free and had regained normal physical function. CONCLUSIONS Intra-tendinous ganglion cysts are rare, especially in the foot and ankle. This makes it challenging for an accurate preoperative diagnosis. When a tendon is arising from a tendon sheath, we recommend exploration of the underlying tendon for an associated tear.

BACKGROUND:Concentrated bone marrow aspirate (cBMA) has garnered widespread and increasing attention in recent years. We aimed to characterize the most influential articles in cBMA research while clarifying controversies surrounding its use and clinical efficacy and identifying important areas on which to focus future research efforts. METHODS:The Science Citation Index Expanded subsection of the Web of Science Core Collection was systematically searched to identify the top 50 most cited publications on orthopedic cBMA research. Publication and study characteristics were extracted, and Spearman correlations were calculated to assess the relationship between citation data and level of evidence. RESULTS:The top 50 articles were published between the years 1996 and 2018, with 58% published in the year 2010 or later. Of the 29 studies for which level of evidence was assessed, the majority were Level IV (24, 83%). Twenty-one articles (42%) were classified as basic science or translational (9 cell culture, 8 animal study, and 4 using human blood samples). Application to treat cartilage defects was the most common focus of studies (17 studies, 34%), followed by analysis of cBMA composition (14 studies, 28%). No correlation was found between rank, citation rate, or year of publication and level of evidence. CONCLUSIONS:The most influential articles on cBMA are recent and consist of a majority low-level of evidence studies. Cohort studies were the most common study type among the top 50 most cited articles, while basic science articles were relatively less common. These results suggest a rapidly evolving field with the potential to better explain inconsistent clinical results with improved understanding and documentation of basic science concepts in addition to large-scale, prospective clinical trials. Orthobiologics and especially cBMA holds great promise for the future, and higher-level clinical trials will help better define the best clinical uses for this treatment.

PURPOSE/OBJECTIVE:The purpose of this systematic review was to evaluate both the clinical and radiographic outcomes following supramalleolar osteotomy (SMO) in patients with ankle osteoarthritis, and to analyse the level of evidence (LOE) and quality of evidence (QOE) of the included studies. METHODS:A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following SMO for the treatment of ankle osteoarthritis were included and assessed. The level and quality of evidence of the included studies were also evaluated. RESULTS:Twenty-four studies with 1160 patients (1182 ankles) were included. Overall, 78.8% patients presented with post-traumatic ankle osteoarthritis. The weighted mean AOFAS score improved from 52.6 ± 9.7 (range 33.8-78.4) preoperatively to 78.1 ± 5.7 postoperatively at weighted mean follow-up of 50.4 ± 18.6 months (range 24.5-99.0).  The most frequently utilised radiographic parameter was the tibial anterior surface angle, which improved from a preoperative weighted mean of 86.3° ± 5.6° (range 76.0°-102.0°) to a postoperative weighted mean of 89.9° ± 3.7° (range 84.9°-99.6°). The complication rate was 5.1% with non-union as the most commonly reported complication (1.6%). Secondary procedures were carried out in 28.2% of patients, the most common of which was implant and hardware removal (17.6%). The failure rate was 6.8%. Two studies were LOE II, 3 studies were LOE III, and 19 studies were LOE IV. The mean Modified Coleman Methodology Score was 59.3 ± 6.6 and the mean MINORS criteria score of all the included studies was 9.5 ± 3.7. CONCLUSION/CONCLUSIONS:This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. However, a moderate reoperation rate (28.2%) was reported. A low failure rate (6.8%) was reported, which must be interpreted in light of the shortcomings of the design of the included studies and a relatively short follow-up period. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data which underscores the need for further higher quality research to be conducted. Our review highlights that SMO may be an effective and safe procedure in the setting of early-to-intermediate-stage ankle osteoarthritis. LEVEL OF EVIDENCE/METHODS:IV.

Bone marrow stimulation (BMS) is indicated for patients who have symptomatic osteochondral lesions of the talus (OLT). Despite differences in ankle biomechanics and cartilage morphology between men and women, there is scant evidence examining whether these differences affect surgical outcomes. The purpose of this study was to compare the outcomes in men and women following BMS for OLTs. A retrospective analysis comparing female and male patients treated with BMS for OLT between 2007 and 2015 was performed. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12). Magnetic resonance imaging at final follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue score. Thirty-one females and 38 males were included. In female patients, the mean FAOS pain score improved from 60 ± 16 preoperatively to 84 ± 8.9 at 1- to 2-year follow-up (p < .01), and then decreased to 80±13 at final follow-up at 3-4 years. In male patients, the mean FAOS pain score improved from 65±17 preoperatively to 83±9.2 at 1-2 year follow-up (p < .01), and then decreased to 76±14.6 at final follow-up at 3-4 years. Lateral lesions were more common in male patients. Medial lesions were more common in female patients. The outcomes following BMS in both female and male patients were good with no significant differences at short-term follow-up. FAOS scores in male patients were more likely to decrease after 1 to 2 years postsurgery, implying a possibly faster decline than in female patients.

We present a case of calcaneal reconstruction after both an improvised explosive device injury and subsequent salvage procedures left the patient with a large calcaneal defect and damaged hindfoot soft tissue. A subtalar arthrodesis was performed with a femoral head allograft, where it was fused to the remaining calcaneus and superiorly through the talus, to successfully reconstruct this defect. Demineralized bone matrix, bone morphogenetic protein, and concentrated bone marrow aspirate were also added as adjuncts to promote bone remodeling. At final follow-up, the patient denied pain, was fully weight-bearing, and had resumed an active lifestyle. Level of Evidence: Level V, Case Report.

Osteochondral lesions of the talar dome (OLT) are common injuries that involve cartilage and subchondral bone. These injuries appear in up to 42% of professional soccer players on magnetic resonance imaging (MRI). Typically, patients are 20 35-yearold male athletes experiencing chronic ankle pain, decreased range of motion, and joint effusion, especially during or after sports activities, and compromised quality of life. The low regeneration potential of chondrocytes and the recent findings revealing subchondral bone architecture's role in cartilage homeostasis, repair durability, and overall clinical outcomes make OLT treatment a challenging topic in orthopedics. The aim of this narrative review was to outline a surgical treatment algorithm for OLT management in the athlete. Debridement and bone marrow stimulation techniques remain the first-line treatment of OLT with satisfactory short- to long-term outcomes, a high return to sports (RTS) rate, and a rapid RTS, with improved results when augmented with PRP. Still, considering the controversy of its potential disadvantages, debridement should be limited to the International Cartilage Repair Society (ICRS) grade I-II injuries regardless of its size and with or without additional bone marrow stimulation (BMS)in ICRS III < 1.0 cm² injuries. In the presence of larger lesions and subchondral plate and bone involvement, the benefits and disadvantages of osteochondral autologous transplantation system (OATS)/mosaicplasty and scaffold-based techniques should be considered for a tailored treatment approach either as a primary procedure or as an off-season procedure for better cartilage tissue quality, functional outcomes, and potentially increasing the player's professional career length.

BACKGROUND:Endoscopic plantar fascia release (EPFR) is an established operative treatment for recalcitrant plantar fasciitis. The purpose of this systematic review is to provide a comprehensive review on the outcomes of EPFR in the treatment of plantar fasciitis at mid-term and long-term follow-up. METHODS:A systematic review was performed using, MEDLINE, EMBASE, and Cochrane library databases in May 2020 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were evaluated regarding level of evidence (LOE) and quality of evidence (QOE) using the modified Coleman methodological score. Clinical outcomes and complications were also evaluated. RESULTS:Twenty-six studies including 978 feet were included in this systematic review with a weighted mean follow-up of 25.6 ± 21.0 months. Eighteen papers used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.66 ± 10.3, and the postoperative score was 89.6 ± 5.2 out of 100. The total number of patients who had complications was 88 of 994 (8.9%). The most common complication was recurrence of pain experienced by 41 patients (4.2%). CONCLUSION/CONCLUSIONS:Endoscopic plantar fascia release provides good clinical and functional outcomes in patients with refractory plantar fasciitis. However, this procedure is associated with a moderately high complication rate (8.9%) and should only be considered following failure of conservative management. Future prospective studies comparing the various endoscopic and open techniques with nonoperative treatment are required to elucidate the most effective management for recalcitrant plantar fasciitis. LEVELS OF EVIDENCE/UNASSIGNED:Level I: Systematic review of level IV studies.

PURPOSE/OBJECTIVE:To evaluate the complication rates, continuous functional outcome scores, and return to play data following bone marrow stimulation (BMS) versus biologics ± BMS for the treatment of osteochondral lesion of the talus (OLT). METHODS:A systematic review was performed. The PubMed and Embase databases were searched using specific search terms and eligibility criteria according to the PRISMA guidelines. The level of evidence was assessed using published criteria by The Journal of Bone & Joint Surgery, and the quality of evidence using the Modified Coleman Methodology Score. Continuous variables were presented as mean ± standard deviation and categorical variables as frequencies (percentages). RESULTS:BMS versus BMS + hyaluronic acid (HA): no complications in either treatment arm were reported. The mean American Orthopaedic Foot and Ankle Society score was 43.5 to 67.3 points and 44.0 to 72.4 points, respectively. The mean 10 mm Visual Analogue Scale pain score was 7.7 to 3.8 points and 7.5 to 2.5 points, respectively. BMS versus BMS + concentrated bone marrow aspirate (CBMA): the pooled overall complication rate was 17/64 (26.6%) versus 11/71 (15.5%), respectively (non-significant). The pool revision rate was 15/64 (23.4%) versus 6/71 (8.5%), respectively (p = 0.016). There has been a notable poor reporting of complication rates for the use of ADSC and PRP as adjuvant biological therapies to BMS for the treatment of OLT. CONCLUSION/CONCLUSIONS:There was an overall limited comparative clinical evidence of adjuvant biologics with BMS versus BMS alone for the treatment of OLT. BMS + HA and BMS + CBMA can provide superior outcomes, albeit the currently limited evidence. Further studies are warranted to establish the true clinical superiority of the various biologics ± BMS versus BMS alone. These studies must also compare the various biologics against one another to determine, if any, the optimal biologic for OLT. Clinicians should counsel patients accordingly on these findings as required. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN) with variable success after surgical treatment. METHOD/METHODS:40 lower-leg specimens were obtained. Dissections were appropriately conducted. Extremities were prepared under formaldehyde solution. The tibial nerve and branches were dissected for measurements and various characteristics. RESULTS:The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM (Dellon-McKinnon malleolar-calcaneal line) line 31.2% distally and 34.3% at the same level. CONCLUSION/CONCLUSIONS:Understanding the tibial nerve anatomy will allow us to adapt our surgical technique to improve the treatment of this recurrent pathology.