Faculty Bibliography

Freiberg's disease is a condition characterized by progressive flattening and eventual collapse of a metatarsal head. Core decompression, metatarsophalangeal joint (MTPJ) debridement, metatarsal osteotomies, autologous osteochondral transplantation (AOT), interpositional arthroplasties, and synthetic implant hemiarthroplasties comprise the surgical management options for patients with Freiberg's disease. Although autografts harvested from the iliac crest have been utilized for the treatment of various osteochondral pathologies of the lower extremity, their use for Freiberg's disease has not been reported to date. We present the case of a novel technique of metatarsal osteoperiostic grafting from the iliac crest (MetOPIC) to the second metatarsal head with injection of concentrated bone marrow aspirate (cBMA) in a 28-year-old former collegiate cheerleader with a longstanding history of chronic pain due to Freiberg's disease. The patient was able to return to her normal activities and participate in sporting activity 8 weeks following the operation. To the authors' knowledge, this is the first report of the use of the MetOPIC procedure to surgically correct Freiberg's disease.Levels of Evidence: V, Case report.

BACKGROUND:This systematic review and meta-analysis aimed to evaluate the outcomes of intra-articular hyaluronic acid (HA) injections for the treatment of ankle osteoarthritis (OA). METHODS:A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was conducted in February 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data extracted included patient demographics, injection protocols, subjective clinical outcomes, ankle range of motion, complications, and failures. RESULTS:Six randomized controlled trials (RCTs) were included, comprising 145 patients (149 ankles) who received intra-articular HA injections and 129 patients (138 ankles) in the control cohorts. The weighted mean follow-up was 5.2 ± 3 months for the HA group. There were no significant differences between HA and control groups in terms of visual analog scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, and ankle osteoarthritis scale (AOS) scores. Complication rates were similar between groups, with transient injection site pain being the most common complication. CONCLUSION/CONCLUSIONS:: I, meta-analysis of randomized controlled trials.

Schwannomas are benign encapsulated nerve sheath tumors that are rarely found in the lower extremity. We report a unique case of a 65-year-old woman presenting with chronic lateral ankle instability and a palpable mass posterior to the lateral malleolus. Magnetic resonance imaging revealed an 11 by 6 by 10 mm lesion contiguous with the sural nerve. The mass was excised via meticulous enucleation with nerve preservation. Histopathology confirmed a cellular schwannoma. The patient underwent concurrent ankle arthroscopy and lateral ligament repair, thereby achieving complete resolution of symptoms and return to function at 6 months. This is the first reported case of a sural nerve schwannoma associated with chronic lateral ankle instability.

Needle arthroscopy is a minimally invasive technique available for the management of common foot and ankle pathologies. Owing to the limitations associated with first-generation needle arthroscopic models, specifically visualization and fluid management, needle arthroscopy has undergone revitalization over the past decade. Newer systems are now using chip on tip visualization capability as well as improved fluid pumps allowing for direct intervention under improved visualization. The smaller diameter of the needle arthroscope permits procedures to be conducted in both the operating room and office setting under wide-awake conditions. We present this review to detail the history of needle arthroscopy and highlight how needle arthroscopy has improved care for patients with foot and ankle disorders.

Osteochondral lesions (OCL) are common among young patients and often require surgical interventions since cartilage has a poor capacity for self-repair. Bone marrow stimulation (BMS) has been used clinically for decades to treat OCLs, however a persisting challenge with BMS and other cartilage repair strategies is the inferior quality of the resulting fibrocartilaginous repair tissue. Lubrication-based therapies have the potential to improve the quality of cartilage repair tissue as joint lubrication is linked to local cartilage tissue strains and subsequent cellular responses including death and apoptosis. Recently, a full length recombinant human lubricin (rhLubricin) was developed and has been shown to lower friction in cartilage. This study investigated the effect of a single delayed injection of rhLubricin on cartilage repair in an in vivo rabbit OCL model using gross macroscopic evaluation, surface profilometry, histology, and tribology. Moderate improvement in macroscopic scores for cartilage repair were observed. Notably, quantitative analysis of Safranin-O histology showed that rhLubricin treated joints had significantly higher glycosaminoglycan content compared to saline treated joints, and there were no differences in repair integration between groups. Furthermore, rhLubricin treated joints had significantly lower friction coefficients tested across three sliding speeds compared to saline treated joints (rhLubricin: 0.15 ± 0.03 at 0.1 mm/s to 0.12 ± 0.03 at 10 mm/s, Saline: 0.22 ± 0.06 at 0.1 mm/s to 0.19 ± 0.05 at 10 mm/s). Overall, a single delayed injection of rhLubricin improved the quality and lubricating ability of the repair cartilage tissue without inhibiting repair tissue integration.

Chronic exertional compartment syndrome is a leading source of lower-leg pain in young athletic populations, attributable to increased pressure within the musculofascial compartments. In-office needle endoscopic procedures are of growing interest for the diagnosis and treatment of various musculoskeletal pathologies. The benefits of such procedures include lower morbidity, faster postoperative recovery, improved patient satisfaction, and decreased cost compared with traditional endoscopy in the operating room setting. The purpose of this Technical Note is to demonstrate a technique for in-office needle endoscopic 4-compartment fasciotomy for lower-extremity chronic exertional compartment syndrome, including a discussion on the advantages of performing this procedure in the office setting, compared with a traditional operating room.

Needle arthroscopy has transitioned from a limited diagnostic adjunct to a versatile tool in ankle surgery. Enabled by advancements in optics, fluid systems, and nano-instruments, this technique allows for effective diagnosis and treatment under local anesthesia. This review explores the evolution, technology, indications, outcomes, and cost-effectiveness of needle arthroscopy in the ankle and discusses its implications for future orthopedic practice.

Patients with cartilage defects often experience increased meniscal degeneration. It remains unclear whether meniscal damage occurs concurrently with cartilage injury or due to later joint pathology. Limited data exists on how isolated cartilage injuries affect meniscal structure and degeneration. In osteoarthritis models, alterations to the structure and composition of meniscal ECM components have been observed, including meniscus hypertrophy characterized by excessive glycosaminoglycan deposition and fibrochondrocyte rounding. Although proteoglycan deposition increases in early OA, the timing of GAG changes relative to collagen disruption remains unclear. This study examined the correlation between changes in local proteoglycan deposition, cell morphology, and the collagen network in the meniscus following cartilage damage using an in vivo rabbit model. A medial osteochondral defect was created on the femoral condyle of New Zealand white male rabbits, and menisci were harvested 12 weeks later. Our results indicate that a medial osteochondral defect drives pathology in the underlying meniscus, likely due to altered loading conditions. The medial menisci of defect joints exhibited increased proteoglycan deposition and hypertrophy, with increased cell roundness and area in regions of elevated GAGs. Local collagen architecture showed increased fiber diameter in the medial menisci of defect joints, which positively correlated with increased GAG coverage. Abnormal collagen structures were observed, including wider variations in fiber diameters and areas of small fibers with low second harmonic generation signals, indicating poorly organized collagen. A deeper understanding of GAG regulation and fibrochondrocyte pathology in injured meniscus tissue could aid in the development of therapeutics and inform disease progression.

OBJECTIVE:To evaluate whether artificial intelligence (AI)-based software was associated with enhanced identification of eight second-trimester fetal ultrasound findings suspicious for congenital heart defects (CHDs) among obstetrician-gynecologists (ob-gyns) and maternal-fetal medicine specialists. METHODS:A dataset of 200 fetal ultrasound examinations from 11 centers, including 100 with at least one suspicious finding, was retrospectively constituted (singleton pregnancy, 18-24 weeks of gestation, patients aged 18 years or older). Only examinations containing two-dimensional grayscale cines with interpretable four-chamber, left ventricular outflow tract, and right ventricular outflow tract standard views were included. Seven ob-gyns and seven maternal-fetal medicine specialists reviewed each examination in randomized order both with and without AI assistance and assessed the presence or absence of each finding suspicious for CHD with confidence scores. Outcomes included readers' performance in identifying the presence of any finding and each finding at the examination level, as measured by the area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. In addition, reading time and confidence were evaluated. RESULTS:The detection of any suspicious finding significantly improved for AI-aided compared with unaided readers with a significantly higher AUROC (0.974 [95% CI, 0.957-0.990] vs 0.825 [95% CI, 0.741-0.908], P=.002), sensitivity (0.935 [95% CI, 0.892-0.978] vs 0.782 [95% CI, 0.686-0.878]), and specificity (0.970 [95% CI, 0.949-0.991] vs 0.759 [95% CI, 0.630-0.887]). AI assistance also resulted in a significant decrease in clinician interpretation time and increase in clinician confidence score (226 seconds [95% CI, 218-234] vs 274 seconds [95% CI, 265-283], P<.001; 4.63 [95% CI, 4.60-4.66] vs 3.90 [95% CI, 3.85-3.95], P<.001, respectively). CONCLUSION/CONCLUSIONS:The use of AI-based software to assist clinicians was associated with enhanced identification of findings suspicious for CHD on prenatal ultrasonography.

BACKGROUND:Concentrated bone marrow aspirate (CBMA) has become increasingly popular in the management of osteochondral lesions of the talus (OLT) due to its rich content of mesenchymal stem cells (MSCs) and bioactive substances that promote chondrogenesis and articular cartilage repair. However, comprehensive evaluations of clinical outcomes regarding the use of CBMA in OLT have yet to be published. The purpose of this review is to provide an evidence-based overview of clinical outcomes following the utilization of CBMA in the surgical management of OLT. METHODS:Using the search terms: ([CBMA] OR [concentrated bone marrow aspirate] OR [bone marrow aspirate] OR [bone marrow-derived mesenchymal stem cells]) AND ([talus] OR [ankle] OR [osteochondral lesion]), we systematically reviewed PubMed/Medline, Scopus, and Cochrane databases in February 2025. Inclusion criteria consisted of clinical studies published in English within the past 10 years that examined ankle pain or functional outcomes after treating OLT in adults with CBMA. Animal studies and studies including patients aged <18 years were excluded, as were systematic reviews and meta-analyses. RESULTS:Fifteen articles met inclusion criteria. CBMA showed beneficial effects in functional and pain outcomes across different applications: as a standalone therapy, in conjunction with debridement, and alongside reparative or replacement techniques. However, results varied, with some studies noting superior outcomes with CBMA compared to controls, while others found no significant differences. Radiologic outcomes assessed by Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring and complications were also mixed, suggesting benefits in some reparative techniques but not in others. CONCLUSIONS:.