Faculty Bibliography

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

BACKGROUND:Reconstructing the ligamentous constraints of the medial arch associated with adult acquired flatfoot deformity remains a challenge. The purpose of this study was to test the efficacy of several reconstruction techniques of the medial arch. We hypothesized that an anatomic reconstruction of the spring ligament complex would correct the deformity better than other techniques tested. METHODS:Three reconstructions of the medial support structures were performed on each specimen to recreate the different lines of action and insertions of the medial ligamentous complex in 12 specimens with a simulated flatfoot deformity. Talonavicular and tibiocalcaneal (hindfoot) orientations were measured in the axial, sagittal, and coronal planes in the intact, flatfoot, and reconstructed conditions. RESULTS:While each reconstruction technique corrected the deformity (P < .05), proximal fixation of the graft corrected the greatest amount of talonavicular deformity while also correcting hindfoot valgus (P < .05). CONCLUSION/CONCLUSIONS:The fixation points and lines of action of a medial arch reconstruction have important implications on deformity correction in a flatfoot model. Despite its fidelity to the native structure, the anatomic spring ligament reconstruction provided the least amount of correction. These findings suggest that other ligamentous structures of the medial arch are critical in supporting the midfoot. CLINICAL RELEVANCE/CONCLUSIONS:Reconstruction of the ligamentous supports of the medial arch might be able to correct substantial amounts of deformity without osseous procedures like calcaneal osteotomies or midfoot fusions.

Surgical correction of hindfoot varus is frequently performed with a lateral displacement calcaneal osteotomy. It has rarely been associated with iatrogenic tarsal tunnel syndrome in patients with pre-existing neurological disease. We report the first case of acute postoperative tarsal tunnel syndrome in a neurologically intact patient with post-traumatic hindfoot varus. Early diagnosis and emergent operative release afforded an excellent clinical outcome. Imaging studies can help outrule a compressive hematoma and assess for possible nerve transection; however it is paramount that a high index of suspicion is utilized with judicious operative intervention to minimize long-term sequelae.

BACKGROUND/UNASSIGNED:The purpose of this study was to validate the Foot and Ankle Outcome Score (FAOS) for osteochondral lesions of the talus (OLTs). We hypothesize that the FAOS will meet all 4 psychometric criteria for validity in this patient population. METHODS/UNASSIGNED: < .05. In total, 229 unique patients were included in this study. RESULTS/UNASSIGNED: < .01). The FAOS symptoms subscale demonstrated the lowest correlation with the SF-12 physical health domains. No floor or ceiling effects were identified. Weak correlations were calculated between the 5 FAOS subscales and the SF-12 mental component summary score. All FAOS domains met the threshold for acceptable content validity (score > 2.0). All FAOS subscales demonstrated acceptable test-retest reliability, with ICC values ranging from 0.81 (ADL) to 0.92 (Pain). CONCLUSION/UNASSIGNED:This study demonstrates the acceptable yet moderate construct and content validity, reliability, and responsiveness of the FAOS for patients with OLTs of the ankle joint. We endorse the use of the FAOS in evaluating ankle OLTs in both the research and clinical setting and consider it a useful patient-reported, self-administered instrument following surgical intervention. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, retrospective case study.

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.

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.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS:A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Background/UNASSIGNED:There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle. Purpose/UNASSIGNED:To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure. Study Design/UNASSIGNED:Systematic review; Level of evidence, 4. Methods/UNASSIGNED:A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed. Results/UNASSIGNED:= .77). Conclusion/UNASSIGNED:Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

BACKGROUND:The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%. RESULTS:A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT. CONCLUSIONS:This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.

BACKGROUND:An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS:Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS:A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION:These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE:Level V, mechanism-based reasoning.