Bone Marrow Stimulation for Osteochondral Lesions of the Tibial Plafond Yields Good Patient-Reported Outcomes in Daily Living but Moderate Outcomes in Sports Activities at 2- to 22-Years Follow-Up.

PURPOSE: To assess the patient-reported outcomes, as well as the revision and complication rates, of patients who underwent arthroscopic bone marrow stimulation (BMS) for an osteochondral lesion of the tibial plafond (OLTP). METHODS: Patients with an OLTP treated with arthroscopic BMS at a minimum follow-up of 2-years were cross-sectionally included from a historical database. The primary outcome was the Numeric Rating Scale (NRS) during walking. Secondary outcomes included the NRS in rest and during running, and the Foot and Ankle Outcome Score. Additionally, the association of baseline patient and lesion demographics with follow-up patient-reported outcome measures (PROMs) was assessed with the Spearman rank correlation test. A subanalysis was performed for PROMs in patients with or without a coexisting talar (i.e., bipolar) lesion. Finally, the revision surgery (i.e., repeat surgery for the OLTP) and complication rates were assessed. RESULTS: Fifty-one patients were included at a mean 8.8 (standard deviation [SD] = 5.7, range, 2-22) years follow-up. Seventy-three percent of patients had a solitary OLTP, and 27% had a coexisting talar (bipolar) lesion. Males had a significantly higher rate of bipolar lesions compared to females (P ≤ .01), and patients with a bipolar lesion had a significantly larger OLTP lesion diameter (P = .02) and volume (P = .04). At final follow-up, the mean NRS during walking was 1.9 (SD = 2.3) out of 10. Anterior-posterior OLTP size (r = 0.36; P ≤ .01) was significantly associated with a higher NRS pain score during walking, although the presence of bipolar lesions did not result in inferior clinical outcomes. At final follow-up, 6% of patients underwent revision surgery. Minor complications were observed in 12% of patients. CONCLUSIONS: Arthroscopic BMS for OLTP results in favorable patient-reported outcomes at mid- to long-term follow-up, although moderate outcomes were observed in sports activities. Lesion size was associated with increased pain scores, although bipolar lesions did not result in inferior patient-reported outcomes. Six percent of patients required revision surgery, and 12% of patients had minor complications after surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

No difference between 5 and 6 weeks of non-weight bearing after osteochondral grafts for medial osteochondral defects of the talus with medial malleolar osteotomy.

PURPOSE: The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT). METHODS: A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed. RESULTS: Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations. CONCLUSION: No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT. LEVEL OF EVIDENCE: Level III, Therapeutic.

Sex-specific analysis in patients undergoing Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large osteochondral lesions of the talus.

PURPOSE: The purpose of the present study is to assess the gender-specific differences in the presentation and outcomes following Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) between male and female patients. METHODS: A prospective comparative analysis was performed comparing consecutive female and male patients having been treated by the press-fit TOPIC procedure. Clinical comparative assessment preoperatively and at 12 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) was also assessed. A computed tomography (CT) scan was performed for lesion size, morphology and localization determination preoperatively as well as 10-12 weeks postoperatively to assess the union of the osteotomy site and at 1 year postoperatively to assess consolidation of the graft as well as intra-graft cyst development. RESULTS: A total of 48 patients (30 women, 18 men) were eligible for inclusion. Both men and women demonstrated significant functional improvements postoperatively concerning the clinical outcomes with no significant differences between men and women (n.s.) except for a significantly greater improvement in postoperative FAOS pain scores in women. Men presented with OLTs significantly larger in both surface area (208 mm2 for males versus 155 mm2 for females, p < 0.05) as well as lesion volume (3.0 cm3 for males versus 1.8 cm3 for females, p < 0.05). At 1-year postoperatively, all patients showed graft consolidation. Cyst formation was present in 11 females (37% of the group) and 10 males (59% of the group), respectively (n.s.). CONCLUSION: Both males and females showed clinically relevant improvements in the clinical outcomes after undergoing the TOPIC procedure with significant differences in preoperative lesion size. The TOPIC procedure is a good treatment strategy for large OLTs in both men and women. LEVEL OF EVIDENCE: Level III, comparative prospective clinical cohort.

Large variation in postoperative rehabilitation protocols following operative treatment of osteochondral lesions of the talus: A systematic review and meta-analysis on >200 studies.

PURPOSE: A treatment-specific rehabilitation protocol and well-defined return-to-play criteria guide clinical decision-making on return to normal function, activity, sports and performance after surgical treatment for osteochondral lesion of the talus (OLT). The optimal rehabilitation protocols in the current literature remain unclear. The purpose of this study was to explore the existing literature on rehabilitation protocols from the early postoperative phase to return to sport onwards after different types of surgical treatment of OLTs. METHODS: PubMed, Embase, CDSR, DARE and Central were searched systematically from inception to February 2023 according to the PRISMA 2020 guidelines. All clinical studies with a description of postoperative rehabilitation criteria after surgical treatment of OLTs were included. The primary outcome of this study is the extent of reportage for each rehabilitation parameter expressed in percentage. The secondary outcome is the reported median time for each parameter in rehabilitation protocols for all different treatment modalities (type of surgery). The median time, expressed as number of weeks, for each parameter was compared between different types of surgery. RESULTS: A total of 227 articles were included reporting on 255 different rehabilitation protocols from seven different types of surgery. Weight-bearing instructions were reported in 84%-100% and the use of a cast or walker was prescribed in 27%-100%. Range of motion exercises were described in 54%-100% whereas physical therapy was advised in 21%-67% of the protocols. Any advice on return to sport was described in 0%-67% protocols. A nonparametric analysis of variance showed significant differences between the different surgical treatment modalities for the following parameters between the treatment groups: time to full weight-bearing (p < 0.0003) and return to high impact level of sports (p < 0.0003). Subjective or objective criteria for progression during rehabilitation were reported in only 24% of the studies. CONCLUSION: An in-depth exploration of the current literature showed substantial variation in postoperative rehabilitation guidelines with an associated underreporting of the most important rehabilitation parameters in postoperative protocols after surgical treatment of OLTs. Furthermore, nearly all rehabilitation protocols were constructed according to a time-based approach. Only one out of four reported either objective or subjective criteria. LEVEL OF EVIDENCE: Level IV, systematic review.

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis.

PURPOSE: Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes. METHODS: A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications. RESULTS: The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections. CONCLUSION: Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications). LEVEL OF EVIDENCE: Level IV, Systematic Review and Meta-Analysis.

Sustained clinical success at 7-year follow-up after arthroscopic Lift-Drill-Fill-Fix (LDFF) of primary osteochondral lesions of the talus.

PURPOSE: To describe the long-term clinical results of arthroscopic fragment fixation for chronic primary osteochondral lesions of the talus (OLT), using the Lift-Drill-Fill-Fix (LDFF) technique. METHODS: Eighteen patients (20 ankles) underwent fixation for a primary OLT with an osteochondral fragment using arthroscopic LDFF and were evaluated at a minimum of 5-year follow-up. Pre- and postoperative clinical assessment was prospectively performed by measuring the Numeric Rating Scale (NRS) of pain at rest, during walking and when running. Additionally, the change in Foot and Ankle Outcome Score (FAOS) and the procedure survival (i.e., no reoperation for the OLT) at final follow-up was assessed. RESULTS: At a mean follow-up of 7 years, the median NRS during walking significantly improved from 7 (IQR 5-8) pre-operatively to 0 (IQR 0-1.5) at final follow-up (p = < 0.001). This result was sustained from 1-year follow-up to final follow-up. The NRS during running significantly improved from 8 (IQR 6-10) to 2 (IQR 0-4.5) (p < 0.001) and the NRS in rest from 2.5 (IQR 1-3) to 0 (IQR 0-0) (p = < 0.001). The median FAOS at final follow-up was 94 out of 100 for pain, 71 for other symptoms, 99 for activities of daily living, 80 for sport and 56 for quality of life. The FOAS remained significantly improved post-operatively on all subscales, except for the symptoms subscale. The procedure survival rate is 87% at final follow-up. CONCLUSION: Arthroscopic LDFF for fixable chronic primary OLTs results in excellent pain reduction and improved patient-reported outcomes, with sustained results at long-term follow-up. These results indicate that surgeons may consider arthroscopic LDFF as treatment of choice for fragmentous OLT. LEVEL OF EVIDENCE: Level IV, prospective case series.

Non-operative management for osteochondral lesions of the talus: a systematic review of treatment modalities, clinical- and radiological outcomes.

PURPOSE: The purpose of the present study was to assess the overall clinical success rate of non-operative management for osteochondral lesions of the talus (OLT). METHODS: A literature search was conducted in the PubMed (MEDLINE), COCHRANE and EMBASE (Ovid) databases. Clinical success rates per separate study were calculated at the latest moment of follow-up and were defined as successful when a good or excellent clinical result at follow-up was reported in a qualitative manner or when a post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score at or above 80 was reached. When clinical outcomes were based on other clinical scoring systems, outcomes reported as good or excellent were considered as clinical success. Studies methodologically eligible for a simplified pooling method were combined to calculate an overall pooled clinical success rate. Radiological changes over the course of conservative treatment were assessed either considering local OLT changes and/or overall ankle joint changes. RESULTS: Thirty articles were included, including an overall of 868 patients. The median follow-up of the included studies was 37 months (range: 3-288 months). A simplified pooling method was possible among 16 studies and yielded an overall pooled clinical success rate of 45% (95% CI 40-50%). As assessed with plain radiographs, progression of ankle joint osteoarthritis was observed in of 9% (95% CI 6-14%) of the patients. As assessed through a Computed Tomography (CT) scan, focal OLT deterioration was observed in 11% (95% CI 7-18%) of the patients. As assessed with a Magnetic Resonance Imaging (MRI) scan, focal OLT deterioration was observed in 12% (95% CI 6-24%) of the patients. An unchanged lesion was detected on plain radiographs in 53% (48/91; CI 43-63%), 76% (99/131; 95% CI 68-82%) on a CT scan and on MRI in 84% (42/50; 95% CI 71-92%) of the patients. CONCLUSION: The current literature on non-operative management of OLTs is scarce and heterogeneous on indication and type of treatment. Promising clinical results are presented but need to interpreted with caution due to the heterogeneity in indication, duration and type of treatment. Further studies need to focus on specific types on conservative management, indications and its results. LEVEL OF EVIDENCE: Systematic review, Level IV.

Watching a movie or listening to music is effective in managing perioperative anxiety and pain: a randomised controlled trial.

PURPOSE: Despite the use of perioperative anxiolytics and pain medication, surgery can be a stressful and painful experience. Providing patients with distractions using video and/or audio tools in addition to medication may be helpful. To date, no studies have compared different distraction modalities in a same-day surgical setting in adults. This study aims to determine whether audio-visual distraction with video glasses (AVD) is more effective in reducing anxiety and pain compared to audio distraction (AD) in conscious patients undergoing orthopaedic surgery. It was hypothesised that AVD, being the more immersive modality, would be more effective than AD on the outcome parameters. METHODS: Fifty patients undergoing orthopaedic surgery with local and/or regional anaesthesia in a clinical day-care setting were randomly assigned to receive either fixed-scenery AVD or patient-choice AD with music. Primary outcome was anxiety, as measured by the Dutch version of the Spielberger State-Trait Anxiety Inventory-6 (STAI-6) prior to and 15 min after the intervention. Secondary outcomes were pain (Numeric Rating Scale Pain [NRS-P]), systolic and diastolic blood pressure, heart rate and patient satisfaction. RESULTS: Within each group, there was a significant reduction in anxiety (p = 0.028 for AVD, p < 0.001 for AD). In contrast to our hypothesis, listening to music without watching a video (AD group) reduced anxiety significantly more than experiencing full AVD (p = 0.018). The mean pain score did not change significantly within either user group, nor did pain scores differ between user groups. CONCLUSION: In conscious patients undergoing surgery, watching a movie (using video glasses and a headphone set) and listening to music (using only a headphone set) are able to significantly reduce anxiety. AVD, although believed to provide higher levels of distraction, did not prove to be superior to AD. The clinical relevance of this study highlights the potential benefits of AVD or AD modalities in improving the surgical experience for conscious patients. Further research is required to examine the influence of freedom of choice in content on the aforementioned outcomes. To estimate the true value of higher immersion levels, different distraction modalities (e.g. AVD versus virtual reality) featuring the exact same scenery or content need to be compared. LEVEL OF EVIDENCE: Level I.

Biomechanical and musculoskeletal changes after flexor tenotomy to reduce the risk of diabetic neuropathic toe ulcer recurrence.

OBJECTIVE: To assess the effect of flexor tenotomy in patients with diabetes on barefoot plantar pressure, toe joint angles and ulcer recurrence during patient follow-up. METHODS: Patients with a history of ulceration on the toe apex were included. They underwent minimally invasive needle flexor tenotomy by an experienced musculoskeletal surgeon. Dynamic barefoot plantar pressure measurements and static weight-bearing radiographs were taken before and 2-4 weeks after the procedure. RESULTS: A total of 14 patients underwent flexor tenotomy on 50 toes in 19 feet. There was a mean follow-up time of 11.4 months. No ulcer recurrence occurred during follow-up. Mean barefoot plantar pressure was assessed on 34 toes and decreased significantly after the procedure by a mean 279 kPa (95% CI: 204-353; p < 0.001). Metatarsophalangeal, proximal interphalangeal and distal interphalangeal joint angles were assessed on nine toes and all decreased significantly (by 7° [95% CI: 4-9; p < 0.001], 19° [95% CI: 11-26; p < 0.001] and 28° [95% CI: 13-44; p = 0.003], respectively). CONCLUSION: These observations show a beneficial effect of flexor tenotomy on biomechanical and musculoskeletal outcomes in the toes, without ulcer recurrence.

Treatment of Osteochondral Lesions of the Talus in the Skeletally Immature Population: A Systematic Review.

INTRODUCTION: Skeletally immature osteochondral lesions of the talus (OLTs) are underreported and little is known about the clinical efficacy of different treatment options. The primary aim of the present study was to investigate the clinical efficacy of different conservative and surgical treatment options. The secondary aim was to assess return to sports (RTS) and radiologic outcomes for the different treatment options. METHODS: An electronic literature search was carried out in the databases PubMed, EMBASE, Cochrane, CDSR, CENTRAL, and DARE from January 1996 to September 2021 to identify suitable studies for this review. The authors separately screened the articles for eligibility and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Clinical success rates were calculated per separate study and pooled per treatment strategy. Radiologic outcomes and sports outcomes for the different treatment strategies were assessed. RESULTS: Twenty studies with a total of 381 lesions were included. The mean MINORS score of the included study was 7.6 (range: 5 to 9). The pooled success rate was 44% [95% confidence interval (CI): 37%-51%] in the conservative group (n=192), 77% (95% CI: 68%-85%) in the bone marrow stimulation (BMS) group (n=97), 95% (95% CI: 78%-99%) in the retrograde drilling (RD) group (n=22), 79% (95% CI: 61%-91%) in the fixation group (n=33) and 67% (95% CI: 35%-88%) in the osteo(chondral) autograft group (n=9). RTS rates were reported in 2 treatment groups: BMS showed an RTS rate of 86% (95% CI: 42%-100%) without specified levels and an RTS rate to preinjury level of 43% (95% CI: 10%-82%). RD showed an RTS rate of 100% (95% CI: 63%-100%) without specified levels, an RTS rate to preinjury level was not given. RTS times were not given for any treatment option. The radiologic success according to magnetic resonance imaging were 29% (95% CI: 16%-47%) (n=31) in the conservative group, 81% (95% CI: 65%-92%) (n=37) in the BMS group, 41% (95% CI: 18%-67%) (n=19) in the RD group, 87% (95% CI: 65%-97%) (n=19) in the fixation group, and were not reported in the osteo(chondral) transplantation group. Radiologic success rates based on computed tomography scans were 62% (95% CI: 32%-86%) (n=13) in the conservative group, 30% (95% CI: 7%-65%) (n=10) in the BMS group, 57% (95% CI: 25%-84%) (n=7) in the RD group, and were not reported for the fixation and the osteo(chondral) transplantation groups. CONCLUSIONS: This study showed that for skeletally immature patients presenting with symptomatic OLTs, conservative treatment is clinically successful in 4 out of 10 children, whereas the different surgical treatment options were found to be successful in 7 to 10 out of 10 children. Specifically, fixation was clinically successful in 8 out of 10 patients and showed radiologically successful outcomes in 9 out of 10 patients, and would therefore be the primary preferred surgical treatment modality. The treatment provided should be tailor-made, considering lesion characteristics and patient and parent preferences. LEVEL OF EVIDENCE: Level IV-systematic review and meta-analysis.

Lower leg symmetry: a Q3D-CT analysis.

PURPOSE: In fracture and realignment surgery, the contralateral unaffected side is often used as a model or template for the injured bone even though clinically valuable quantitative data of bilateral symmetry are often unavailable. Therefore, the objective of the present study was to quantify and present the bilateral symmetry of the tibia and fibula. METHODS: Twenty bilateral lower-leg CT scans were acquired in healthy volunteers. The left and right tibia and fibula were segmented resulting in three-dimensional polygons for geometrical analyses (volume, surface and length). The distal and proximal segment of the right tibia of each individual was subsequently matched to the left tibia to quantify alignment differences (translation and rotation). Bone symmetry on group level was assessed using the Student's t test and intra-individual differences were assessed using mixed-models analyses. RESULTS: Intra-individuals differences were found for tibia volume (5.2 ± 3.3 cm3), tibia surface (5.2 ± 3.3 cm2), translations in the lateral (X-axis; 9.3 ± 8.9 mm) and anterior direction (Y-axis; 7.1 ± 7.0 mm), for tibia length (translation along Z-axis: 3.1 ± 2.4 mm), varus/valgus (φz: 1.7o ± 1.4°), and endotorsion/exotorsion (φz: 4.0o ± 2.7°). CONCLUSION: This study shows intra-individual tibia asymmetry in both geometric and alignment parameters of which the surgeon needs to be aware in pre-operative planning. The high correlation between tibia and fibula length allows the ipsilateral fibula to aid in estimating the original tibia length post-injury. Future studies need to establish whether the found asymmetry is clinically relevant when the contralateral side is used as reference in corrective surgery. LEVEL OF EVIDENCE: III cohort study.

8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions.

BACKGROUND: The primary aim was to determine the clinical success rate after treatment for talocalcaneal (TCC) and calcaneonavicular coalitions (CNC). The secondary aim was to evaluate the complication, recurrence and revision rate. METHODS: A search was carried out in MEDLINE, EMBASE and Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria. The primary outcome was the clinical success rate and was pooled per type of coalition and treatment modality. 95% Confidence Intervals (CI) of the success rates were calculated. Secondary outcomes included complication rates, coalition recurrence rates, revision rates and pain improvement using the Visual Analogue Scale (VAS). A sub-analysis on interposition material was performed. RESULTS: 43 articles comprising of 1284 coalitions were included, with a pooled mean follow-up of 51 months. Methodological quality was fair. The overall pooled success rate for TCCs was 79% (95% CI, 75%-83%). Conservative treatment, open resection and arthroscopic resection of TCCs resulted in success rates of 58% (95% CI, 42%-73%), 80% (95% CI, 76%-84%) and 86% (95% CI, 71%-94%), respectively. CNCs have an overall success rate of 81% (95% CI, 75%-85%), with 100% (95% CI, 34%-100%), 80% (95% CI, 74%-85%) and 100% (95% CI, 65%-100%) for conservative treatment, open resection and arthroscopic resection, respectively. Pooled complication rates of 4% (95% CI, 3%-7%) for TCCs and 6% (95% CI, 4%-11%) for CNCs were found. The success rates of resection with and without interposition material for TCCs were 83% (95% CI, 78%-87%) and 79% (95% CI, 65%-88%), and for CNCs 81% (95% CI, 76%-86%) and 69% (95% CI, 44%-85%), respectively. CONCLUSION: Treatment of tarsal coalitions can be considered good to excellent as well as safe, with an overall clinical success rate of 79% for TCCs and 81% for CNCs. Arthroscopic resection of the coalition appears to be non-inferior to open resection of TCCs and CNCs. LEVEL OF EVIDENCE: Level IV, Systematic Review.

Morphometric analysis of the incisura fibularis in patients with unstable high ankle sprains.

OBJECTIVE: The role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques. MATERIALS AND METHODS: Fifteen patients with a mean age of 44 years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4 years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio. RESULTS: The mean incisura depth (M = 4.7 mm, SD = 1.1 mm), incisura height (M = 36.1 mm, SD = 5.3 mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8 mm, SD = 1.1 mm; M = 31.9 mm, SD = 3.2 mm; M = 143.2°, SD = 8.3°) (P < 0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (P > 0.05). CONCLUSION: Our three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.

Six out of ten patients with sinus tarsi syndrome returned to pre-injury type of sport after subtalar arthroscopy.

PURPOSE: The purpose of this study was to determine multiple return to sport rates, long-term clinical outcomes and safety for subtalar arthroscopy for sinus tarsi syndrome. METHODS: Subtalar arthroscopies performed for sinus tarsi syndrome between 2013 and 2018 were analyzed. Twenty-two patients were assessed (median age: 28 (IQR 20-40), median follow-up 60 months (IQR 42-76). All patients were active in sports prior to the injury. The primary outcome was the return to pre-injury type of sport rate. Secondary outcomes were time and rate of return to any type of sports, return to performance and to improved performance. Clinical outcomes consisted of Numerous Rating Scale of pain, Foot and Ankle Outcome Score, 36-item Short Form Survey and complications and re-operations. RESULTS: Fifty-five percent of the patients returned to their preoperative type of sport at a median time of 23 weeks post-operatively (IQR 9.0-49), 95% of the patients returned to any type and level sport at a median time of 12 weeks post-operatively (IQR 4.0-39), 18% returned to their preoperative performance level at a median time of 25 weeks post-operatively (IQR 8.0-46) and 5% returned to improved performance postoperatively at 28 weeks postoperatively (one patient). Median NRS in rest was 1.0 (IQR 0.0-4.0), 2.0 during walking (IQR 0.0-5.3) during walking, 3.0 during running (IQR 1.0-8.0) and 2.0 during stair-climbing (IQR 0.0-4.5). The summarized FAOS score was 62 (IQR 50-90). The median SF-36 PCSS and the MCSS were 46 (IQR 41-54) and 55 (IQR 49-58), respectively. No complications and one re-do subtalar arthroscopy were reported. CONCLUSION: Six out of ten patients with sinus tarsi syndrome returned to their pre-injury type of sport after being treated with a subtalar arthroscopy. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures. LEVEL OF EVIDENCE: IV.

The ankle cartilage cascade: incremental cartilage damage in the ankle joint.

Level of evidence Editorial, Level V.

Satisfactory long-term clinical outcomes after bone marrow stimulation of osteochondral lesions of the talus.

PURPOSE: The purpose of the present study was to evaluate the clinical and radiological outcomes of arthroscopic bone marrow stimulation (BMS) for the treatment of osteochondral lesions of the talus (OLTs) at long-term follow-up. METHODS: A literature search was conducted from the earliest record until March 2021 to identify studies published using the PubMed, EMBASE (Ovid), and Cochrane Library databases. Clinical studies reporting on arthroscopic BMS for OLTs at a minimum of 8-year follow-up were included. The review was performed according to the PRISMA guidelines. Two authors independently conducted the article selection and conducted the quality assessment using the Methodological index for Non-randomized Studies (MINORS). The primary outcome was defined as clinical outcomes consisting of pain scores and patient-reported outcome measures. Secondary outcomes concerned the return to sport rate, reoperation rate, complication rate, and the rate of progression of degenerative changes within the tibiotalar joint as a measure of ankle osteoarthritis. Associated 95% confidence intervals (95% CI) were calculated based on the primary and secondary outcome measures. RESULTS: Six studies with a total of 323 ankles (310 patients) were included at a mean pooled follow-up of 13.0 (9.5-13.9) years. The mean MINORS score of the included studies was 7.7 out of 16 points (range 6-9), indicating a low to moderate quality. The mean postoperative pooled American Orthopaedic Foot and Ankle Society (AOFAS) score was 83.8 (95% CI 83.6-84.1). 78% (95% CI 69.5-86.8) participated in sports (at any level) at final follow-up. Return to preinjury level of sports was not reported. Reoperations were performed in 6.9% (95% CI 4.1-9.7) of ankles and complications related to the BMS procedure were observed in 2% (95% CI 0.4-3.0) of ankles. Progression of degenerative changes was observed in 28% (95% CI 22.3-33.2) of ankles. CONCLUSION: Long-term clinical outcomes following arthroscopic BMS can be considered satisfactory even though one in three patients show progression of degenerative changes from a radiological perspective. These findings indicate that OLTs treated with BMS may be at risk of progressing towards end-stage ankle osteoarthritis over time in light of the incremental cartilage damage cascade. The findings of this study can aid clinicians and patients with the shared decision-making process when considering the long-term outcomes of BMS. LEVEL OF EVIDENCE: Level IV.

High union rates following surgical treatment of proximal fifth metatarsal stress fractures.

PURPOSE: The primary purpose of this study was to determine the union rate and time for surgical- and non-surgical treatment of stress fractures of the proximal fifth metatarsal (MT5). The secondary purpose was to assess the rate of adverse bone healing events (delayed union, non-union, and refractures) as well as the return to sports time and rate. METHODS: A literature search of the EMBASE (Ovid), MEDLINE (PubMed), CINAHL, Web of Science and Google Scholar databases until March 2020 was conducted. Methodological quality was assessed by two independent reviewers using the methodological index for non-randomized studies (MINORS) criteria. The primary outcomes were the union time and rate. Secondary outcomes included the delayed union rate, non-union rate, refracture rate, and return to sport time and rate. A simplified pooling technique was used to analyse the different outcomes (i.e. union rate, time to union, adverse bone healing rates, return to sport rate, and return to sport time) per treatment modality. Additionally, 95% confidence intervals were calculated for the union rate, adverse bone healing rates, and the return to sport rate. RESULTS: The literature search resulted in 2753 articles, of which thirteen studies were included. A total of 393 fractures, with a pooled mean follow-up of 52.5 months, were assessed. Overall, the methodological quality of the included articles was low. The pooled bone union rate was 87% (95% CI 83-90%) and 56% (95% CI 41-70%) for surgically and non-surgically treated fractures, respectively. The pooled radiological union time was 13.1 weeks for surgical treatment and 20.9 weeks for non-surgical treatment. Surgical treatment resulted in a delayed union rate of 3% (95% CI 1-5%), non-union rate of 4% (95% CI 2-6%) and refracture rate of 7% (95% CI 4-10%). Non-surgical treatment resulted in a delayed union rate of 0% (95% CI 0-8%), a non-union rate of 33% (95% CI 20-47%) and a refracture rate of 12% (95% CI 5-24%), respectively. The return to sport rate (at any level) was 100% for both treatment modalities. Return to pre-injury level of sport time was 14.5 weeks (117 fractures) for surgical treatment and 9.9 weeks (6 fractures) for non-surgical treatment. CONCLUSION: Surgical treatment of stress fractures of the proximal fifth metatarsal results in a higher bone union rate and a shorter union time than non-surgical treatment. Additionally, surgical and non-surgical treatment both showed a high return to sport rate (at any level), albeit with limited clinical evidence for non-surgical treatment due to the underreporting of data. LEVEL OF EVIDENCE: Level IV, systematic review.

High incidence of (osteo)chondral lesions in ankle fractures.

PURPOSE: To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to 50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL). METHODS: A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis-Weber and/or Lauge-Hansen classification) was calculated and pooled. Two-sided p values of less than 0.05 were considered statistically significant. RESULTS: Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (n = 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge-Hansen categories (p = 0.049). Post hoc pairwise comparisons between Lauge-Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.). CONCLUSION: OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45-47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery. LEVEL OF EVIDENCE: IV.

Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial.

Importance: Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis. Objective: To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis. Design, Setting, and Participants: A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020. Interventions: Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52). Main Outcomes and Measures: The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks. Results: Among 100 randomized patients (mean age, 56 years; 45 [45%] women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points [95% CI, 6-14]; P < .001) and 11 points in the placebo group (from 64 to 75 points [95% CI, 7-15]; P < .001). The adjusted between-group difference over 26 weeks was -1 ([95% CI, -6 to 3]; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group. Conclusions and Relevance: Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis. Trial Registration: Netherlands Trial Register: NTR7261.

Two-millimetre diameter operative arthroscopy of the ankle is safe and effective.

PURPOSE: Technical innovation now offers the possibility of 2-mm diameter operative arthroscopy: an alternative to conventional arthroscopy that no longer uses inner rod-lenses. The purpose of this study was to assess whether all significant structures in the ankle could be visualized and surgically reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage. METHODS: A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh-frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed. RESULTS: All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage. CONCLUSION: 2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.