Ankle Arthroscopy for Diagnosis of Full-thickness Talar Cartilage Lesions in the Setting of Acute Ankle Fractures.

PURPOSE: To delineate the prevalence of chondral lesions, in particular full-thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture open reduction-internal fixation (ORIF) and evaluate the impact on clinical outcomes. METHODS: We conducted a retrospective chart review of prospectively collected registry data at our institution from 2012 to 2016. Consecutive patients who underwent acute ankle fracture ORIF with concurrent arthroscopy were identified. Charts were reviewed to determine the prevalence and grade of chondral lesions, fracture type, and associated factors. Clinical outcomes with a minimum of 1 year of follow-up were assessed using the Foot and Ankle Outcome Score. RESULTS: The study included 116 consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy. A chondral lesion was identified in 78% (90 of 116). A full-thickness talar dome chondral lesion was identified in 43% of these patients (39 of 90). Patient age was a significant predictor, with patients younger than 30 years being less likely to have a chondral injury than those aged 30 years or older (59% vs 85%, P = .0077). Of the patients who sustained a dislocation at the time of injury, 100% had a chondral lesion (P = .039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, P = .013). Patients with chondral lesions had statistically significantly worse clinical outcomes than those without them (Foot and Ankle Outcome Score, 81.2 vs 92.1; P = .009). CONCLUSIONS: Ankle arthroscopy performed concomitantly with ankle ORIF is a useful tool in diagnosing chondral injuries. Chondral lesions are common with ankle fractures. An ankle with a dislocation at presentation or a syndesmotic injury may be more likely to present with a chondral lesion and should thus prompt evaluation. The presence of a talar chondral injury may be associated with a negative impact on clinical outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Treatment of Osteochondral Lesions of the Talus Using Juvenile Articular Cartilage Allograft and Autologous Bone Marrow Aspirate Concentration.

Juvenile allogenic chondrocyte implantation (JACI; DeNovo NT Natural Tissue Graft®; Zimmer, Warsaw, IN) with autologous bone marrow aspirate concentrate (BMAC) is a relatively new all-arthroscopic procedure for treating critical-size osteochondral lesions (OCLs) of the talus. Few studies have investigated the clinical and radiographic outcomes of this procedure. We collected the clinical and radiographic outcomes of patients who had undergone JACI-BMAC for talar OCLs to assess treatment efficacy and cartilage repair tissue quality using magnetic resonance imaging (MRI). Forty-six patients with critical-size OCLs (≥6 mm widest diameter) received JACI-BMAC from 2012 to 2014. We performed a retrospective medical record review and assessed the functional outcomes pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short-Form 12-item general health questionnaire. MRI was performed preoperatively and at 12 and 24 months postoperatively. Cartilage morphology was evaluated on postoperative MRI scans using the magnetic resonance observation of cartilage tissue (MOCART) score. The pre- to postoperative changes and relationships between outcomes and lesion size, bone grafting, lesion location, instability, hypertrophy, and MOCART scores were analyzed. Overall, the mean questionnaire scores improved significantly, with almost every FAOS subscale showing significant improvement postoperatively. Concurrent instability resulted in more changes that were statistically significant. The use of bone grafting and the presence of hypertrophy did not result in statistically significant changes in the outcomes. Factors associated with outcomes were lesion size and hypertrophy. Increasing lesion size was associated with decreased FAOS quality of life subscale and hypertrophy correlating with changes in the pain subscale. Of the 46 patients, 22 had undergone postoperative MRI scans that were scored. The average MOCART score was 46.8. Most patients demonstrated a persistent bone marrow edema pattern and hypertrophy of the reparative cartilage. Juvenile articular cartilage implantation of the DeNovo NT allograft and BMAC resulted in improved functional outcome scores; however, the reparative tissue still exhibited fibrocartilage composition radiographically. Further studies are needed to investigate the long-term outcomes and determine the superiority of the arthroscopic DeNovo procedure compared with microfracture and other cartilage resurfacing procedures.

The Disappearing Phalanx: A Case Report of a Vascular Tumor of the Toe.

We report a unique case of an epithelioid hemangioma of the third middle phalanx in which the lesion replaced the phalanx, became symptomatic, and then required resection, bone grafting, and joint arthroplasty. To the best of our knowledge, this is the first report of an epithelioid hemangioma in the toe that was treated using this approach.

Bracing versus casting in ankle fractures.

Casting and splinting techniques for treating patients with fractures have been used for centuries. Functional bracing after ankle fracture has recently been utilized in an effort to avoid the atrophy and stiffness sometimes associated with casting; functional bracing allows for early mobilization of the ankle joint during recovery. Our review investigated the published literature comparing bracing with casting after ankle fracture. Studies examining both operatively and nonoperatively treated ankle fractures were included. There is minimal evidence supporting the use of functional bracing over cast immobilization to improve functional outcome, range of motion, swelling, or post-traumatic arthrosis after ankle fracture in the long term. The primary benefits of functional bracing are the potential to return to work earlier and bracing may facilitate activities of daily living, such as bathing and dressing. In addition, there may be a decreased patient risk of developing deep vein thrombosis due to immobilization. However, there is an increased risk of wound infection when using a brace after open reduction and internal fixation of an unstable ankle fracture. Functional bracing can be used for treating stable and postoperative ankle fractures in compliant patients to potentially expedite and facilitate the recovery process.

Strength and Functional Outcomes Following Achilles Tendon Reconstruction With Hamstring Tendon Autograft Augmentation.

BACKGROUND: The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes. METHODS: Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected. RESULTS: For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement. CONCLUSION: Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity. LEVEL OF EVIDENCE: Level IV, case series.

Synthetic playing surfaces and athlete health.

Synthetic playing surfaces have evolved considerably since their introduction in the 1960s. Today, third-generation turf is routinely installed in professional, collegiate, and community settings. Proponents of artificial surfaces tout their versatility and durability in a variety of climates. However, the health and injury ramifications have yet to be clearly defined. Musculoskeletal injury is largely affected by the shoe-playing surface interface. However, conclusive statements cannot be made regarding the risk of certain shoe-playing surface combinations because of the variety of additional factors, such as weather conditions, shoe wear, and field wear. Historically, clinical studies have indicated that higher injury rates occur on artificial turf than on natural surfaces. This conclusion is backed by robust biomechanical data that suggest that torque and strain may be greater on artificial surfaces than on natural grass. Recent data on professional athletes suggest that elite athletes may sustain injuries at increased rates on the newer surfaces. However, these surfaces remain attractive to athletes and administrators alike because of their durability, relative ease of maintenance, and multiuse potential.

The arthroscopic "subdeltoid approach" to the anterior shoulder.

Surgical management of shoulder pathologies has evolved tremendously during the past 3 decades, such that many lesions previously treated with open techniques are now addressed arthroscopically. Despite this movement, many surgeons and outcome studies continue to prefer open repairs as the gold standard, criticizing--with good reason--the reliability, reproducibility, and extended operative time of arthroscopic repairs, particularly with respect to anterior stabilizations and subscapularis repairs. With this in mind, we present the arthroscopic "subdeltoid approach," a novel standardized exposure technique for extracompartmental anterior shoulder arthroscopy. We define the subdeltoid space as the fascial plane bound superiorly by the acromion and coracoacromial ligament, medially by the coracoid and the conjoint tendon, inferiorly by the musculotendinous insertion of the pectoralis major to the humerus, and laterally by the lateral border of the humerus. When coupled with existing arthroscopic tools, this space dramatically enhances our ability to apply open techniques to some of the more challenging anterior shoulder pathoanatomy and expand the indications and efficacy of arthroscopy. This exposure technique has been used in more than 300 cases during the past decade to treat a myriad of shoulder pathologies, without any longstanding postoperative complications.

A review of synthetic playing surfaces, the shoe-surface interface, and lower extremity injuries in athletes.

The evolution of synthetic playing surfaces began in the 1960s and has had an impact on field use, shoe-surface dynamics, and the incidence of sports-related injuries. Modern third-generation turfs are being installed in recreational facilities and professional stadiums worldwide. Currently, > two-thirds of National Football League teams, > 100 National Collegiate Athletic Association Division I football teams, and > 1000 high schools in the United States have installed synthetic playing surfaces. Those in favor of such playing surfaces note their unique combination of versatility and durability; they can be used in both ideal and inclement weather conditions. However, the more widespread installation and use of these surfaces have raised questions and concerns regarding the impact of artificial turf on the type and severity of sports-related injuries. There appears to be no question that the shoe-surface interface has a significant impact on such injuries. Independent variables such as weather conditions, contact versus noncontact sport, shoe design, and field wear complicate many of the results reported in the literature, thereby preventing an accurate assessment of the true risk(s) associated with certain shoe-surface combinations. Historically, studies suggest that artificial turf is associated with a higher incidence of injury. Furthermore, reliable biomechanical data suggest that both the torque and strain experienced by lower extremity joints generated by artificial surfaces may be more than those generated by natural grass fields. Recent data from the National Football League support this theory and suggest that elite athletes may sustain more injuries, even when playing on the newer artificial surfaces. By contrast, some reports based on data collected from lower-level athletes suggest that artificial turf may protect against injury. This review discusses the history of artificial surfaces, the biomechanics of the shoe-surface interface, and some common turf-related lower extremity injuries.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

BACKGROUND: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. PURPOSE: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. STUDY DESIGN: Descriptive laboratory study. METHODS: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. RESULTS: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). CONCLUSION: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. CLINICAL RELEVANCE: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Kinematic Analysis of Sequential Partial-Midfoot Arthrodesis in Simulated Gait Cadaver Model.

BACKGROUND: Primary tarsometatarsal (TMT) arthrodesis is gaining popularity in the surgical treatment of Lisfranc injuries. However, few studies have evaluated biomechanical effects of TMT arthrodesis. The purpose of this study was to compare the kinematics of joints adjacent to the midfoot during simulations of stance before and after sequential arthrodesis of the first, second, and third TMT joints. METHODS: Ten midtibia cadaveric specimens were loaded on a 6-degree-of-freedom robotic gait simulator. Motion capture cameras were used to collect joint kinematics throughout simulations of the stance phase. Simulations were performed for the intact and sequential arthrodesis conditions of the first, second, and third TMT joints. The sagittal, coronal, and transverse plane rotational kinematics of the intact condition were compared to kinematics after each sequential arthrodesis condition. RESULTS: Sequential arthrodesis of the first and second TMT joints had no significant effect on ankle, subtalar, talonavicular, and first metatarsophalangeal joint motion during simulated stance when compared to the intact condition. In contrast, inclusion of the third TMT joint into the sequential arthrodesis significantly increased subtalar inversion (P = .032) in late stance and increased range of motion values in the ankle and subtalar joints by 2.1 degrees (P = .009) and 2.8 degrees (P = .014), respectively. CONCLUSION: Sequential primary arthrodesis induced changes to ankle and adjacent joint kinematics during stance phase simulations, although not until the third TMT joint was included into the primary arthrodesis. The significant changes to kinematics due to arthrodesis of the first, second, and third TMT joints were small. CLINICAL RELEVANCE: The minimal changes in sagittal, coronal, and transverse plane rotational kinematics support the positive clinical outcomes reported in the literature for primary partial arthrodesis of Lisfranc injuries. The inclusion of the third TMT joint should be done judiciously.

Augmenting Osteochondral Autograft Transplantation and Bone Marrow Aspirate Concentrate with Particulate Cartilage Extracellular Matrix Is Associated With Improved Outcomes.

BACKGROUND: Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT. METHODS: Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups. RESULTS: Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs -3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina (P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02). CONCLUSION: The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

Orthosis and Foot Structure Affect the Fifth Metatarsal Principal Strains During Simulated Level Walking.

BACKGROUND: Fractures of the proximal fifth metatarsal bone are common injuries in elite athletes and are associated with high rates of delayed union and nonunion. Structural features of the foot may increase fracture risk in some individuals, emphasizing the need for intervention strategies to prevent fracture. Although orthotic devices have shown promise in reducing fractures of the fifth metatarsal bone, the effect of orthosis on fifth metatarsal strains is not well understood. PURPOSE: To quantify the effects of different foot orthotic constructs on principal tensile strains in the proximal fifth metatarsal bone during cadaveric simulations of level walking. An additional purpose was to investigate the relationships between structural features of the foot and corresponding strains on the fifth metatarsal bone during level walking. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 10 midtibial cadaveric specimens were attached to a 6 degrees of freedom robotic gait simulator. Strain gauges were placed at the metaphyseal-diaphyseal junction (zone II) and the proximal diaphysis (zone III) during level walking simulations using 11 different foot orthotic configurations. Images of each specimen were used to measure structural features of the foot in an axially loaded position. The peak tensile strains were measured and reported relative to the sneaker-only condition for each orthotic condition and orthotic-specific association between structural features and principal strains of both zones. RESULTS: In total, 2 of the 11 orthotic conditions significantly reduced strain relative to the sneaker-only condition in zone II. Further, 6 orthotic conditions significantly reduced strain relative to the sneaker-only condition in zone III. Increased zone II principal strain incurred during level walking in the sneaker-only condition showed a significant association with increases in the Meary's angle. Changes in zone III principal strain relative to the sneaker-only condition were significantly associated with increases in the Meary's angle and fourth-fifth intermetatarsal angle. CONCLUSION: The use of orthotic devices reduced principal strain relative to the condition of a sneaker without any orthosis in zone II and zone III. The ability to reduce strain relative to the sneaker-only condition in zone III was indicated by increasing values of the Meary's angle and levels of the fourth-fifth intermetatarsal angle. CLINICAL RELEVANCE: Clinicians can use characteristics of foot structure to determine the proper foot orthosis to potentially reduce stress fracture risk in high-risk individuals.

Lateral Ligament Reconstruction With Hamstring Graft for Ankle Instability: Outcomes for Primary and Revision Cases.

BACKGROUND: Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device. RESULTS: A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (-4.94° vs -7.03°; P = .415). CONCLUSION: Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

Navicular Stress Fractures.

Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.

Comparison of Functional and Radiographic Outcomes of Talar Osteochondral Lesions Repaired With Micronized Allogenic Cartilage Extracellular Matrix and Bone Marrow Aspirate Concentrate vs Microfracture.

BACKGROUND: Microfracture (MF) has been used historically to treat osteochondral lesions of the talus (OLTs), with favorable outcomes reported in approximately 80% to 85% of cases. However, MF repairs have been shown to degrade over time at long-term follow-up, suggesting that further study into optimal OLT treatment is warranted. The use of adjuvant extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) has not been extensively evaluated in the literature. We present a comparison of patient-reported and radiographic outcomes following ECM-BMAC repair vs traditional MF. METHODS: Patients who underwent MF (n = 67) or ECM-BMAC (n = 62) treatment for an OLT were identified and their charts were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) was evaluated and patient-reported outcome scores, either Foot and Ankle Outcome Scores (FAOS) or Patient-Reported Measurement Information System (PROMIS) scores, were collected. MRIs were scored by a radiologist, fellowship trained in musculoskeletal radiology, using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) system. Radiographic and clinical outcomes were compared between groups. RESULTS: On average, patients treated with ECM-BMAC demonstrated a higher total MOCART score compared to the MF group (73 ± SD 11.5 vs 54.0 ± 24.1; P = .0015). ECM-BMAC patients also had significantly better scores for the Infill, Integration, and Signal MOCART subcategories. Last, patients treated with ECM-BMAC had a lower rate of revision compared to those treated with MF (4.8% vs 20.9%; P = .007). FAOS scores were compared between groups, with no significant differences observed. CONCLUSION: When comparing outcomes between patients treated for an OLT with ECM-BMAC vs traditional MF, we observed superior MRI results for ECM-BMAC patients. The rate of revision surgery was higher for MF patients, although patient-reported outcomes were similar between groups. The use of ECM-BMAC as an adjuvant therapy in the treatment of OLTs may result in improved reparative tissue when compared to MF. LEVEL OF EVIDENCE: Level III, comparative series.

Association Between Baseline PROMIS Scores, Patient-Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery.

BACKGROUND: Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery. METHODS: Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient-surgeon communication and musculoskeletal health literacy were assessed via the modified Patients' Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively. RESULTS: Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function (P = .003), Pain Interference (P = .001), Pain Intensity (P = .009), Global Physical Health (P < .001), and Depression (P = .009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above (P ≤ .003) and with worse Global Mental Health (P = .003). Patient perceptions of higher surgeons' partnership building were associated with a greater number of patient than surgeon expectations (P = .017). There were no associations found between musculoskeletal health literacy and differences in expectations. CONCLUSION: Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery. LEVEL OF EVIDENCE: Level II, prospective comparative series.

Clinical and Patient-Reported Outcomes Following Peroneus Brevis Reconstruction With Hamstring Tendon Autograft.

BACKGROUND: Peroneal tendon injuries are a common cause of lateral ankle pain and instability. While the use of hamstring autograft has been proposed as a viable surgical option for peroneus brevis reconstruction, reported outcomes with this technique are limited in the literature. We present patient-reported and clinical outcomes for patients who underwent peroneus brevis reconstruction with hamstring autograft. METHODS: Thirty-one patients were retrospectively identified who underwent a procedure including peroneus brevis reconstruction with hamstring autograft for peroneal tendinopathy between February 2016 and May 2019. All patients who had a peroneus brevis reconstruction were included, and all concomitant procedures were noted. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were prospectively collected preoperatively and at a minimum of 1 year postoperatively (mean, 24.3; range, 12-52.7) months. Retrospective chart review was performed to evaluate the incidence of postoperative complications and reoperations. RESULTS: When evaluating pre- and postoperative patient-reported outcome surveys (n = 26; 84%), on average, patients reported improvement in every PROMIS domain evaluated, with significant improvement in Physical Function (+5.99; P = .006), Pain Interference (-8.11; P < .001), Pain Intensity (-9.02; P < .001), and Global Physical Health (+7.29; P = .001). Three patients reported persistent pain at a minimum of 1 year postoperatively, of whom 2 required reoperation. No patient reported persistent pain or discomfort at the harvest site of the hamstring autograft. CONCLUSION: Patients undergoing peroneus brevis reconstruction with hamstring autograft experienced clinically significant improvement in patient-reported and clinical outcomes. Few postoperative complications were observed, and patients reported improvements across all patient-reported outcome domains, with significant improvements for pain and function domains. Reconstruction with hamstring autograft represents a viable surgical option in the setting of peroneal tendinitis or tears. LEVEL OF EVIDENCE: Level IV, case series.

Comparison of Clinical and Radiographic Outcomes Following Arthroscopic Debridement With Extracellular Matrix Augmentation and Osteochondral Autograft Transplantation for Medium-Size Osteochondral Lesions of the Talus.

BACKGROUND: Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm2, above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs). METHODS: Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group (P = .38). RESULTS: Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups. CONCLUSION: The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Modified Lapidus vs Scarf Osteotomy Outcomes for Treatment of Hallux Valgus Deformity.

BACKGROUND: The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy. METHODS: This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders. RESULTS: A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA; <9 degrees) was 25% lower (P = .04) with the scarf osteotomy compared with the Lapidus procedure. CONCLUSION: Although the modified Lapidus procedure led to a higher probability of achieving a normal IMA, both procedures yielded similar improvements in 1-year patient-reported outcome measures. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair.

BACKGROUND: There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. METHODS: A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution's registry. Demographics and complications were recorded. RESULTS: PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). CONCLUSION: Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. LEVEL OF EVIDENCE: Level III, retrospective cohort study.