Ten-Year Survival Rate of 82% in 262 Cases of Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

BACKGROUND: The long-term sustainability of arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT) remains a matter of debate. The primary aim of the present study was to assess the 10-year survival free from revision in ankles that had undergone arthroscopic BMS for an OLT. The secondary aim was to evaluate the influence of baseline patient and lesion characteristics on survival. METHODS: Patients who underwent arthroscopic BMS for a symptomatic OLT and had a minimum follow-up of 10 years were included to assess procedure survival. The primary outcome, the 10-year cumulative survival rate, was analyzed by the Kaplan-Meier survival method. Secondary outcomes were the median time to revision and the effects of baseline factors (lesion size, primary or non-primary lesion type, preoperative cysts, and obesity as defined by a body mass index [BMI] of ≥30 kg/m2) on survival, analyzed with a Cox regression model and reported using hazard ratios (HRs). RESULTS: The 262 included patients had a mean follow-up of 15.3 ± 4.8 years. The 10-year cumulative survival rate of the arthroscopic BMS procedures was 82% (95% confidence interval [CI]: 77% to 87%). At 15 years of follow-up, the cumulative survival rate was 82% (95% CI: 76% to 86%). The median time to revision was 2.4 years (interquartile range: 1.3 to 5.1 years). Of the baseline factors, obesity (HR: 3.0 [95% CI: 1.44 to 6.43], p < 0.01) was associated with decreased survival. Lesion size (HR: 0.9 [95% CI: 0.5 to 1.8], p = 0.8), non-primary lesion type (HR: 1.8 [95% CI: 0.9 to 3.4], p = 0.1), and the presence of preoperative cysts (HR: 1.0 [95% CI: 0.6 to 1.9], p = 0.9) were not significantly associated with survival. CONCLUSIONS: At a minimum follow-up of 10 years, the survival rate of arthroscopic BMS for OLT was 82%. At 15 and 20 years of follow-up, survival appeared to remain stable. Obesity (BMI ≥ 30 kg/m2) was associated with a higher likelihood of revision surgery. This risk factor should be incorporated into the treatment algorithm for OLT when counseling patients regarding surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Wide-Awake Needle Arthroscopy of the Anterior Ankle: A Standardized Approach.

Over the years, possibilities in ankle arthroscopy have evolved from diagnostic inspection to complex interventional procedures. Further innovation may come from needle arthroscopy, which has improved substantially in image quality in recent years and can now be used for interventional procedures as well. We here present a standardized approach to wide-awake needle arthroscopy of the anterior ankle under local anesthesia. As new needle arthroscopic procedures of the ankle arise, this approach serves to help ensure safe, uniform, and beneficial adoption of this emergent technique.

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.

Ankle Cartilage: Chondral and Osteochondral Lesions: A Further Dive into the Incidence, Terminology, and the Cartilage Cascade.

The current concepts thoroughly highlight the ankle cartilage cascade focusing on the different stages and the different etiologic factors that can introduce a patient into the cascade. Moreover, the authors will provide the reader with a comprehensive overview of the types of lesions that may present as symptomatic, asymptomatic, and dangerous for progression into osteoarthritis, and the authors supply the reader with considerations and directions for future clinical implications and scientific endeavors.

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options. METHODS: PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated. RESULTS: Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001). CONCLUSIONS: Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: Uniformity of reporting is a requisite to be able to compare results of clinical studies on the treatment of osteochondral lesions of the talus (OLT). The primary aim of this study was to evaluate the frequency and quality of reporting of size, morphology, and location of OLTs. DESIGN: A literature search was performed from 1996 to 2023 to identify clinical studies on surgical treatment of OLTs. Screening was performed by 2 reviewers, who subsequently graded the quality using the methodological index for non-randomized studies (MINORS). The primary outcome was the frequency and qualitative assessment of reporting of size, morphology, and location. RESULTS: Of 3,074 articles, 262 articles were included. This comprised a total of 11,785 patients. Size was reported in 248 (95%) of the articles and was described with a measure for surface area in 83%, however, in 56%, definition of measurement is unknown. Intraclass coefficient (ICC) value for the reliability of size measurement was 0.94 for computed tomography (CT) scan and 0.87 for MRI scan. Morphology was reported in 172 (66%) of the articles and using a classification system in 23% of the studies. Location was reported in 220 (84%) of the studies. CONCLUSION: No consensus was found on the reporting of morphology, with non-validated classification systems and different terminologies used. For location, reporting in 9 zones is underreported. Size was well reported and measurements are more reliable for CT compared with MRI. As these prognostic factors guide clinical decision-making, we advocate the development of a standardized and validated OLT classification to reach uniform reporting in literature. LEVEL OF EVIDENCE: Level III, systematic review.

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.

Higher Age is Associated with Lower Likelihood of Conversion to Surgery after Primary Nonoperative Treatment for Osteochondral Lesions of the Talus.

INTRODUCTION: The first line of treatment for osteochondral lesions of the talus (OLT) is nonoperative. To date, there is limited evidence on risk factors that may influence conversion to surgery after primary nonoperative treatment for symptomatic OLTs. The aim of this study was therefore to identify risk factors for conversion to surgery after initial nonoperative treatment of OLTs. METHODS: For this cohort study, patients with a primary OLT who were nonoperatively treated for at least 6 months between 1990 and 2020 were included. Univariable Cox regression analysis, resulting in hazard ratios (HRs), on the primary outcome (i.e. conversion to surgery after initial nonoperative treatment) was performed for potential risk factors. The following risk factors were analyzed: gender, age, body mass index (BMI), numeric rating scale (NRS), lesion size (depth, sagittal length, coronal length, volume, surface), lesion morphology (presence of fragments and presence of cysts), lesion location (medial/central/lateral), congruency of the ankle joint and trauma in history. Data imputation was conducted according to the multiple data principle with pooling. RESULTS: Forty-two patients with primary OLTs were included in this study: 23 (55%) males and 19 (45%) females with a mean age of 39.1 (SD: 14.2). The median overall follow-up time was 66 months (range: 7-188). Around 23% of the patients had a conversion to surgery at the median observation time. The Kaplan-Meier analysis revealed a survival rate of 93% (95% confidence interval [CI]:84-100), 90% (95% CI: 81-99), and 77% (95% CI: 63-91) at 1, 2, and 5 years after the initiation of treatment, respectively. After performing the COX regression analysis, age was the sole risk factor significantly associated with conversion to surgery with an HR of 0.93 (95% CI: 0.87-0.99). The different HRs for all other risk factors were as follows: gender: 0.33 (95% CI: 0.08-1.34), BMI: 0.87 (95% CI 0.76-1.01), depth: 0.97 (95% CI: 0.79-1.18), coronal length: 1.19 (95% CI: 0.97-1.44), sagittal length: 0.98 (95% CI: 0.87-1.12), surface area: 1.17 (95% CI: 0.41-3.31), volume: 0.96 (95% CI: 0.24-3.91), presence of fragments: 4.17 (95% CI: 0.84-20.61). CONCLUSION: For primary OLTs, 77% of the patients were successfully treated nonoperatively at a median follow-up of 66 months without the need for a surgical intervention. Survival rates of 93%, 90%, and 77% were found at 1, 2, and 5 years after the initiation of treatment, respectively. We found that a higher age at the moment of diagnosis was significantly associated with a lower likelihood of conversion to surgery with a 7% decrease of likelihood each year the patient is older at the moment of diagnosis. The findings of this study are clinically relevant as it ameliorates the quality of the shared decision-making process between the patient and the treating team as we can advise OLT patients at a higher age with tolerable symptomatology that there is a relatively lower risk of conversion to surgery.

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.

Back in Action: High Return to Pre-Injury Level of Sports after Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the First Metatarsophalangeal (MTP-1) Joint.

OBJECTIVE: The primary aim was to assess the return to sports outcomes of patients with symptomatic osteochondral lesions (OCLs) to the first metatarsophalangeal (MTP-1) joint treated by arthroscopic bone marrow stimulation (BMS). Secondary aims were to present patient-reported outcome measures (PROMs) on pain scores as well as surgery-related complications or reoperations to the MTP-1 joint. DESIGN: All patients with MTP-1 OCLs treated by arthroscopic BMS with a minimum follow-up of 12 months were included. Outcomes included return to sports and work outcomes, satisfaction outcomes with the performed treatment, PROMs, as well as postoperative complications and reoperations. Medical records were screened by 2 independent reviewers and patients were contacted by phone to partake in an in-depth interview. Complications, reoperations, and revision surgeries were additionally assessed. RESULTS: Nine patients (median age: 22 years with interquartile range (IQR) 20-29 years) were included with a median follow-up time of 47 (IQR: 23-92) months. Six (86%) out of 7 patients who participated in sports preoperatively returned to sports at any level at a median of 4 (IQR: 2.6-5.8) months. Five patients (71%) returned to pre-injury level of sport and eventually returned to performance at a median of 4 (IQR 2.8-7.5) and 8 (IQR: 4.0-10.5) months, respectively. The median Numeric Rating Scale for pain during walking was 1 (IQR 0-2.5) and all (100%) patients were able to return to work at a median of 4 (IQR: 2-17) weeks. Eighty-nine percent of the patients were very or fairly satisfied with the result of their treatment. No complications, reoperations, or revision surgeries were reported. CONCLUSIONS: Arthroscopic BMS for patients with symptomatic OCLs to the MTP-1 joint can be considered safe and yields an 86% return to sport at any level and a 71% return to pre-injury and performance level, with good clinical, return to work, as well as satisfaction outcomes.

Prospective Outcomes of a Biological Resurfacing Arthroplasty with Fascia Lata Autograft (BioJoint) for the Treatment of Osteoarthritis of the Midtarsal Joint Complex.

OBJECTIVE: To determine the clinical, safety, and radiological outcomes after biological resurfacing arthroplasty for the treatment of osteoarthritis (OA) of one or more joints of the midtarsal joint complex. DESIGN: All prospectively followed patients with OA to one of or multiple joints of the midtarsal joint complex who were operated with a biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) were included. A total of 7 patients were included (5 males, 2 females), with a median age of 52 (interquartile range [IQR] 44-55) years. The primary outcome was the Numeric Rating Scale (NRS) for pain during walking 2 years postoperatively. Range of motion (ROM), revision rates, and complications were assessed. A postoperative MRI scan was performed to assess progression of OA, graft position and ingrowth, and the degree of bone marrow edema. RESULTS: There was a 100% follow-up of the patients (median follow-up: 33 [IQR 26-33] months). The NRS during walking improved from 6 preoperatively to 2 at 2 years postoperatively (P < 0.05). There were no reoperations nor severe complications. The limitations in the ROM remained limited in the majority of the cases. MRI at 2 years of follow-up showed no progression of OA, reduced bone marrow edema, and no loosening of the grafts. CONCLUSION: Biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) for OA to one or more joints in the midtarsal joint complex showed clinically relevant pain reduction during walking, improvement in clinical and radiological outcomes, and proved to be safe and durable.

Osteochondral Lesions of the Subtalar Joint: Clinical Outcomes in 11 Patients.

OBJECTIVE: The purpose of this retrospective case series was to evaluate clinical outcomes following both conservative treatment and arthroscopic bone marrow stimulation (BMS) for the management of symptomatic subtalar osteochondral lesions (OCLs). DESIGN: All symptomatic subtalar OCLs with a minimum of 12 months follow-up having undergone either a conservative management or arthroscopic procedure were included. Patient-reported outcomes were collected via questionnaires consisting of the Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS) of pain in rest, during walking, during stair climbing, and during running. In addition, return to sports data, return to work data, reoperations, and complications were collected and assessed. In total, 11 patients across 2 academic institutions were included (3 males, 8 females). The median age was 43 years (interquartile range [IQR]: 32-53). RESULTS: All patients underwent conservative treatment first; in addition, 9 patients underwent subtalar arthroscopic debridement with or without BMS. The median follow-up time was 15 months (IQR: 14-100). In the surgically treated group, the median NRS scores were 2 (IQR: 1-3) during rest, 3 (IQR: 2-4) during walking, 4 (IQR: 4-5) during stair climbing, 5 (IQR: 4-5) during running and the median FAOS score at final follow-up was 74 (IQR: 65-83). In the conservatively treated patients, the median NRS scores were all 0 (IQR: 0-0) and the median FAOS scores were 90 (IQR: 85-94). In the group of surgical treated patients, 4 were able to return to the same level of sports, 2 returned to a lower level of sports. Both conservatively treated patients returned to the sport and the same level of prior participation. All patients except one in the surgical group returned to work. CONCLUSIONS: This retrospective case series demonstrated that a high number of patients converted to surgery after initial conservative treatment. In addition, debridement and BMS show good clinical outcomes for the management of symptomatic subtalar OCLs at short-term follow-up. No complications nor secondary surgical procedures were noted in the surgically treated group. The high rate of failure of conservative treatment suggests that surgical intervention for symptomatic subtalar OCLs can be the primary treatment strategy; however, further research is warranted in light of the small number of patients.

Open lift-drill-fill-fix for medial osteochondral lesions of the talus: surgical technique.

OBJECTIVE: Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy. INDICATIONS: Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment. CONTRAINDICATIONS: Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered. SURGICAL TECHNIQUE: The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws. POSTOPERATIVE MANAGEMENT: Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of a physical therapist.

Evidence-Based Treatment Algorithm for Freiberg Disease.

Freiberg disease is a type of osteonecrosis of the metatarsal head that predominantly occurs in young females and adolescents, although it may occur at any age. The pathophysiology is multifactorial and may involve trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. The most typical location is the second metatarsal head, but Freiberg disease may also occur in other lesser toes. Nonoperative treatment is best applied in the early stage of the disease; if this is ineffective, surgical treatment is recommended. Currently available surgical procedures include debridement, osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, and metatarsal shortening arthroplasty. In this article, we propose a treatment algorithm for Freiberg disease based on the current literature and expert opinion.

Talonavicular Osteochondral Lesions: Surgical Technique and Clinical Outcomes from the Boston and Amsterdam Perspectives.

PURPOSE: The primary purpose of the present study was to assess the patient-reported outcomes, complications, and reoperation rate of patient who underwent surgical treatment for symptomatic osteochondral lesions of the talonavicular joint (TNJ). METHODS: Patients undergoing surgical treatment for symptomatic osteochondral lesions of the TNJ with a minimum of 12-month follow-up were included. Outcomes included clinical patient-reported outcome measures (PROMs), return to sports and work outcomes, and postoperative complications or reoperations. Medical records were screened by 2 independent reviewers. Patients were contacted by phone and underwent an in-depth interview. Additionally, operative techniques for both arthroscopic and open surgical approaches for treating TNJ osteochondral lesions were described. DESIGN: Retrospective Case Series (Level IV) and Surgical Technique. RESULTS: A total of 7 patients were included with a final follow-up time of 25.4 (SD: 15.2) months follow-up. PROMs were considered satisfactory for 5 out of 7 patients, 6 out of 7 patients returned to any level of sports at a mean of 3.7 (SD: 4.2) months, and 5 out of 6 patients returned to preinjury level of sports at a mean of 14 (SD: 7.5) months. All patients returned to work at an average of 5.4 (SD: 3.6) weeks. No complications or reoperations after index surgery were reported. CONCLUSION: Surgical treatment of TNJ osteochondral lesions is a feasible procedure that may offer successful clinical, sport, and work outcomes in the majority of patients. Both open and arthroscopic surgical treatments are available and can be considered in a patient-specific treatment plan.

Cuboid Cobbles Hinder Elite Youth Football Player.

We describe an elite youth football player who developed lateral foot pain of previously unknown origin. A thorough patient history and physical examination as well as an in-depth presentation of radiographic findings on Computed tomography (CT) and Magnetic Resonance Imaging (MRI) scan were described. Through this combination, the puzzle was resolved and a rare peroneus longus tendinopathy due to bony spurs in the cuboid groove was diagnosed. A peroneus longus exploration, release and reduction of the cuboidal bone spurs was performed and intensive rehabilitation phase followed. The patient successfully returned to performance and set a career in professional football.

Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta-analysis.

PURPOSE: Bone marrow aspirate concentrate can be used as an additive to surgical treatment of osteochondral lesions of the talus. This systematic literature review aims to study the effect of the additional use of bone marrow aspirate concentrate on top of a surgical treatment for osteochondral lesions of the talus on clinical outcomes compared to surgical treatment alone. METHODS: An online literature search was conducted using PubMed (Medline), Embase (Ovid), and the Cochrane library for all studies comparing a surgical intervention with bone marrow aspirate concentrate, with a surgical intervention without bone marrow aspirate concentrate. The methodological quality was rated according to the methodological index for non-randomised studies checklist. The primary outcome measure were clinical outcomes. Secondary outcome measures consisted of revision rate, complication rate, radiographic outcome measures and histological analyses. Subgroups were created based on type of surgical intervention used in the studies. If multiple articles were included in a subgroup, a linear random-effects model was used to compare the bone marrow aspirate concentrate-augmented group with the control group. RESULTS: Out of 1006 studies found, eight studies with a total of 718 patients were included. The methodological quality, assessed according to the methodological index for non-randomised studies checklist, was weak. A significantly better functional outcome measures (p < 0.05) was found in the subgroup treated with bone marrow stimulation + bone marrow aspirate concentrate compared to the group treated with bone marrow stimulation alone, based on three non-blinded studies. No significant differences regarding clinical outcomes were found in the subgroups comparing matrix-induced autologous chondrocyte implantation with matrix-induced bone marrow aspirate concentrate, osteochondral autologous transplantation alone with osteochondral autologous transplantation + bone marrow aspirate concentrate and autologous matrix-induced chondrogenesis plus peripheral blood concentrate vs. matrix-associated stem cell transplantation bone marrow aspirate concentrate. CONCLUSION: There is insufficient evidence to support a positive effect on clinical outcomes of bone marrow aspirate concentrate as an additive to surgical treatment of osteochondral lesions of the talus. However, based on the safety reports and initial results, sufficiently powered, patient- and researcher-blinded, prospective randomised controlled trials are justified and recommended. Until then, we advise not to implement a therapy (addition of bone marrow aspirate concentrate) without clinical evidence that justifies the additional costs involved. LEVEL OF EVIDENCE: Level III.

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.