Current and Emerging Techniques in Articular Cartilage Repair.

Osteochondral lesions (OCL) of the knee are a common pathology that can be challenging to address. Due to the innate characteristics of articular cartilage, OCLs generally do not heal in adults and often progress to involve the subchondral bone, ultimately resulting in the development of osteoarthritis. The goal of articular cartilage repair is to provide a long-lasting repair that replicates the biological and mechanical properties of articular cartilage, but there is no widely adopted technique that results in true pre-injury state hyaline cartilage. Current treatment modalities have seen reasonable clinical success, but significant limitations remain. Microfracture provides short-term benefit with a fibrocartilage-based repair. While osteochondral autograft or allograft and autologous chondrocyte implantation can be effective, each have their strengths and shortcomings. Emerging concepts in cartilage repair, including scaffold engineering and one stage cell-based options, are continually advancing. These have the benefits of reduced surgical morbidity and potentially improved integration with surrounding articular cartilage but have not yet reached widespread clinical application. Tissue engineering strategies and gene therapy have the potential to advance the field, however, they remain in the early stages. The current article reviews the structure and physiology of articular cartilage, the strengths and limitations of present treatment modalities, and the newer ongoing innovations that may change the way we approach osteochondral lesions and osteoarthritis.

Patient-reported hip pain and function are worse among elite Nordic ski athletes competing in ski jumping versus Nordic combined: a cross-sectional analysis.

OBJECTIVES: Nordic ski athletes are at increased risk of developing hip pain and dysfunction secondary to femoroacetabular impingement syndrome (FAIS), but it is unclear whether hip symptomatology differs between ski jumping (SJ) and Nordic combined (NC) athletes. The purpose of this study was to compare patient-reported hip pain and dysfunction between elite Nordic ski athletes participating in SJ versus NC. METHODS: A cross-sectional study was conducted involving SJ and NC athletes who competed at the international and U.S. national levels during the 2021-2022 season. Subjects were excluded if they had hip surgery within two years prior to enrollment. Subjects were asked to undergo diagnostic workups for FAIS, including physical examination and plain radiographic imaging. Subjects were asked to complete a survey that collected information on athletic and training history and to complete the hip disability and osteoarthritis outcome score (HOOS). Demographics, athletic/training history, and HOOS sub-scores were compared between the SJ and NC groups using the Student's t-test, Wilcoxon rank-sum test, or Fisher's exact test, as appropriate. p-values < 0.05 were considered significant. RESULTS: Twenty-four athletes (13 SJ, 11 NC) were included in the study. There were no statistically significant differences in age, sex, BMI, or age of menarche between the two groups (all p â€‹> â€‹0.05). There were also no statistically significant differences in the number of prior sports participated in, total hours of participation in prior sports, or total hours of training in Nordic specialization (all p â€‹> â€‹0.05). Among the 18 athletes who underwent physical examination (9 SJ, 9 NC), there were no statistically significant inter-group differences in hip range of motion or incidence of positive impingement tests (all p â€‹> â€‹0.05). Among the 19 athletes who underwent imaging (9 SJ, 10 NC), there were no statistically significant inter-group differences in the incidence of cam or pincer morphology in at least one hip (all p â€‹> â€‹0.05). SJ athletes had statistically significantly worse HOOS sub-scores for hip symptoms and stiffness, hip function in sports/recreational activities, and hip-related quality of life compared to NC athletes (all p â€‹< â€‹0.05). CONCLUSION: Elite SJ athletes have worse self-reported hip function compared to elite NC athletes, despite comparable demographics, athletic history, and duration of ski training. LEVEL OF EVIDENCE: IV.

The Use of Computer Navigation and Robotic Technology in Complex Total Hip Arthroplasty.

Computer assisted surgical (CAS) navigation and robotic-assisted total hip arthroplasty (THA) have the potential to improve the reproducibility of accurate component positioning and facilitate complex cases, including revision and preoperative deformity. Numerous studies, including multiple comparing technology with conventional THA control groups, suggest that CAS navigation may improve component accuracy in cases of deformity such as hip dysplasia and significant leg length discrepancy. Revision THA data is also encouraging but limited. The functional benefits compared to conventional techniques remain unclear. The evidence for robot-assisted THA in complex cases is more limited but also demonstrates utility. For complex cases, studies comparing results with conventional THA are not yet available. The limitations of these systems, including cost, operative time, learning curves, and possible complications, require further study. The available data for CAS navigation and robotic-assisted THA indicates that they may play a role in complex deformity and revision cases. Further high-quality randomized studies should be undertaken.

Characterization of pincer-type Hip impingement in professional women's ice hockey players.

OBJECTIVE: Femoroacetabular impingement (FAI) appears common in ice hockey, but there is a lack of data examining pincer-type impingement in women's ice hockey athletes. The objective of this study was to assess the prevalence of pincer-type impingement in National Women's Hockey League (NWHL) athletes. Our hypothesis was that there would be an increased prevalence of pincer impingement in these athletes. METHODS: Data were gathered for a team of NWHL players, and age, gender, and body mass index (BMI) matched controls were also retrospectively collected. All subjects were above 18 years of age. Control patients were excluded if they had undergone prior hip surgery, were greater than age 30, or had BMI greater than 35. Radiographs of both groups were assessed for lateral center edge angle (LCEA), Tönnis angle, and crossover sign. Tönnis angle <0 or LCEA >40 degrees was considered pincer morphology. An alpha angle >55 degrees was considered cam morphology. RESULTS: Thirty-seven NWHL players and 37 female controls were included. Overall 32% of the players had a pincer lesion in either hip based on LCEA, 8% had a Tönnis angle <0, and 22% had a crossover sign in either hip compared to 9%, 19%, and 13% for the controls, respectively. None of these findings were significantly different between the groups (p > 0.05). An alpha angle ≥55 degrees in either hip was found in 84% of players, but lateral Dunn images for alpha angle measurements were not available for the control group. CONCLUSIONS: Pincer-type morphology and crossover signs were present in a larger portion of NWHL players than has been reported in the general population, but these findings were not statistically different than in the control group. Cam-type morphology was even more prevalent in these athletes and may be related to age at menarche due impingement at the physis prior to closure.

Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

PURPOSE: The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. METHODS: A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n = 246), 10° superior glenoid augments (n = 97), or combined 10° superior/8° posterior glenoid augments (n = 177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. RESULTS: The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P < .05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P = .006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P < .001), nearly 33% less intraoperative blood loss volume (P < .001), approximately 3-fold less scapular notching (P < .01), and approximately 8-fold less adverse events requiring revision (P < .01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P = .003 and P = .013). CONCLUSION: The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.

The effect of specialization and level of competition on injury in elite male ice hockey players.

OBJECTIVE: Young players experience pressure to focus on ice hockey at the exclusion of other sports in order to improve chances of success. Early specialization in other sports has been associated with increased injury without the benefit of improved success. The objective of the current study was to investigate whether earlier specialization results in increased injury without higher rates of career success. This study also aimed to compare rates of injury in athletes at various levels of competition. METHODS: An original survey was issued to men's ice hockey players at the juniorA, collegiate, and professional levels. The survey consisted of 34 questions on various demographic, specialization, and injury variables. All participants were >18 years of age. RESULTS: The survey was completed by 101 athletes. The mean age at specialization was 13 (±4) overall and 14 (±3), 13 (±4), and 11(±4) for professional, collegiate, and junior players, respectively. There was no difference in age at specialization between each group and professional players did not specialize earlier than the remainder of the cohort as a whole (p > 0.05). There was no significant correlation between age at specialization and total injuries (p > 0.05). There was no difference in concussions causing missed play time between groups (p > 0.05) but professional players had more overall concussions and underwent more surgeries due to hockey-related injuries (p = 0.01). CONCLUSIONS: Specializing exclusively in ice hockey earlier in life was not associated with playing professionally. Both collegiate and professional players do not tend to specialize prior to age 12. Age at specialization was not associated with overall number of injuries. Professional players with longer careers appear to sustain more concussions and undergo more surgery.

The Use of Computer Navigation and Robotic Technology in Complex Total Knee Arthroplasty.

¼: The potential benefits of computer-assisted surgical (CAS) navigation and robotic total knee arthroplasty (TKA) systems, such as increased reliability of restoring the mechanical axis, fewer outliers, more rapid hospital discharge, less physical therapy requirements, decreased blood loss, and decreased revision rates, have led to their application not only in primary cases but also in complex cases such as preoperative deformity and revision. ¼: Early evidence demonstrates that CAS navigation may help to improve alignment in complex cases of femoral and tibial deformity and in cases of femoral bowing. ¼: Data regarding deformity correction with robotic systems are similar to CAS navigation with regard to alignment, but are more limited. There are also scant data regarding revision cases and cases of previous intramedullary canal instrumentation. ¼: Concerns remain regarding cost, learning curves, and operative times. There are potential long-term cost savings associated with a decrease in revisions and readmissions that require additional investigation. ¼: Early evidence for the use of these emerging technologies for deformity correction and revision cases is promising, but their impact on long-term functional outcomes remains to be demonstrated. Additional well-designed comparative studies are warranted.

Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration.

PURPOSE: Bone marrow concentrate (BMC) and platelet-rich plasma (PRP) are used extensively in regenerative medicine. The aim of this study was to determine differences in the cellular composition and cytokine concentrations of BMC and PRP and to compare two commercial BMC systems in the same patient cohort. METHODS: Patients (29) undergoing orthopaedic surgery were enrolled. Bone marrow aspirate (BMA) was processed to generate BMC from two commercial systems (BMC-A and BMC-B). Blood was obtained to make PRP utilizing the same system as BMC-A. Bone marrow-derived samples were cultured to measure colony-forming units, and flow cytometry was performed to assess mesenchymal stem cell (MSC) markers. Cellular concentrations were assessed for all samples. Catabolic cytokines and growth factors important for cartilage repair were measured using multiplex ELISA. RESULTS: Colony-forming units were increased in both BMCs compared to BMA (p < 0.0001). Surface markers were consistent with MSCs. Platelet counts were not significantly different between BMC-A and PRP, but there were differences in leucocyte concentrations. TGF-ß1 and PDGF were not different between BMC-A and PRP. IL-1ra concentrations were greater (p = 0.0018) in BMC-A samples (13,432 pg/mL) than in PRP (588 pg/mL). The IL-1ra/IL-1ß ratio in all BMC samples was above the value reported to inhibit IL-1ß. CONCLUSIONS: The bioactive factors examined in this study have differing clinical effects on musculoskeletal tissue. Differences in the cellular and cytokine composition between PRP and BMC and between BMC systems should be taken into consideration by the clinician when choosing a biologic for therapeutic application. LEVEL OF EVIDENCE: Clinical, Level II.

Platelet-Rich Plasma and Hyaluronic Acid Are Not Synergistic When Used as Biological Adjuncts with Autologous Osteochondral Transplantation.

Introduction Autologous osteochondral transplantation (AOT) is a treatment for osteochondral lesions with known concerns, including histological degradation of the graft and poor cartilage integration. Platelet-rich plasma (PRP) and hyaluronic acid (HA) have been described has having the potential to improve results. The aim of this study was to evaluate the effect of PRP and HA on AOT in a rabbit model. Methods Thirty-six rabbits underwent bilateral knee AOT treated with either the biological adjunct (PRP, n = 12; HA, n = 12; PRP + HA, n = 12) or saline (control). PRP and HA were administered as an intra-articular injection. The rabbits were euthanized at 3, 6, or 12 weeks postoperatively. The graft sections were assessed using the modified International Cartilage Repair Society (ICRS) scoring system. The results from the PRP alone group is from previously published data. Results The mean modified ICRS histological score for the PRP-treated group was higher than its control ( P = 0.002). The mean modified ICRS histological score for the HA-treated group showed no difference compared with its control ( P = 0.142). The mean modified ICRS histological score for the PRP + HA-treated group was higher than its control ( P = 0.006). There was no difference between the mean modified ICRS scores of the PRP- and the PRP + HA-treated grafts ( P = 0.445). Conclusion PRP may decrease graft degradation and improve chondral integration in an animal model. In this model, the addition of HA was not synergistic for the parameters assessed. LEVEL OF EVIDENCE: Basic science, Level V. CLINICAL RELEVANCE: PRP can be used as an adjunct to AOT, which may decrease graft degeneration and improve clinical outcomes. HA may not influence AOT.

Current concepts review: Arthroscopic treatment of anterior ankle impingement.

Anterior ankle impingement is a common cause of chronic ankle pain, particularly in athletic populations. Morris and McMurray provided the earliest descriptions of anterior impingement, coining the condition as "athlete's ankle" or "footballer's ankle". The pathology has since been a topic of considerable investigation and has been re-termed "anterior ankle impingement syndrome". Treatment with open surgery has provided good results historically, but at the price of significant complications. Advancements in ankle arthroscopy have decreased the risk of complication drastically and evidence in the literature indicates that anterior arthroscopy is an effective approach to treating osseous and soft tissue impingement. Effective clinical diagnosis and diagnostic imaging are critical for pre-surgical planning. Preoperative detection of anterior osteophytes has been correlated with outcomes. Factors such as joint space narrowing and large osteophytes may also influence outcomes. Therefore, a comprehensive understanding of diagnosis and surgical technique can influence patient outcomes, and patient expectations can be managed around prognostic indicators such as the presence of osteoarthritis. The purpose of this review is to discuss the etiology, clinical presentation, diagnosis, surgical technique, and postoperative rehabilitation of anteromedial and anterolateral anterior ankle impingement syndrome and to evaluate the evidence-based outcomes of arthroscopic management.

Magnetic Resonance Imaging Evidence of Postoperative Cyst Formation Does Not Appear to Affect Clinical Outcomes After Autologous Osteochondral Transplantation of the Talus.

PURPOSE: To identify potential cysts using magnetic resonance imaging (MRI) after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLTs) as well as to determine the effect of cysts on short-term clinical outcomes. METHODS: Eighty-nine MRI scans of 37 patients who had AOT for an OLT were evaluated. Radiographic variables examined included cyst presence, cyst location, bone edema, and cartilage integrity. Patient clinical variables recorded and examined for association with the presence of a cyst included gender, age, preoperative lesion size, size and number of osteochondral graft used, symptoms reported, and pre- and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) scores measured at final follow-up. RESULTS: Twenty-four patients (64.8%) had MRI evidence of cystic change after AOT for an OLT at a mean MRI follow-up time of 15 months after surgery (range 2-54). Patients with presence of a cyst after surgery were older (mean age, 42.7 years) than those without cysts (mean age, 32.7 years) (P = .041), and among patients with a cyst, older patients more often had involvement of the subchondral plate (57.3 v 36.7 years) (P < .001). No other variables associated with cyst formation had statistical significance. Mean patient FAOS scores increased from 50 (±19) preoperatively to 87 (±8) postoperatively. Mean SF-12 scores increased from 52 (±18) preoperatively to 85 (±6) postoperatively. Patients not identified as having a cyst had lower SF-12 (P = .028) and FAOS (P = .032) preoperative scores and more improvement in SF-12 (P = .006) and FAOS (P = .016) scores than patients with cysts. CONCLUSIONS: Postoperative cyst formation on MRI was found to be a common occurrence after AOT for OLT. Although increasing age was related to increased cyst prevalence, the clinical impact of cyst formation was not found to be significant at short-term follow-up. Continued long-term longitudinal follow-up of postoperative cysts is needed. LEVEL OF EVIDENCE: Level IV, prognostic case series.

The Effect of Different Bone Marrow Stimulation Techniques on Human Talar Subchondral Bone: A Micro-Computed Tomography Evaluation.

PURPOSE: To evaluate morphological alterations, microarchitectural disturbances, and the extent of bone marrow access to the subchondral bone marrow compartment using micro-computed tomography analysis in different bone marrow stimulation (BMS) techniques. METHODS: Nine zones in a 3 × 3 grid pattern were assigned to 5 cadaveric talar dome articular surfaces. A 1.00-mm microfracture awl (s.MFX), a 2.00-mm standard microfracture awl (l.MFX), or a 1.25-mm Kirschner wire (K-wire) drill hole was used to penetrate the subchondral bone in each grid zone. Subchondral bone holes and adjacent tissue areas were assessed by micro-computed tomography to analyze adjacent bone area destruction and communicating channels to the bone marrow. Grades 1 to 3 were assigned, where 1 = minimal compression/sclerosis; 2 = moderate compression/sclerosis; 3 = severe compression/sclerosis. Bone volume/total tissue volume, bone surface area/bone volume, trabecular thickness, and trabecular number were calculated in the region of interest. RESULTS: Visual assessment revealed that the s.MFX had significantly more grade 1 holes (P < .001) and that the l.MFX had significantly more poor/grade 3 holes (P = .002). Bone marrow channel assessment showed a statistically significant increase in the number of channels in the s.MFX when compared with both K-wire and l.MFX holes (P < .001). Bone volume fraction for the s.MFX was significantly less than that of the l.MFX (P = .029). CONCLUSIONS: BMS techniques using instruments with larger diameters resulted in increased trabecular compaction and sclerosis in areas adjacent to the defect. K-wire and l.MFX techniques resulted in less open communicating bone marrow channels, denoting a reduction in bone marrow access. The results of this study indicate that BMS using larger diameter devices results in greater microarchitecture disturbances. CLINICAL RELEVANCE: The current study suggests that the choice of a BMS technique should be carefully considered as the results indicate that smaller diameter hole sizes may diminish the amount of microarchitectural disturbances in the subchondral bone.

Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: Does Previous Bone Marrow Stimulation Negatively Affect Clinical Outcome?

PURPOSE: To determine if functional outcomes and magnetic resonance imaging (MRI) outcomes were significantly different between patients receiving primary autologous osteochondral transplantation (AOT) and patients receiving secondary AOT surgery after failed microfracture. METHODS: A group of 76 patients enrolled into the Foot and Ankle Service between 2006 and 2012 was retrospectively analyzed. Patient-reported outcomes were evaluated in 76 patients using the Foot and Ankle Outcome Score (FAOS). Superficial and deep tissues at the repaired defect site, as well as the adjacent normal cartilage, were analyzed using quantitative T2 mapping MRI. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) allowed for morphological evaluation of the repair tissue. The mean clinical follow-up time was 51 ± 23 months (range, 12 to 97 months), and the mean MRI follow-up time was 26 months (range, 24 to 36 months). RESULTS: Twenty-two patients received primary AOT and 54 received secondary AOT after failed microfracture. Patient characteristics between groups were similar with regard to age, gender, lesion size, and follow-up time. The mean postoperative FAOS was 10 points higher in the primary AOT group (83.2 ± 17.0) compared with the secondary AOT group (72.4 ± 19.4) (P = .01). Regression analysis showed that secondary AOT patients preoperative to postoperative change in FAOS was 9 points lower than in primary AOT patients after adjustment for age, preoperative FAOS, and lesion size (P = .045). The mean MOCART score, superficial T2 and deep T2 values, and the difference between normal and repair cartilage T2 values were not significantly different between groups. Lesion size was negatively correlated with MOCART scores (ρ = -0.2, P = .04), but positively correlated with difference in T2 values between repair and adjacent normal cartilage in the superficial layer (ρ = 0.3, P = .045). CONCLUSIONS: Primary AOT shows better functional outcomes compared with secondary AOT after failed microfracture in patients with similar characteristics and lesion size. No significant differences in T2 mapping relaxation times and MOCART scores were identified. LEVEL OF EVIDENCE: Level III, case control study.

Platelet-Rich Plasma May Improve Osteochondral Donor Site Healing in a Rabbit Model.

PURPOSE: The purpose of this study was to assess the effect(s) of platelet-rich plasma (PRP) on osteochondral donor site healing in a rabbit model. METHODS: Osteochondral donor sites 3 mm in diameter and 5 mm in depth were created bilaterally on the femoral condyles of 12 New Zealand White rabbits. Knees were randomized such that one knee in each rabbit received an intra-articular injection of PRP and the other received saline (placebo). Rabbits were euthanized at 3, 6, and 12 weeks following surgery. Repair tissue was evaluated using the International Cartilage Repair Society (ICRS) macroscopic and histological scores. RESULTS: No complications occurred as a result of the interventions. There was no significant difference in macroscopic scores between the 2 groups (5.5 ± 3.8 vs. 3.8 ± 3.5; P = 0.13). Subjective macroscopic assessment determined greater tissue infill with fewer fissures and a more cartilage-like appearance in PRP-treated knees. Overall ICRS histological scores were better in the PRP group compared with the placebo (9.8 ± 2.0 vs. 7.8 ± 1.8; P = 0.04). Histological scores were also higher in the PRP group compared with the placebo group at each time point. Greater glycosaminoglycan and type II collagen content were noted in the repair tissue of the PRP group compared with the placebo group. CONCLUSION: The results of this study indicate that PRP used as an intra-articular injection may improve osteochondral healing in a rabbit model.

Arthroscopic Bone Marrow Stimulation and Concentrated Bone Marrow Aspirate for Osteochondral Lesions of the Talus: A Case-Control Study of Functional and Magnetic Resonance Observation of Cartilage Repair Tissue Outcomes.

PURPOSE: This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. METHODS: Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. RESULTS: The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively). CONCLUSIONS: BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.

Primary Tumors of the Foot and Ankle.

UNLABELLED: Tumors of the foot and ankle are rarely encountered in the general patient population. Even among studies of tumor patients, foot and ankle neoplasms are uncommon. Given the weight-bearing demands of the foot and its relatively small area, even small masses are likely to be symptomatic and/or palpable to both patient and physician. Only 3% of osseous neoplasms are found in this region, while 8% of benign soft tissue tumors and 5% of malignant soft tissue tumors are localized to the foot and ankle. Despite the rarity of presentation, it is important for orthopaedic surgeons to be familiar with the diagnostic criteria and therapeutic options for these patients, as each tumor varies in its presentation, level of aggressiveness, and natural history of the disease. With appropriate diagnostic tests and treatment, patients can anticipate a reasonable chance of survival and preservation of function. In this review article, the authors survey the current literature regarding the presentation, diagnostic workup, and treatment for the most common benign and malignant tumors of the foot and ankle. LEVELS OF EVIDENCE: Level IV: Literature Review.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle.

PURPOSE: To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle. METHODS: A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest. RESULTS: Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256). CONCLUSIONS: Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review.

BACKGROUND: Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis. METHODS: A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis. RESULTS: The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed. CONCLUSIONS: There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Functional Outcomes of Tibialis Posterior Tendoscopy With Comparison to Magnetic Resonance Imaging.

BACKGROUND: The purpose of the current study was to report functional outcomes of tendoscopy for treatment of tibialis posterior tendon pathology as well as compare its diagnostic capability with magnetic resonance imaging (MRI). METHODS: Clinical records and MRI of 12 patients who underwent tendoscopy of the tibialis posterior tendon (TPT) were retrospectively reviewed. Mean follow-up was 31 months (range, 26-43 months). Preoperative MRI findings were compared with tendoscopic findings to assess the diagnostic agreement between each modality. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) General Health Questionnaire pre- and postoperatively. Mean patient age was 43 years (range, 17-63 years). Mean duration of preoperative symptoms was 15.5 months (range, 3-36 months). RESULTS: Pathologies addressed via tendoscopy included tenosynovitis, tendinosis, stenosis, tendon subluxation, and partial thickness tear (via mini-arthrotomy). Preoperative MRI findings were in agreement with tendoscopic findings in 8 of 12 cases (67%). Tendoscopy diagnosed and allowed access for treating pathology that was missed on MRI in the remaining four cases. The FAOS improved from a mean preoperative score of 58 (range, 36-78) to a mean postoperative score of 81 (range, 44-98) (P < .01). The SF-12 score improved from a mean preoperative score of 34 (range, 13-51) to a mean postoperative score of 51 (range, 21-76) (P = .01). CONCLUSIONS: Although MRI is considered an effective imaging technique for tendon pathology, tendoscopy may be a more sensitive diagnostic tool. Tendoscopy was an effective minimally invasive tool to diagnose and treat tibialis posterior tendon pathology resulting in functional improvements in the short-term for early stage TPT dysfunction. Further studies comparing tendoscopy with traditional open approaches are warranted. LEVEL OF EVIDENCE: Level IV case series.

Anterolateral tibial osteotomy for accessing osteochondral lesions of the talus in autologous osteochondral transplantation: functional and t2 MRI analysis.

BACKGROUND: Autologous osteochondral transplantation (AOT) is a primary treatment strategy for large or cystic osteochondral lesions of the talus (OLT) or a secondary replacement strategy after failed bone marrow stimulation. The technique requires perpendicular access to the talar dome, which is often difficult to obtain for posterior or lateral lesions. Traditional methods to access these areas have required disruption of the syndesmotic complex with concern over osteotomy reduction, malalignment, and ligament disruption. An alternate to these traditional methods of access is an anterolateral tibial osteotomy. The purpose of this study was to report functional and magnetic resonance imaging (MRI) outcomes in a series of patients that underwent AOT for treatment of an OLT via an anterolateral tibial osteotomy. METHODS: Records of patients that underwent an anterolateral tibial osteotomy for AOT were retrospectively reviewed. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS) and demographic data were recorded. Magnetic resonance observation of cartilage repair tissue (MOCART) was used to assess morphologic state of tibial cartilage at the repair site of the osteotomy. Quantitative T2 mapping MRI was analyzed in the superficial and deep cartilage layers of the repair site of the osteotomy and in adjacent normal cartilage to serve as control tissue. Seventeen patients with a mean age of 36.9 (range, 17-76) years underwent anterolateral tibial osteotomy with a mean follow-up of 64 (range, 29 to 108) months. MOCART data were available in 9 of 17 patients, and quantitative T2 mapping was available in 6 patients. RESULTS: FAOS significantly improved from an average 39.2 (range, 14 to 66) out of 100 points preoperatively to 81.2 (range, 19 to 98) postoperatively (P < .01). The average MOCART score was 73.9 out of 100 points (range, 40 to 100). Quantitative T2 analysis demonstrated relaxation times that were not significantly different from the normal native cartilage in both the deep half and superficial half of interface repair tissue (P > .05). CONCLUSION: This study demonstrated that the anterolateral tibial osteotomy was a reasonable alternative for accessing centrolateral or posterolateral OLT for AOT with limited morbidity associated with the osteotomy. The evidence demonstrated adequate osteotomy and cartilaginous healing with improvement in functional outcome scores at medium-term follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.