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

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

Bone marrow stimulation for talar osteochondral lesions at long-term follow-up shows a high sports participation though a decrease in clinical outcomes over time.

PURPOSE: Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up. METHODS: Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS). RESULTS: The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up. CONCLUSION: At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up. LEVEL OF EVIDENCE: Level II.

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

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

Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for primary talar osteochondral defects.

PURPOSE: The purpose of this study was to describe the mid-term clinical and radiological results of a novel arthroscopic fixation technique for primary osteochondral defects (OCD) of the talus, named the lift, drill, fill and fix (LDFF) technique. METHODS: Twenty-seven ankles (25 patients) underwent an arthroscopic LDFF procedure for primary fixable talar OCDs. The mean follow-up was 27 months (SD 5). Pre- and post-operative clinical assessments were prospectively performed by measuring the Numeric Rating Scale (NRS) of pain in/at rest, walking and when running. Additionally, the Foot and Ankle Outcome Score (FAOS) and the Short Form-36 (SF-36) were used to assess clinical outcome. The patients were radiologically assessed by means of computed tomography (CT) scans pre-operatively and 1 year post-operatively. RESULTS: The mean NRS during running significantly improved from 7.8 pre-operatively to 2.9 post-operatively (p = 0.006), the NRS during walking from 5.7 to 2.0 (p < 0.001) and the NRS in rest from 2.3 to 1.2 (p = 0.015). The median FAOS at final follow-up was 86 for pain, 63 for other symptoms, 95 for activities of daily living, 70 for sport and 53 for quality of life. A pre- and post-operative score comparison was available for 16 patients, and improved significantly in most subscores. The SF-36 physical component scale significantly improved from 42.9 to 50.1. Of the CT scans at 1 year after surgery, 81% showed a flush subchondral bone plate and 92% of OCDs showed union. CONCLUSION: Arthroscopic LDFF of a fixable primary talar OCD results in excellent improvement of clinical outcomes. The radiological follow-up confirms that fusion of the fragment is feasible in 92%. This technique could be regarded as the new gold standard for the orthopedic surgeon comfortable with arthroscopic procedures. LEVEL OF EVIDENCE: Prospective case series, therapeutic level IV.

The subchondral bone healing after fixation of an osteochondral talar defect is superior in comparison with microfracture.

PURPOSE: Arthroscopic bone marrow stimulation (BMS) has been considered the primary surgical treatment for osteochondral defects (OCDs) of the talus. However, fixation has been considered as a good alternative. Recently, a new arthroscopic fixation technique was described: the lift, drill, fill and fix procedure (LDFF). The purpose of this study was to evaluate the clinical and radiological results between arthroscopic LDFF and arthroscopic BMS in primary fixable talar OCDs at 1-year follow-up. METHODS: In a prospective comparative study, 14 patients were treated with arthroscopic BMS and 14 patients with arthroscopic LDFF. Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and the numeric rating scales (NRSs) of pain at rest and running. Additionally, the level of the subchondral plate (flush or depressed) was analysed on the 1 year postoperative computed tomography scans. RESULTS: No significant differences in the AOFAS and NRS pain at rest and running were found between both groups at 1-year follow-up. After LDFF the level of the subchondral bone plate was flush in 10 patients and after BMS in three patients (p = 0.02). CONCLUSION: No clinical differences were found between arthroscopic LDFF and arthroscopic BMS in the treatment of talar OCDs at 1-year follow-up. However, the subchondral bone plate restores significantly superior after arthroscopic LDFF compared to arthroscopic BMS. It may therefore give less progression of ankle osteoarthritis in the future with a thus potential better long-term outcome. LEVEL OF EVIDENCE: III.

No superior treatment for primary osteochondral defects of the talus.

PURPOSE: The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults. METHODS: A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined. RESULTS: Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%]. CONCLUSIONS: For primary talar osteochondral defects, none of the treatment options showed any superiority over others. LEVEL OF EVIDENCE: IV.

No superior surgical treatment for secondary osteochondral defects of the talus.

PURPOSE: The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery. METHODS: A literature search was conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle-Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined. RESULTS: Twenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% [CI 82-95%] for the osteochondral autograft transfer procedure, 65% [CI 46-81%] for mosaicplasty and 55% [CI 40-70%] for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% [CI 39-77%]) and matrix-associated chondrocyte implantation (success rate of 73% [CI 56-85%]). CONCLUSIONS: Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery. LEVEL OF EVIDENCE: IV.

Incidence of patients with lower extremity injuries presenting to US emergency departments by anatomic region, disease category, and age.

BACKGROUND: The incidence of patients with lower extremity injuries presenting to emergency departments in the United States with respect to specific anatomic regions and disease categories is unknown. Such information might be used for injury prevention, resource allocation, and training priorities. QUESTIONS/PURPOSES: We determined the anatomic regions, disease categories, and circumstances that account for the highest incidence of leg problems among patients presenting to emergency departments in the United States. METHODS: We used the National Electronic Injury Surveillance System (NEISS) to obtain a probability sample of all lower extremity injuries treated at emergency departments during 2009. A total of 119,815 patients who presented to emergency departments with lower extremity injuries in 2009 were entered in the NEISS database. Patient and injury characteristics were analyzed. Incidence rates for various regions, disease categories, injuries, and age groups were calculated using US census data. RESULTS: We identified 112 unique combinations of disease categories and anatomic regions. Strains and sprains accounted for 36% of all lower extremity injuries. The injury with the greatest incidence was an ankle sprain (206 per 100,000; 95% confidence interval, 181-230). Younger patients were more likely to have ankle sprains, foot contusions/abrasions, and foot strains/sprains. Older patients were more likely to have lower trunk fractures and lower trunk contusions/abrasions. The most common incidence for injury was at home (45%). CONCLUSIONS: Given relatively low-acuity leg problems such as strains and sprains account for a substantial number of emergency department visits pertaining to leg problems, use of telephone triage, scheduled same or next-day urgent care appointments, and other alternatives to the traditional emergency room might result in better use of emergency healthcare resources.

Quantitative measurement of radial head fracture location.

BACKGROUND: The most common location of a displaced fracture of part of the radial head is often described as the anterior lateral aspect of the radial head with the forearm in neutral position, based on observation rather than precise measurements. The purpose of our study was to measure the exact location of fractures involving part of the radial head using quantitative 3-dimensional computed tomography (CT). MATERIALS AND METHODS: We measured the fracture lines with respect to the biceps tuberosity in 24 patients with a displaced articular fracture of part of the radial head (Mason type 2). Two observers preformed each measurement twice. Reliability was measured using the concordance correlation coefficient according to Lin. RESULTS: The average start of the fracture was 97° (standard deviation [SD]) 48.3°; range 31°-254°) clockwise from the biceps tuberosity, the average end of the fracture was 241.6° (SD, 61.0; range 19°-330°), and the average fracture subtends was 170° (SD, 32.8°; range 99°-252°). The fracture was through the anterolateral quadrant of the radial head in 22 of the 24 patients and through the posteromedial quadrant in 2 patients. CONCLUSION: This quantitative analysis of CT scans of displaced articular fractures of part of the radial head (Mason type 2) confirms that the most common location is the anterolateral quadrant with the forearm in neutral rotation. Given the important role of the radial head in elbow stability, more accurate characterization of incomplete radial head fractures may improve our understanding of treatment and outcome of these fractures.

Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

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

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

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

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

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

Elbow fracture-dislocation with triceps avulsion: report of 2 cases.

We report 2 cases of elbow fracture dislocation with triceps avulsion. Despite immobilizing the elbow in neutral for 2 to 4 weeks to protect the triceps repair, good elbow motion was obtained.

Adequate return to sports and sports activities after treatment of Lisfranc injury: a meta-analysis.

IMPORTANCE: Although a large number of Lisfranc injuries occur during sports, data on sports outcomes, such as return to sport (RTS) rates and times as well as level of sports activities after treatment of this injury remain limited. OBJECTIVE: The aim is to assess the RTS rates, times and the sports activity levels after different treatments of Lisfranc injuries. EVIDENCE REVIEW: The electronic databases PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL were searched to identify relevant articles from January 1985 to July 2020. The mean RTS rates (to any level and preinjury level of sports) and times were extracted per study, and pooled wherever methodologically possible. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies criteria (MINORS). FINDINGS: Fifteen studies were included in this review. Methodological quality of the studies was poor. The treatments reported in the studies were conservative treatment, surgical fixation and primary partial arthrodesis. For conservative treatment, the RTS rate regardless of sports level was 93% (95% CI 81% to 98%; n=42) and for return to preinjury level of sports was 88% (95% CI 75% to 95%; n=42). The fixation group showed a RTS percentage of 94% (95% CI 91% to 97%; n=270) to each level of sports and for return to the level before injury was 86% (95% CI 80% to 90%; n=188). In the primary partial arthrodesis group, the return to any level of sports was 94% (95% CI 85% to 98%; n=65) and for return to preinjury level was 74% (95% CI 62% to 83%; n=65). Mean time to RTS ranged from 7 to 33 weeks across all treatment groups. No data pooling was possible for this outcome measure. From the different studies, a total of 43 different sports and 440 physical activities were reported before treatment. After treatment, patients participated in 37 different sports (88%) and 391 different physical activities (89%). CONCLUSIONS AND RELEVANCE: The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport. These sport-specific outcomes can be used to inform patients about their expected sport-specific outcomes after different treatments of Lisfranc injuries. LEVEL OF EVIDENCE: Systematic review and meta-analysis.

Feasibility Study to Determine if Microfracture Surgery Using Water Jet Drilling Is Potentially Safe for Talar Chondral Defects in a Caprine Model.

OBJECTIVE: Surgical microfracture is considered a first-line treatment for talar osteochondral defects. However, current rigid awls and drills limit access to all locations in human joints and increase risk of heat necrosis of bone. Using a flexible water jet instrument to drill holes can improve the reachability of the defect without inducing thermal damage. The aim of this feasibility study is to determine whether water jet drilling is potentially safe compared with conventional microfracture awls by studying side effects and perioperative complications, as well as the quality of cartilage repair tissue. DESIGN: Talar chondral defects with 6-mm diameter were created bilaterally in 6 goats (12 samples). One defect in each goat was treated with microfracture created with conventional awls, the contralateral defect was treated with holes created with 5-second water jet bursts at a pressure of 50 MPa. Postoperative complications were recorded and after 24 weeks analyses were performed using the ICRS (International Cartilage Repair Society) macroscopic score and modified O'Driscoll histological score. RESULTS: Several practical issues using the water jet in the operating theatre were noted. Water jet drilling resulted in fibrocartilage repair tissue similar to the repair tissue from conventional awls. CONCLUSIONS: These results suggest that water jet drilling gives adequate fibrocartilage repair tissue. Furthermore, the results highlight essential prerequisites for safe application of surgical water jet drilling: stable water pressure, water jet beam coherence, stable positioning of the nozzle head when jetting, and minimizing excessive fluid extravasation.

Effect on Overall Health Status With Weightbearing at 2 Weeks vs 6 Weeks After Open Reduction and Internal Fixation of Ankle Fractures.

BACKGROUND: Ongoing controversy exists on postoperative weightbearing status after open reduction and internal fixation of an ankle fracture. This prospective randomized controlled trial aimed to compare patient-based and physician-based outcomes after early weightbearing at 2 vs 6 weeks postoperatively. METHODS: Fifty patients with unstable rotational-type ankle fractures were treated operatively with subsequent immobilization in a below-the-knee cast for 2 weeks and were then randomly allocated to 2 groups. The first group had early weightbearing at 2 weeks postoperation and the second group at 6 weeks postoperation. Follow-up included subjective and objective evaluations performed at 2, 6, 12, and 26 weeks postoperatively. The primary outcome was the patient-based general health status as measured with the EuroQol-5D (EQ-5D) scoring system. Secondary outcome was the Olerud and Molander ankle score. Power analysis revealed a study group of 50 patients was needed to show a clinically relevant effect size of 10 points in both EQ-5D visual analog scale (VAS) score and Olerud and Molander score. RESULTS: Patients in the early weightbearing group had higher mean EQ-5D VAS scores at a 6-week follow-up (P = .014) of 77 ± 14 compared to 66 ± 15 for late mobilization. No difference was found at other follow-up points or between groups for physician-based outcome measures. At 26 weeks postoperatively, mean Olerud and Molander ankle scores were similar at 84 ± 16 and 81 ± 17 for mobilization at 2 and 6 weeks postoperation, respectively. CONCLUSION: Early weightbearing after operative fixation of rotational-type ankle fractures had a clinically relevant and statistically significant benefit in patient-based general health status, as quantified with EQ-5D VAS scores, at 6 weeks postoperation. These results contribute to our understanding of early weightbearing and may encourage consideration of weightbearing at 2 weeks postoperatively in standard protocols. LEVEL OF EVIDENCE: Therapeutic Level I, prospective randomized controlled trial.

Prevalence of Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures: Can We Reliably Use the Contralateral Uninjured Side as the Reference Standard?

BACKGROUND: Intramedullary (IM) nailing is the treatment of choice for most tibial shaft fractures. However, an iatrogenic pitfall may be rotational malalignment. The aims of this retrospective analysis were to determine (1) the prevalence of rotational malalignment using postoperative computed tomography (CT) as the reference standard; (2) the average baseline tibial torsion of uninjured limbs; and (3) based on that normal torsion, whether the contralateral, uninjured limb can be reliably used as the reference standard. METHODS: The study included 154 patients (71% male and 29% female) with a median age of 37 years. All patients were treated for a unilateral tibial shaft fracture with an IM nail and underwent low-dose bilateral postoperative CT to assess rotational malalignment. RESULTS: More than one-third of the patients (n = 55; 36%) had postoperative rotational malalignment of ≥10°. Right-sided tibial shaft fractures were significantly more likely to display external rotational malalignment whereas left-sided fractures were predisposed to internal rotational malalignment. The uninjured right tibiae were an average of 4° more externally rotated than the left (mean rotation and standard deviation, 41.1° ± 8.0° [right] versus 37.0° ± 8.2° [left]; p < 0.01). Applying this 4° correction to our cohort not only reduced the prevalence of rotational malalignment (n = 45; 29%), it also equalized the distribution of internal and external rotational malalignment between the left and right tibiae. CONCLUSIONS: This study confirms a high prevalence of rotational malalignment following IM nailing of tibial shaft fractures (36%). There was a preexisting 4° left-right difference in tibial torsion, which sheds a different light on previous studies and current clinical practice and could have important implications for the diagnosis and management of tibial rotational malalignment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Return to Sports After Surgical Treatment of Osteochondral Defects of the Talus: A Systematic Review of 2347 Cases.

BACKGROUND: Osteochondral defects (OCDs) of the talus are found subsequent to ankle sprains and ankle fractures. With many surgical treatment strategies available, there is no clear evidence on return-to-sport (RTS) times and rates. PURPOSE: To summarize RTS times and rates for talar OCDs treated by different surgical techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The literature from January 1996 to November 2018 was screened, and identified studies were divided into 7 different surgical treatment groups. The RTS rate, with and without associated levels of activity, and the mean time to RTS were calculated per study. When methodologically possible, a simplified pooling method was used to combine studies within 1 treatment group. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system. RESULTS: A total of 61 studies including 2347 talar OCDs were included. The methodological quality of the studies was poor. There were 10 retrospective case series (RCSs) that investigated bone marrow stimulation in 339 patients, with a pooled mean rate of RTS at any level of 88% (95% CI, 84%-91%); 2 RCSs investigating internal fixation in 47 patients found a pooled RTS rate of 97% (95% CI, 85%-99%), 5 RCSs in which autograft transplantation was performed in 194 patients found a pooled RTS rate of 90% (95% CI, 86%-94%), and 3 prospective case series on autologous chondrocyte implantation in 39 patients found a pooled RTS rate of 87% (95% CI, 73%-94%). The rate of return to preinjury level of sports was 79% (95% CI, 70%-85%) for 120 patients after bone marrow stimulation, 72% (95% CI, 60%-83%) for 67 patients after autograft transplantation, and 69% (95% CI, 54%-81%) for 39 patients after autologous chondrocyte implantation. The mean time to RTS ranged from 13 to 26 weeks, although no pooling was possible for this outcome measure. CONCLUSION: Different surgical treatment options for talar OCDs allow for adequate RTS times and rates. RTS rates decreased when considering patients' return to preinjury levels versus return at any level.