The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study.

BACKGROUND: The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads. METHODS: Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size. RESULTS: CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used. CONCLUSIONS: Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.

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

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

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

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

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

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

Bracing versus casting in ankle fractures.

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

Association Between Patellar Tendon Abnormality and Land-Jump Biomechanics in Male Collegiate Basketball Players During the Preseason.

Background: Patellar tendinopathy is a degenerative condition that predominantly affects jumping athletes. Symptoms may be subtle or nonexistent at preseason, but structural abnormalities may be present. Assessing patellar tendon abnormality (PTA) through magnetic resonance imaging (MRI) and ultrasound (US) and classifying symptoms using the Victorian Institute for Sport Assessment-Patellar tendon (VISA-P) may provide useful insights if combined with biomechanics measurements. Purpose: To (1) assess whether land-jump biomechanical patterns are associated with clinically pertinent PTA as seen on imaging and through VISA-P scores and (2) model the contributing risk and accuracy of biomechanics to classify PTA and symptomatic observations. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 26 National Collegiate Athletic Association Division I and II male basketball players (n = 52 limbs) were recruited during the preseason. We collected VISA-P scores, bilateral PTA through US and MRI morphology measurements, and bilateral 3-dimensional lower extremity kinematics and kinetics measurements from a land-jump test from an 18-inch-high (45.7-cm-high) box. Statistically, each limb was treated independently. The association of biomechanics with PTA and symptoms (VISA-P score <80) was tested with multivariate models and post hoc tests. Logistic regression modeled relative risk and accuracy of biomechanical variables to classify PTA and symptomatic limbs. Results: There were 19 to 24 limbs with PTA depending on US and MRI measurements. Differences in hip and knee kinematic strategies and ground-reaction loads were associated with PTA and symptomatic limbs. Peak landing vertical ground-reaction force was significantly decreased (169 ± 26 vs 195 ± 29 %body weight; P = .001), and maximum hip flexion velocity was significantly increased (416 ± 74 vs 343 ± 94 deg/s; P = .005) in limbs with versus without PTA on imaging. Knee flexion at the initial contact was decreased in symptomatic versus healthy limbs (17°± 5° vs 21°± 5°, respectively; P = .045). Regression models classified PTA limbs and symptomatic limbs with 71.2% to 86.5% accuracy. Hip and knee maximum flexion velocity and vertical ground-reaction force variables were most common across models observing clinically pertinent PTA. Conclusion: Our findings suggested that functional kinematic and kinetic biomechanical strategies at the hip and knee were associated with PTA, identified on imaging, and symptomatic limbs.

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

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

Synthetic playing surfaces and athlete health.

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

Proximity of arthroscopic ankle stabilization procedures to surrounding structures: an anatomic study.

PURPOSE: To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk. METHODS: Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged. RESULTS: Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity. CONCLUSIONS: Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction. CLINICAL RELEVANCE: Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

The arthroscopic "subdeltoid approach" to the anterior shoulder.

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

Biomechanical analysis of Brostrom versus Brostrom-Gould lateral ankle instability repairs.

BACKGROUND: The traditional Brostrom repair and the modified Brostrom-Gould repair are 2 historically reliable procedures used to address lateral ankle instability. The purpose of this study was to evaluate the biomechanical stability conferred by the Brostrom repair as compared to the Brostrom-Gould modification in an unstable cadaveric ankle model. METHODS: A total of 10 cadaveric specimens were placed in a Telos ankle stress apparatus in an anterior-posterior position and then in a lateral position, while a 170 N load was applied to simulate anterior drawer (AD) and talar tilt (TT) tests, respectively. In both circumstances, the ankle was held in 15 degrees of plantarflexion, neutral, and 15 degrees of dorsiflexion, while the movement of the sensors was measured using a video motion analysis system. Measurement of the translation between the talus and tibia in the AD test and the angle between the tibia and talus in the TT test were calculated for specimens in the (1) intact, (2) sectioned (division of the ATFL and CFL), (3) Brostrom repair and (4) Gould modification states. RESULTS: When compared to both the repaired states and the intact states, the sectioned state demonstrated increased inversion and translation at all ankle positions during TT and AD testing. Furthermore, no significant differences were found between the intact state and either of the repaired states. Finally, no difference in the biomechanical stability could be identified between the traditional Brostrom repair and the modified Brostrom-Gould procedure. CONCLUSIONS: Our findings indicate that there is no significant biomechanical difference in initial ankle stability conferred by augmenting the traditional Brostrom repair with the Gould modification in this time-zero cadaveric model. CLINICAL RELEVANCE: These data suggest that the additional reinforcement of an ankle's lateral ligament complex repair of the ankle with the inferior extensor retinaculum may be marginal at the time of surgery.

Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus.

Background: Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods: This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results: Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. Conclusion: In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level of Evidence: Level III, retrospective cohort study.

Popliteal venotomy during posterior cruciate ligament reconstruction in the setting of a popliteal artery bypass graft.

Injury to the vascular structures in the popliteal fossa during arthroscopic cruciate ligament reconstruction can be limb threatening or even life threatening. We present the first report, to our knowledge, of an isolated injury to a popliteal vein during arthroscopic posterior cruciate ligament reconstruction. Unfortunately, the venotomy led to cardiopulmonary arrest and flash pulmonary edema in this patient. Preoperative planning is paramount to assess risk of injury to vascular structures, which may be increased in patients who have had prior procedures on the affected knee. Furthermore, vascular surgery consultation preoperatively after a magnetic resonance angiogram or venogram and avoiding the use of epinephrine in the arthroscopy fluid should be considered when performing these higher-risk procedures.

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

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

Ankle Instability.

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity.

BACKGROUND: Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL. METHODS: Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups. RESULTS: STF patients were older (P < .05), with higher BMIs (P < .004). STF had significantly worse TNU (P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively (P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function (P = 0.04). CONCLUSIONS: STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse. LEVELS OF EVIDENCE: Level III: Retrospective chart review comparison study (case control).

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

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

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

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

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

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

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

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