Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip.

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

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.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: Treatment guidelines for cartilage lesions of the talus have been 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 on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus. METHODS: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. RESULTS: A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Evaluation of Posterior Cruciate Ligament and Intercondylar Notch in Subjects With Anterior Cruciate Ligament Tear: A Comparative Flexed-Knee 3D Magnetic Resonance Imaging Study.

PURPOSE: To determine if posterior cruciate ligament (PCL) and intercondylar notch (IN) morphometries and volumetrics act as risk factors for anterior cruciate ligament (ACL) tears. METHODS: A prospective case-controlled magnetic resonance imaging (MRI) study was conducted with subjects presenting noncontact knee injuries. Exclusion criteria were previous surgery, PCL tear, osteoarthritis, tumors, or infectious and inflammatory conditions. All participants underwent a flexed-knee 3-dimensional (3D) magnetic resonance imaging (MRI) to uniformly straighten PCL. MR images were independently reviewed by 2 radiologists and assessed for 2D and 3D measurements (bicondylar width; IN angle, depth, width, and cross-sectional area; PCL width, thickness, and cross-sectional area; and IN and PCL volumes). Clinical profiles were tabulated and subjects were divided into cases (ACL tear) and controls (without ACL tear). RESULTS: The study was composed of 50 cases versus 52 controls (N = 102), with a mean age of 36.8 years. There was no difference between groups (P > .05) regarding age, gender, body mass index, time from injury, Tegner score, flexion angle, limb side, intensity of injury, or familial or opposite limb history of tear. Agreement between readers ranged from substantial to almost perfect. Subjects with ACL tear presented with lower IN width, lower IN minus PCL widths, lower Notch Width Index, higher PCL/IN width proportion, higher PCL thickness, lower IN depth minus PCL thickness, and higher PCL thickness/IN depth proportion (P < .05). Moreover, higher PCL/IN cross-sectional area proportion, higher PCL volumes (OR = 9.01), and higher PCL/IN volume proportion were also found in cases. CONCLUSIONS: Our study shows that subjects with ACL tears present not only reduced IN but also larger PCL dimensions. These findings, isolated and combined, and especially PCL volume, might be suggestive as risk factors for ACL tears owing to the reduction of its space inside the IN. LEVEL OF EVIDENCE: Level III, comparative group.

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 in an athletic population.

PURPOSE: To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. METHODS: A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity. RESULTS: The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee. CONCLUSION: The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

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.