Bone Marrow Stimulation for Osteochondral Lesions of the Tibial Plafond Yields Good Patient-Reported Outcomes in Daily Living but Moderate Outcomes in Sports Activities at 2- to 22-Years Follow-Up.

PURPOSE: To assess the patient-reported outcomes, as well as the revision and complication rates, of patients who underwent arthroscopic bone marrow stimulation (BMS) for an osteochondral lesion of the tibial plafond (OLTP). METHODS: Patients with an OLTP treated with arthroscopic BMS at a minimum follow-up of 2-years were cross-sectionally included from a historical database. The primary outcome was the Numeric Rating Scale (NRS) during walking. Secondary outcomes included the NRS in rest and during running, and the Foot and Ankle Outcome Score. Additionally, the association of baseline patient and lesion demographics with follow-up patient-reported outcome measures (PROMs) was assessed with the Spearman rank correlation test. A subanalysis was performed for PROMs in patients with or without a coexisting talar (i.e., bipolar) lesion. Finally, the revision surgery (i.e., repeat surgery for the OLTP) and complication rates were assessed. RESULTS: Fifty-one patients were included at a mean 8.8 (standard deviation [SD] = 5.7, range, 2-22) years follow-up. Seventy-three percent of patients had a solitary OLTP, and 27% had a coexisting talar (bipolar) lesion. Males had a significantly higher rate of bipolar lesions compared to females (P ≤ .01), and patients with a bipolar lesion had a significantly larger OLTP lesion diameter (P = .02) and volume (P = .04). At final follow-up, the mean NRS during walking was 1.9 (SD = 2.3) out of 10. Anterior-posterior OLTP size (r = 0.36; P ≤ .01) was significantly associated with a higher NRS pain score during walking, although the presence of bipolar lesions did not result in inferior clinical outcomes. At final follow-up, 6% of patients underwent revision surgery. Minor complications were observed in 12% of patients. CONCLUSIONS: Arthroscopic BMS for OLTP results in favorable patient-reported outcomes at mid- to long-term follow-up, although moderate outcomes were observed in sports activities. Lesion size was associated with increased pain scores, although bipolar lesions did not result in inferior patient-reported outcomes. Six percent of patients required revision surgery, and 12% of patients had minor complications after surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping.

PURPOSE: Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volume and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention. METHODS: This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured. RESULTS: Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement. CONCLUSION: WBCT-based 3D modules and DM can be used to measure the lesion's surface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignment and assess if additional surgeries are needed. LEVEL OF EVIDENCE: Level III.

Large variation in postoperative rehabilitation protocols following operative treatment of osteochondral lesions of the talus: A systematic review and meta-analysis on >200 studies.

PURPOSE: A treatment-specific rehabilitation protocol and well-defined return-to-play criteria guide clinical decision-making on return to normal function, activity, sports and performance after surgical treatment for osteochondral lesion of the talus (OLT). The optimal rehabilitation protocols in the current literature remain unclear. The purpose of this study was to explore the existing literature on rehabilitation protocols from the early postoperative phase to return to sport onwards after different types of surgical treatment of OLTs. METHODS: PubMed, Embase, CDSR, DARE and Central were searched systematically from inception to February 2023 according to the PRISMA 2020 guidelines. All clinical studies with a description of postoperative rehabilitation criteria after surgical treatment of OLTs were included. The primary outcome of this study is the extent of reportage for each rehabilitation parameter expressed in percentage. The secondary outcome is the reported median time for each parameter in rehabilitation protocols for all different treatment modalities (type of surgery). The median time, expressed as number of weeks, for each parameter was compared between different types of surgery. RESULTS: A total of 227 articles were included reporting on 255 different rehabilitation protocols from seven different types of surgery. Weight-bearing instructions were reported in 84%-100% and the use of a cast or walker was prescribed in 27%-100%. Range of motion exercises were described in 54%-100% whereas physical therapy was advised in 21%-67% of the protocols. Any advice on return to sport was described in 0%-67% protocols. A nonparametric analysis of variance showed significant differences between the different surgical treatment modalities for the following parameters between the treatment groups: time to full weight-bearing (p < 0.0003) and return to high impact level of sports (p < 0.0003). Subjective or objective criteria for progression during rehabilitation were reported in only 24% of the studies. CONCLUSION: An in-depth exploration of the current literature showed substantial variation in postoperative rehabilitation guidelines with an associated underreporting of the most important rehabilitation parameters in postoperative protocols after surgical treatment of OLTs. Furthermore, nearly all rehabilitation protocols were constructed according to a time-based approach. Only one out of four reported either objective or subjective criteria. LEVEL OF EVIDENCE: Level IV, systematic review.

No difference between 5 and 6 weeks of non-weight bearing after osteochondral grafts for medial osteochondral defects of the talus with medial malleolar osteotomy.

PURPOSE: The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT). METHODS: A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed. RESULTS: Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations. CONCLUSION: No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT. LEVEL OF EVIDENCE: Level III, Therapeutic.

From technical to understandable: Artificial Intelligence Large Language Models improve the readability of knee radiology reports.

PURPOSE: The purpose of this study was to evaluate the effectiveness of an Artificial Intelligence-Large Language Model (AI-LLM) at improving the readability of knee radiology reports. METHODS: Reports of 100 knee X-rays, 100 knee computed tomography (CT) scans and 100 knee magnetic resonance imaging (MRI) scans were retrieved. The following prompt command was inserted into the AI-LLM: 'Explain this radiology report to a patient in layman's terms in the second person:[Report Text]'. The Flesch-Kincaid reading level (FKRL) score, Flesch reading ease (FRE) score and report length were calculated for the original radiology report and the AI-LLM generated report. Any 'hallucination' or inaccurate text produced by the AI-LLM-generated report was documented. RESULTS: Statistically significant improvements in mean FKRL scores in the AI-LLM generated X-ray report (12.7 ± 1.0-7.2 ± 0.6), CT report (13.4 ± 1.0-7.5 ± 0.5) and MRI report (13.5 ± 0.9-7.5 ± 0.6) were observed. Statistically significant improvements in mean FRE scores in the AI-LLM generated X-ray report (39.5 ± 7.5-76.8 ± 5.1), CT report (27.3 ± 5.9-73.1 ± 5.6) and MRI report (26.8 ± 6.4-73.4 ± 5.0) were observed. Superior FKRL scores and FRE scores were observed in the AI-LLM-generated X-ray report compared to the AI-LLM-generated CT report and MRI report, p < 0.001. The hallucination rates in the AI-LLM generated X-ray report, CT report and MRI report were 2%, 5% and 5%, respectively. CONCLUSIONS: This study highlights the promising use of AI-LLMs as an innovative, patient-centred strategy to improve the readability of knee radiology reports. The clinical relevance of this study is that an AI-LLM-generated knee radiology report may enhance patients' understanding of their imaging reports, potentially reducing the responder burden placed on the ordering physicians. However, due to the 'hallucinations' produced by the AI-LLM-generated report, the ordering physician must always engage in a collaborative discussion with the patient regarding both reports and the corresponding images. LEVEL OF EVIDENCE: Level IV.

Sex-specific analysis in patients undergoing Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large osteochondral lesions of the talus.

PURPOSE: The purpose of the present study is to assess the gender-specific differences in the presentation and outcomes following Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) between male and female patients. METHODS: A prospective comparative analysis was performed comparing consecutive female and male patients having been treated by the press-fit TOPIC procedure. Clinical comparative assessment preoperatively and at 12 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) was also assessed. A computed tomography (CT) scan was performed for lesion size, morphology and localization determination preoperatively as well as 10-12 weeks postoperatively to assess the union of the osteotomy site and at 1 year postoperatively to assess consolidation of the graft as well as intra-graft cyst development. RESULTS: A total of 48 patients (30 women, 18 men) were eligible for inclusion. Both men and women demonstrated significant functional improvements postoperatively concerning the clinical outcomes with no significant differences between men and women (n.s.) except for a significantly greater improvement in postoperative FAOS pain scores in women. Men presented with OLTs significantly larger in both surface area (208 mm2 for males versus 155 mm2 for females, p < 0.05) as well as lesion volume (3.0 cm3 for males versus 1.8 cm3 for females, p < 0.05). At 1-year postoperatively, all patients showed graft consolidation. Cyst formation was present in 11 females (37% of the group) and 10 males (59% of the group), respectively (n.s.). CONCLUSION: Both males and females showed clinically relevant improvements in the clinical outcomes after undergoing the TOPIC procedure with significant differences in preoperative lesion size. The TOPIC procedure is a good treatment strategy for large OLTs in both men and women. LEVEL OF EVIDENCE: Level III, comparative prospective clinical cohort.

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis.

PURPOSE: Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes. METHODS: A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications. RESULTS: The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections. CONCLUSION: Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications). LEVEL OF EVIDENCE: Level IV, Systematic Review and Meta-Analysis.

Particulated juvenile cartilage allograft for the treatment of osteochondral lesions of the talus is associated with a high complication rate and a high failure rate at short-term follow-up: A systematic review.

PURPOSE: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following particulated juvenile cartilage allograft (PJCA) for the management of osteochondral lesions of the talus (OLT). METHODS: During October 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJCA for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failures were extracted and analysed. RESULTS: Twelve studies were included. In total, 241 patients underwent PJCA for the treatment of OLT at a weighted mean follow-up of 29.0 ± 24.9 months. The weighted mean lesion size was 138.3 ± 59.6 mm2 . Prior surgical intervention was recorded in seven studies, the most common of which was microfracture (65.9%). The weighted mean American Orthopaedic Foot and Ankle Society score improved from a preoperative score of 58.5 ± 3.2 to a postoperative score of 83.9 ± 5.3. The weighted mean postoperative magnetic resonance observation of cartilage repair tissue (MOCART) score was 48.2 ± 3.3. The complication rate was 25.2%, the most common of which was allograft hypertrophy (13.2%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8 ± 9.6 months following the index procedure. CONCLUSION: This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJCA for the treatment of OLT at short term follow-up. However, postoperative MOCART scores were reported as poor. In addition, a high complication rate (25.2%) and a high failure rate (12.4%) at short-term follow-up was observed, calling into question the efficacy of PJCA for the treatment of large OLTs. In light of the available evidence, PJCA for the treatment of large OLTs cannot be currently recommended. LEVEL OF EVIDENCE: Level IV.

A guide to appropriately planning and conducting meta-analyses-Part 1: indications, assumptions and understanding risk of bias.

A meta-analysis is the quantitative synthesis of data from two or more individual studies and are as a rule an important method of obtaining a more accurate estimate of the direction and magnitude of a treatment effect. However, it is imperative that the meta-analysis be performed with proper, rigorous methodology to ensure validity of the results and their interpretation. In this article the authors will review the most important questions researchers should consider when planning a meta-analysis to ensure proper indications and methodologies, minimize the risk of bias, and avoid misleading conclusions.

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

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

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.

A guide to appropriately planning and conducting meta-analyses: part 2-effect size estimation, heterogeneity and analytic approaches.

Meta-analyses by definition are a subtype of systematic review intended to quantitatively assess the strength of evidence present on an intervention or treatment. Such analyses may use individual-level data or aggregate data to produce a point estimate of an effect, also known as the combined effect, and measure precision of the calculated estimate. The current article will review several important considerations during the analytic phase of a meta-analysis, including selection of effect estimators, heterogeneity and various sub-types of meta-analytic approaches.

Non-operative management for osteochondral lesions of the talus: a systematic review of treatment modalities, clinical- and radiological outcomes.

PURPOSE: The purpose of the present study was to assess the overall clinical success rate of non-operative management for osteochondral lesions of the talus (OLT). METHODS: A literature search was conducted in the PubMed (MEDLINE), COCHRANE and EMBASE (Ovid) databases. Clinical success rates per separate study were calculated at the latest moment of follow-up and were defined as successful when a good or excellent clinical result at follow-up was reported in a qualitative manner or when a post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score at or above 80 was reached. When clinical outcomes were based on other clinical scoring systems, outcomes reported as good or excellent were considered as clinical success. Studies methodologically eligible for a simplified pooling method were combined to calculate an overall pooled clinical success rate. Radiological changes over the course of conservative treatment were assessed either considering local OLT changes and/or overall ankle joint changes. RESULTS: Thirty articles were included, including an overall of 868 patients. The median follow-up of the included studies was 37 months (range: 3-288 months). A simplified pooling method was possible among 16 studies and yielded an overall pooled clinical success rate of 45% (95% CI 40-50%). As assessed with plain radiographs, progression of ankle joint osteoarthritis was observed in of 9% (95% CI 6-14%) of the patients. As assessed through a Computed Tomography (CT) scan, focal OLT deterioration was observed in 11% (95% CI 7-18%) of the patients. As assessed with a Magnetic Resonance Imaging (MRI) scan, focal OLT deterioration was observed in 12% (95% CI 6-24%) of the patients. An unchanged lesion was detected on plain radiographs in 53% (48/91; CI 43-63%), 76% (99/131; 95% CI 68-82%) on a CT scan and on MRI in 84% (42/50; 95% CI 71-92%) of the patients. CONCLUSION: The current literature on non-operative management of OLTs is scarce and heterogeneous on indication and type of treatment. Promising clinical results are presented but need to interpreted with caution due to the heterogeneity in indication, duration and type of treatment. Further studies need to focus on specific types on conservative management, indications and its results. LEVEL OF EVIDENCE: Systematic review, Level IV.

A guide to appropriately planning and conducting meta-analyses: part 3. Special considerations-the network meta-analysis.

The meta-analysis has become one of the predominant studies designs in orthopaedic literature. Within recent years, the network meta-analysis has been implicated as a powerful approach to comparing multiple treatments for an outcome of interest when conducting a meta-analysis (as opposed to two competing treatments which is typical of a traditional meta-analysis). With the increasing use of the network meta-analysis, it is imperative for readers to possess the ability to independently and critically evaluate these types of studies. The purpose of this article is to provide the necessary foundation of knowledge to both properly conduct and interpret the results of a network meta-analysis.

No difference in return to amateur sports after medial and lateral unicompartmental knee arthroplasty in patients younger than 65 years.

PURPOSE: The aim of this study was to assess the return to amateur sports of patients under 65 years, following medial unicompartmental knee arthroplasty (mUKA) versus lateral unicompartmental knee arthroplasty (lUKA). It was hypothesized that patients younger than 65 years who underwent lateral or medial unicondylar knee replacement will result in similar rates to amateur sports, at a minimum follow-up of 2 years. METHOD: Patients who underwent medial or lateral UKA participated in a 2-year follow-up program, where they were clinically evaluated for their return to amateur sports, using the University of California, Los Angeles (UCLA) activity scale and the High-Activity Arthroplasty Score (HAAS). Furthermore, subgroup analyses by gender and age were performed. Power analysis was performed to ensure sample size considering that lUKA is implanted ten times less frequently than its medial counterpart. RESULTS: There were 85 patients who completed the entire minimum 2-year follow-up of which 73 belonged to the mUKA group and 12 to the lUKA group. No preoperative differences were found between the groups regarding the gender, the affected side, age, and mean follow-up. Both groups showed statistically significant improvement (p < 0.05) in their return to amateur sports in all parameters (UCLA and HAAS). No differences among the two groups were found at T0 and T1 (n.s.). All subgroups showed a statistically significant improvement (p < 0.05) with respect to the preoperative value, except for UCLA for lUKA with less than 60 years and HAAS for males in the lUKA group (n.s.). No differences were found among subgroups both at To and T1 (n.s.). CONCLUSION: Both mUKA and lUKA procedures enabled all young and active patients a certain return to amateur sports 2 years after surgery, regardless of age and gender. UKA, medial or lateral, should always be considered for the treatment of isolated osteoarthritis in young and active patients with high functional demands. LEVEL OF EVIDENCE: Cohort Study, Level of Evidence III. REGISTRATION: Researchregistry6221 - Research Registry www.researchregistry.com .

Treatment of Osteochondral Lesions of the Talus in the Skeletally Immature Population: A Systematic Review.

INTRODUCTION: Skeletally immature osteochondral lesions of the talus (OLTs) are underreported and little is known about the clinical efficacy of different treatment options. The primary aim of the present study was to investigate the clinical efficacy of different conservative and surgical treatment options. The secondary aim was to assess return to sports (RTS) and radiologic outcomes for the different treatment options. METHODS: An electronic literature search was carried out in the databases PubMed, EMBASE, Cochrane, CDSR, CENTRAL, and DARE from January 1996 to September 2021 to identify suitable studies for this review. The authors separately screened the articles for eligibility and conducted the quality assessment using the Methodological Index for Non-Randomized Studies (MINORS). Clinical success rates were calculated per separate study and pooled per treatment strategy. Radiologic outcomes and sports outcomes for the different treatment strategies were assessed. RESULTS: Twenty studies with a total of 381 lesions were included. The mean MINORS score of the included study was 7.6 (range: 5 to 9). The pooled success rate was 44% [95% confidence interval (CI): 37%-51%] in the conservative group (n=192), 77% (95% CI: 68%-85%) in the bone marrow stimulation (BMS) group (n=97), 95% (95% CI: 78%-99%) in the retrograde drilling (RD) group (n=22), 79% (95% CI: 61%-91%) in the fixation group (n=33) and 67% (95% CI: 35%-88%) in the osteo(chondral) autograft group (n=9). RTS rates were reported in 2 treatment groups: BMS showed an RTS rate of 86% (95% CI: 42%-100%) without specified levels and an RTS rate to preinjury level of 43% (95% CI: 10%-82%). RD showed an RTS rate of 100% (95% CI: 63%-100%) without specified levels, an RTS rate to preinjury level was not given. RTS times were not given for any treatment option. The radiologic success according to magnetic resonance imaging were 29% (95% CI: 16%-47%) (n=31) in the conservative group, 81% (95% CI: 65%-92%) (n=37) in the BMS group, 41% (95% CI: 18%-67%) (n=19) in the RD group, 87% (95% CI: 65%-97%) (n=19) in the fixation group, and were not reported in the osteo(chondral) transplantation group. Radiologic success rates based on computed tomography scans were 62% (95% CI: 32%-86%) (n=13) in the conservative group, 30% (95% CI: 7%-65%) (n=10) in the BMS group, 57% (95% CI: 25%-84%) (n=7) in the RD group, and were not reported for the fixation and the osteo(chondral) transplantation groups. CONCLUSIONS: This study showed that for skeletally immature patients presenting with symptomatic OLTs, conservative treatment is clinically successful in 4 out of 10 children, whereas the different surgical treatment options were found to be successful in 7 to 10 out of 10 children. Specifically, fixation was clinically successful in 8 out of 10 patients and showed radiologically successful outcomes in 9 out of 10 patients, and would therefore be the primary preferred surgical treatment modality. The treatment provided should be tailor-made, considering lesion characteristics and patient and parent preferences. LEVEL OF EVIDENCE: Level IV-systematic review and meta-analysis.

Lower leg symmetry: a Q3D-CT analysis.

PURPOSE: In fracture and realignment surgery, the contralateral unaffected side is often used as a model or template for the injured bone even though clinically valuable quantitative data of bilateral symmetry are often unavailable. Therefore, the objective of the present study was to quantify and present the bilateral symmetry of the tibia and fibula. METHODS: Twenty bilateral lower-leg CT scans were acquired in healthy volunteers. The left and right tibia and fibula were segmented resulting in three-dimensional polygons for geometrical analyses (volume, surface and length). The distal and proximal segment of the right tibia of each individual was subsequently matched to the left tibia to quantify alignment differences (translation and rotation). Bone symmetry on group level was assessed using the Student's t test and intra-individual differences were assessed using mixed-models analyses. RESULTS: Intra-individuals differences were found for tibia volume (5.2 ± 3.3 cm3), tibia surface (5.2 ± 3.3 cm2), translations in the lateral (X-axis; 9.3 ± 8.9 mm) and anterior direction (Y-axis; 7.1 ± 7.0 mm), for tibia length (translation along Z-axis: 3.1 ± 2.4 mm), varus/valgus (φz: 1.7o ± 1.4°), and endotorsion/exotorsion (φz: 4.0o ± 2.7°). CONCLUSION: This study shows intra-individual tibia asymmetry in both geometric and alignment parameters of which the surgeon needs to be aware in pre-operative planning. The high correlation between tibia and fibula length allows the ipsilateral fibula to aid in estimating the original tibia length post-injury. Future studies need to establish whether the found asymmetry is clinically relevant when the contralateral side is used as reference in corrective surgery. LEVEL OF EVIDENCE: III cohort study.

8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions.

BACKGROUND: The primary aim was to determine the clinical success rate after treatment for talocalcaneal (TCC) and calcaneonavicular coalitions (CNC). The secondary aim was to evaluate the complication, recurrence and revision rate. METHODS: A search was carried out in MEDLINE, EMBASE and Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria. The primary outcome was the clinical success rate and was pooled per type of coalition and treatment modality. 95% Confidence Intervals (CI) of the success rates were calculated. Secondary outcomes included complication rates, coalition recurrence rates, revision rates and pain improvement using the Visual Analogue Scale (VAS). A sub-analysis on interposition material was performed. RESULTS: 43 articles comprising of 1284 coalitions were included, with a pooled mean follow-up of 51 months. Methodological quality was fair. The overall pooled success rate for TCCs was 79% (95% CI, 75%-83%). Conservative treatment, open resection and arthroscopic resection of TCCs resulted in success rates of 58% (95% CI, 42%-73%), 80% (95% CI, 76%-84%) and 86% (95% CI, 71%-94%), respectively. CNCs have an overall success rate of 81% (95% CI, 75%-85%), with 100% (95% CI, 34%-100%), 80% (95% CI, 74%-85%) and 100% (95% CI, 65%-100%) for conservative treatment, open resection and arthroscopic resection, respectively. Pooled complication rates of 4% (95% CI, 3%-7%) for TCCs and 6% (95% CI, 4%-11%) for CNCs were found. The success rates of resection with and without interposition material for TCCs were 83% (95% CI, 78%-87%) and 79% (95% CI, 65%-88%), and for CNCs 81% (95% CI, 76%-86%) and 69% (95% CI, 44%-85%), respectively. CONCLUSION: Treatment of tarsal coalitions can be considered good to excellent as well as safe, with an overall clinical success rate of 79% for TCCs and 81% for CNCs. Arthroscopic resection of the coalition appears to be non-inferior to open resection of TCCs and CNCs. LEVEL OF EVIDENCE: Level IV, Systematic Review.

Editorial Commentary: How Far Can the Arthroscope Reach in the Ankle Joint?

Surgical access to pathology of the talar dome (e.g., osteochondral lesions of the talus) can be limited because of the ankle joint congruity. When considering arthroscopic treatment, anterior arthroscopy with the ankle in plantar flexion or posterior arthroscopy with the ankle in dorsiflexion is used. The surgeon should carefully assess different clinical and radiologic aspects to plan the optimal operative approach. Meticulous physical examination, including ankle range of motion and possible palpation of a talar lesion, in combination with exact lesion localization on computed tomography or magnetic resonance imaging usually provide sufficient preoperative information. Most lesions with the anterior border localized on or anterior to the midline of the talus are accessible by anterior arthroscopy. In the case of preoperative doubt concerning the intraoperative accessibility, a computed tomography scan of the ankle in full plantarflexion is used to mirror arthroscopic reachability. Intraoperative surgical tricks to increase accessibility to the lesion may consist of an adjunct soft-tissue distraction device, reduction of the distal tibial rim, and treating the lesion from anteriorly to posteriorly, thereby gaining further exposure to the lesion throughout the procedure.

Six out of ten patients with sinus tarsi syndrome returned to pre-injury type of sport after subtalar arthroscopy.

PURPOSE: The purpose of this study was to determine multiple return to sport rates, long-term clinical outcomes and safety for subtalar arthroscopy for sinus tarsi syndrome. METHODS: Subtalar arthroscopies performed for sinus tarsi syndrome between 2013 and 2018 were analyzed. Twenty-two patients were assessed (median age: 28 (IQR 20-40), median follow-up 60 months (IQR 42-76). All patients were active in sports prior to the injury. The primary outcome was the return to pre-injury type of sport rate. Secondary outcomes were time and rate of return to any type of sports, return to performance and to improved performance. Clinical outcomes consisted of Numerous Rating Scale of pain, Foot and Ankle Outcome Score, 36-item Short Form Survey and complications and re-operations. RESULTS: Fifty-five percent of the patients returned to their preoperative type of sport at a median time of 23 weeks post-operatively (IQR 9.0-49), 95% of the patients returned to any type and level sport at a median time of 12 weeks post-operatively (IQR 4.0-39), 18% returned to their preoperative performance level at a median time of 25 weeks post-operatively (IQR 8.0-46) and 5% returned to improved performance postoperatively at 28 weeks postoperatively (one patient). Median NRS in rest was 1.0 (IQR 0.0-4.0), 2.0 during walking (IQR 0.0-5.3) during walking, 3.0 during running (IQR 1.0-8.0) and 2.0 during stair-climbing (IQR 0.0-4.5). The summarized FAOS score was 62 (IQR 50-90). The median SF-36 PCSS and the MCSS were 46 (IQR 41-54) and 55 (IQR 49-58), respectively. No complications and one re-do subtalar arthroscopy were reported. CONCLUSION: Six out of ten patients with sinus tarsi syndrome returned to their pre-injury type of sport after being treated with a subtalar arthroscopy. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures. LEVEL OF EVIDENCE: IV.