Microfracture for osteochondral lesions of the talus: a systematic review of reporting of outcome data.

BACKGROUND: Microfracture is recognized as a primary treatment strategy for osteochondral lesions of the talus up to 15 mm in size. The ability of fibrocartilage to withstand the mechanical loading of the joint over time is unknown. PURPOSE: The purpose of this study was to systematically review studies of microfracture for OLT and descriptively analyze the outcome data reported to determine whether it is consistent from one study to another and able to be pooled for systematic review. METHODS: A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published between January 1966 and June 2011 were included in the review. Only studies that reported data specifically on microfracture for treatment of osteochondral lesions of the talus and written in English were included in this review. RESULTS: Twenty-four studies were included in this systematic review. The categories of general demographics and study design were generally well reported (each over 80% of studies). Patient history and patient-reported outcome data were reported less (55%-66%). Clinical variables (48%) and imaging data (39%) were the least reported in studies. CONCLUSION: There were gross inconsistencies and an underreporting of data between studies such that pooling was deemed impossible. A concerted effort must be made by investigators to ensure that there is adequate reporting of data in studies of microfracture treatment for OLT. A set of guidelines to assist surgeons in reporting data may be useful for future research.

Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population.

BACKGROUND: Anatomic and checkrein tenodesis reconstruction techniques have been described as a means of treatment for chronic lateral ligament instability in the ankle. The current article describes a hybrid procedure using the most advantageous concepts of both techniques for use when insufficient normal ligament remains to fashion a direct repair of the anterior talofibular ligament (ATFL). PURPOSE: The authors report the results at a minimum 1-year follow-up of 57 patients who underwent a hybrid anatomic lateral ligament reconstruction technique in the ankle. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-seven patients underwent a hybrid anatomic lateral ligament reconstruction procedure under the care of the senior author. All patients were assessed preoperatively and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) outcome score. The mean patient age at the time of surgery was 28 years (range, 17-65 years), including 39 male and 18 female patients. The mean follow-up time was 32 months (range, 12-47 months). RESULTS: The FAOS improved from 58 points preoperatively to 89 points postoperatively (P < .01). The SF-12 score improved from 48 points before surgery to 80 points at final follow-up (P < .01). All patients achieved mechanical stability at final clinical follow-up; 7 patients (12%) demonstrated functional instability. Functional instability was found to significantly influence not returning to sport at the previous level. CONCLUSION: This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible.

The lateral dorsal cutaneous branch of the sural nerve: clinical importance of the surgical approach to proximal fifth metatarsal fracture fixation.

BACKGROUND: Fractures of the proximal fifth metatarsal are one of the most common forefoot injuries encountered by orthopaedic surgeons in sports medicine. The percutaneous surgical approach to Jones fracture fixation and corresponding anatomy has received little attention in the literature to date. PURPOSE: To describe in detail the location of the lateral dorsal cutaneous nerve (LDCN) and its branches relative to the base of the fifth metatarsal and to the standard lateral approach. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten fresh-frozen cadaveric foot specimens were used for this study. Specimens were dissected at the lateral aspect of the foot over the proximal fifth metatarsal, and the LDCN and its branches were identified. The distance of the LDCN to the superior border of the peroneus brevis tendon (PBT) was measured relative to standard reference points in all specimens, and the presence of an anastomotic branch was noted. A set of vertical and horizontal reference lines were also constructed to determine whether the LDCN or its branches would be compromised by a standard lateral approach. RESULTS: The LDCN was superficial (ie, lateral) and inferior to the superior border of the PBT in all specimens and at all reference points. A bifurcation of the LDCN was present in 8 specimens, located an average of 18 mm posterior and 11 mm dorsal to the base of the fifth metatarsal. The dorsolateral branch and dorsomedial branch of the LDCN each intersected with the base of the fifth metatarsal horizontal line and vertical line, respectively, indicating potential compromise of the nerve with a standard lateral surgical approach. CONCLUSION: The standard lateral approach to the base of the fifth metatarsal carries a higher risk for surgical injury to the LDCN. A "high and inside" approach that remains superior to the superior border of the PBT is anatomically safe and may decrease the chance of intraoperative nerve injury and irritation postoperatively.

Autologous osteochondral transplantation of the talus partially restores contact mechanics of the ankle joint.

BACKGROUND: Autologous osteochondral transplantation procedures provide hyaline cartilage to the site of cartilage repair. It remains unknown whether these procedures restore native contact mechanics of the ankle joint. PURPOSE: This study was undertaken to characterize the regional and local contact mechanics after autologous osteochondral transplantation of the talus. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric lower limb specimens were used for this study. Specimens were loaded using a 6 degrees of freedom robotic arm with 4.5 N·m of inversion and a 300-N axial compressive load in a neutral plantar/dorsiflexion. An osteochondral defect was created at the centromedial aspect of the talar dome and an autologous osteochondral graft from the ipsilateral knee was subsequently transplanted to the defect site. Regional contact mechanics were analyzed across the talar dome as a function of the defect and repair conditions and compared with those in the intact ankle. Local contact mechanics at the peripheral rim of the defect and at the graft site were also analyzed and compared with the intact condition. A 3-dimensional laser scanning system was used to determine the graft height differences relative to the native talus. RESULTS: The creation of an osteochondral defect caused a significant decrease in force, mean pressure, and peak pressure on the medial region of the talus (P = .037). Implanting an osteochondral graft restored the force, mean pressure, and peak pressure on the medial region of the talus to intact levels (P = .05). The anterior portion of the graft carried less force, while mean and peak pressures were decreased relative to intact (P = .05). The mean difference in graft height relative to the surrounding host cartilage for the overall population was -0.2 ± 0.3 mm (range, -1.00 to 0.40 mm). Under these conditions, there was no correlation between height and pressure when the graft was sunken, flush, or proud. CONCLUSION/CLINICAL RELEVANCE: Placement of the osteochondral graft in the most congruent position possible partially restored contact mechanics of the ankle joint. Persistent deficits in contact mechanics may be due to additional factors besides graft congruence, including structural differences in the donor cartilage when compared with the native tissue.