Jones Fracture Treatment: A Novel Surgical Technique and Case Series.

BACKGROUND: Jones fractures remain a challenging treatment entity in orthopaedics. Biomechanical stresses, including increased fifth metatarsal (5MT) lateral angle deviation (MLAD), are associated with increased fracture and refracture rates. Current fixation techniques produce good outcomes; however, they do not address metatarsal morphology, which can predispose to refracture. This study describes a novel surgical technique and case series utilizing intramedullary screw fixation and distal metatarsal corrective osteotomy for the management of Jones fractures. METHODS: A retrospective case series was undertaken, including 22 consecutive Jones fracture patients operated on by a single surgeon. Patient demographics, imaging, and operative information were obtained, with return to sport/previous function and radiological outcomes, including fracture union being the outcomes of interest. The surgical technique utilizes a distal osteotomy of the 5MT followed by retrograde guidewire and drilling utilizing the osteotomy. A cannulated screw is passed antegrade along the entire length of the 5MT with manual MLAD correction. Autograft or bone substitute (Augment) was then injected at the fracture site. RESULTS: Median age was 30 years (Q1, Q3: 18, 49 years). Median time from injury to operation was 13 weeks (Q1, Q3: 9, 30 weeks), and clinical follow-up period was 37 months (Q1, Q3: 14, 74 months). Radiological union was achieved at a median of 12 weeks (Q1, Q3: 8, 15 weeks) with clinical union at 11 weeks (Q1, Q3: 8, 14 weeks). All but one patient returned to preinjury functional levels, including 6 professional athletes who returned to preinjury national competition. No refractures were identified. CONCLUSION: The technique described in this study is a viable and safe means of managing Jones fractures. The technique may be particularly useful in patients with excessive MLAD. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

Lesion Size Measured on MRI Does Not Accurately Reflect Arthroscopic Measurement in Talar Osteochondral Lesions.

BACKGROUND: Lesion size is a major determinant of treatment strategy for osteochondral lesions of the talus (OLTs). Although magnetic resonance imaging (MRI) is commonly used in the preoperative evaluation of OLTs, the reliability of the MRI measurement compared with the arthroscopic measurement is unknown. PURPOSE: To compare preoperative lesion size measured on MRI versus intraoperative lesion size measured during arthroscopy. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We retrospectively reviewed a consecutive series of patients treated with bone marrow stimulation for OLTs. The diameter of the lesion was measured at its widest point in 2 planes, and MRI measurements were compared with those made during arthroscopy using a custom-made graduated probe. RESULTS: A total of 39 patients with 45 OLTs were analyzed. Mean ± SD area measurements on MRI were significantly greater than the equivalent arthroscopic measurements (42.2 ± 30.5 vs 28.6 ± 23.1 mm2, respectively; P = .03). Compared with the arthroscopic measurement, MRI overestimated OLT size in 53.3% (24/45) of ankles and underestimated OLT size in 24.4% (11/45). The mean MRI diameter measurement was significantly greater than the arthroscopic measurement in the coronal plane (MRI diameter vs arthroscopic measurement coronal plane, 6.1 ± 2.6 vs 4.9 ± 2.3 mm, P = .03; sagittal plane, 8.0 ± 3.6 vs 6.3 ± 3.6 mm, P = .05). Further, MRI overestimated coronal diameter in 48.9% (22/45) of ankles and underestimated in 26.7% (12/45) compared with the arthroscopic measurement. Similarly, sagittal plane MRI diameter measurements overestimated lesion size in 46.7% (21/45) of ankles and underestimated lesion size in 28.9% (13/45) compared with the arthroscopic findings. CONCLUSION: In a majority of lesions, MRI overestimated OLT area and diameter compared with arthroscopy. Surgeons should be aware of the discrepancies that can exist between MRI and arthroscopic measurements, as these data are important in making treatment decisions and educating patients.

Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration.

PURPOSE: Bone marrow concentrate (BMC) and platelet-rich plasma (PRP) are used extensively in regenerative medicine. The aim of this study was to determine differences in the cellular composition and cytokine concentrations of BMC and PRP and to compare two commercial BMC systems in the same patient cohort. METHODS: Patients (29) undergoing orthopaedic surgery were enrolled. Bone marrow aspirate (BMA) was processed to generate BMC from two commercial systems (BMC-A and BMC-B). Blood was obtained to make PRP utilizing the same system as BMC-A. Bone marrow-derived samples were cultured to measure colony-forming units, and flow cytometry was performed to assess mesenchymal stem cell (MSC) markers. Cellular concentrations were assessed for all samples. Catabolic cytokines and growth factors important for cartilage repair were measured using multiplex ELISA. RESULTS: Colony-forming units were increased in both BMCs compared to BMA (p < 0.0001). Surface markers were consistent with MSCs. Platelet counts were not significantly different between BMC-A and PRP, but there were differences in leucocyte concentrations. TGF-ß1 and PDGF were not different between BMC-A and PRP. IL-1ra concentrations were greater (p = 0.0018) in BMC-A samples (13,432 pg/mL) than in PRP (588 pg/mL). The IL-1ra/IL-1ß ratio in all BMC samples was above the value reported to inhibit IL-1ß. CONCLUSIONS: The bioactive factors examined in this study have differing clinical effects on musculoskeletal tissue. Differences in the cellular and cytokine composition between PRP and BMC and between BMC systems should be taken into consideration by the clinician when choosing a biologic for therapeutic application. LEVEL OF EVIDENCE: Clinical, Level II.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies.

BACKGROUND: The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation. METHODS: Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported. RESULTS: A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability. CONCLUSION: This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Arthroscopic Surgical Technique for an Acute Talar Dome Osteochondral Lesion in a Professional Rugby League Player.

BACKGROUND: Talar osteochondral lesions represent challenging clinical entities, particularly in high-demand athletes. Surgical treatment of large lesions often requires a 2-step procedure, or the use of osteotomy in the case of autologous osteochondral transfer, which can delay return to sport. METHODS: A professional rugby league player underwent surgery for a complex injury to the ankle. A talar osteochondral lesion with a maximal diameter of 15 mm was treated in an arthroscopic fashion using the cartilage taken from the completely displaced osteochondral fragment. Cartilage was cut into chips and combined with bone graft product containing platelet-derived growth factor and a porous collagen scaffold. Autologous cartilage was then reimplanted arthroscopically. The patient was allowed full ankle motion from 2 weeks postoperatively, and weightbearing was commenced at 6 weeks. Follow-up imaging and functional outcomes, including return to sport, were assessed at regular intervals. RESULTS: The patient was able to return to professional rugby league by 23 weeks postoperatively. Magnetic resonance imaging at 16 months postoperatively showed restoration of the subchondral plate and osseous infill. At final follow-up, the patient remained pain free and was playing at preinjury level. CONCLUSION: This report describes good outcomes using a novel, 1-step cartilage repair technique to treat a large talar osteochondral lesion in a professional athlete. LEVELS OF EVIDENCE: Level V: Expert opinion.

Clinical and MRI Donor Site Outcomes Following Autologous Osteochondral Transplantation for Talar Osteochondral Lesions.

BACKGROUND: Autologous osteochondral transplantation (AOT) has an inherent risk of donor site morbidity (DSM). The reported rates of DSM vary from 0% to 50%, with few studies reporting clinical or imaging outcomes at the donor site as a primary outcome and even fewer report these outcomes when a biosynthetic plug backfill is employed. Although TruFit (Smith & Nephew, Andover, MA) plugs have been removed from the market for regulatory purposes, biphasic plugs (including TruFit plugs) have been used for several years and the evaluation of these is therefore pertinent. METHODS: Thirty-nine patients who underwent forty AOT procedures of the talus, with the donor graft being taken from the ipsilateral knee, were included. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site graded with magnetic resonance observation of cartilage repair tissue (MOCART) scoring. Lysholm scores were collected preoperatively, at the time of magnetic resonance imaging (MRI), and again at 24 months and at final follow-up to assess clinical outcomes. Statistical analysis was performed to establish if there was any correlation between MRI assessment of the donor site and clinical outcomes. The mean patient age was 36.2 ± 15.7 years with a mean follow-up of 41.8 ± 16.7 months. RESULTS: All patient donor site defects were filled with OBI TruFit biphasic plugs. DSM was encountered in 12.5% of the patient cohort at 24 months, and in these patients, the Lysholm score was a mean 87.2 ± 5.0. At final follow-up, DSM was reduced to 5%. Lysholm scores for the entire cohort were 98.4 ± 4.6 and 99.4 ± 3.1 at 24 months and final follow-up, respectively. MRI of the donor sites were taken at an average of 18.1 ± 13.5 (range, 3-48) months postoperatively and the mean MOCART score was 60.0 ± 13.5. No correlation was found between the MOCART score and Lysholm outcomes at the donor knee (P = .43, r = 0.13). CONCLUSION: Low incidence of DSM and good functional outcomes were achieved with AOT. Additionally, MRI findings did not predict clinical outcomes in our study. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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: Does Previous Bone Marrow Stimulation Negatively Affect Clinical Outcome?

PURPOSE: To determine if functional outcomes and magnetic resonance imaging (MRI) outcomes were significantly different between patients receiving primary autologous osteochondral transplantation (AOT) and patients receiving secondary AOT surgery after failed microfracture. METHODS: A group of 76 patients enrolled into the Foot and Ankle Service between 2006 and 2012 was retrospectively analyzed. Patient-reported outcomes were evaluated in 76 patients using the Foot and Ankle Outcome Score (FAOS). Superficial and deep tissues at the repaired defect site, as well as the adjacent normal cartilage, were analyzed using quantitative T2 mapping MRI. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) allowed for morphological evaluation of the repair tissue. The mean clinical follow-up time was 51 ± 23 months (range, 12 to 97 months), and the mean MRI follow-up time was 26 months (range, 24 to 36 months). RESULTS: Twenty-two patients received primary AOT and 54 received secondary AOT after failed microfracture. Patient characteristics between groups were similar with regard to age, gender, lesion size, and follow-up time. The mean postoperative FAOS was 10 points higher in the primary AOT group (83.2 ± 17.0) compared with the secondary AOT group (72.4 ± 19.4) (P = .01). Regression analysis showed that secondary AOT patients preoperative to postoperative change in FAOS was 9 points lower than in primary AOT patients after adjustment for age, preoperative FAOS, and lesion size (P = .045). The mean MOCART score, superficial T2 and deep T2 values, and the difference between normal and repair cartilage T2 values were not significantly different between groups. Lesion size was negatively correlated with MOCART scores (ρ = -0.2, P = .04), but positively correlated with difference in T2 values between repair and adjacent normal cartilage in the superficial layer (ρ = 0.3, P = .045). CONCLUSIONS: Primary AOT shows better functional outcomes compared with secondary AOT after failed microfracture in patients with similar characteristics and lesion size. No significant differences in T2 mapping relaxation times and MOCART scores were identified. LEVEL OF EVIDENCE: Level III, case control study.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management.

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

Trends of Concurrent Ankle Arthroscopy at the Time of Operative Treatment of Ankle Fracture: A National Database Review.

BACKGROUND: The purpose of this study was to report trends associated with concurrent ankle arthroscopy at the time of operative treatment of ankle fracture. METHOD: The current procedural terminology (CPT) billing codes were used to search the PearlDiver Patient Record Database and identify all patients who were treated for acute ankle fracture in the United States. The Medicare Standard Analytic Files were searchable between 2005 and 2011 and the United Healthcare Orthopedic Dataset from 2007 to 2011. Annual trends were expressed only between 2007 and 2011, as it was the common time period among both databases. Demographic factors were identified for all procedures as well as the cost aspect using the Medicare data set. RESULTS: In total, 32 307 patients underwent open reduction internal fixation (ORIF) of an ankle fracture, of whom 313 (1.0%) had an ankle arthroscopy performed simultaneously. Of those 313 cases, 70 (22.4%) patients received microfracture treatment. Between 2005 and 2011, 85 203 patients were treated for an ankle fracture whether via ORIF or closed treatment. Of these, a total of 566 patients underwent arthroscopic treatment within 7 years. The prevalence of arthroscopy after ankle fracture decreased significantly by 45% from 2007 to 2011 (P< .0001). When ORIF and microfracture were performed concurrently, the total average charge for both procedures drops to $4253.00 and average reimbursement to $818.00 compared with approximately $4964.00 and $1069.00, respectively, when they were performed subsequently. CONCLUSION: Despite good evidence in favor of arthroscopy at the time of ankle fracture treatment, it appears that only a small proportion of surgeons in the United States perform these procedures concurrently. LEVELS OF EVIDENCE: Therapeutic, Level IV: Retrospective.

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.

Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review.

BACKGROUND: Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis. METHODS: A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis. RESULTS: The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed. CONCLUSIONS: There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature.

PURPOSE: To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. METHODS: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. RESULTS: Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. CONCLUSIONS: Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. LEVEL OF EVIDENCE: Level IV, systematic review of Level II and IV studies.

Clinical presentation of chorioretinitis sclopetaria.

PURPOSE: To report the clinical manifestations of a case of chorioretinitis sclopetaria. METHODS: Observational case report. RESULTS: A 30-year-old prison inmate sustained a traumatic injury to his left eye. Fundus examination showed a large chorioretinal detachment revealing bare sclera, vitreous hemorrhage, and commotio retinae. CONCLUSION: The patient was diagnosed with chorioretinitis sclopetaria. Given the mechanism of injury, retinal detachment is rare. Observation is appropriate as initial management.