Medium- to Long-term Results of Nonanatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity With Severe Abduction Deformity.

BACKGROUND: Spring ligament reconstruction (SLR) has been suggested as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity. Most clinical reports present short-term follow-up data and a small number of patients. The purpose of this study was to examine the medium- to long-term outcomes of an SLR using allograft tendon augmentation as part of PCFD surgical reconstruction. This study to our knowledge represents the largest number of patients and the longest follow-up to date. METHODS: This study retrospectively reviewed 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5-13.4). Radiographic evaluation consisted of 5 parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure. RESULTS: Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction. All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except 1 patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and 1 (3.7%) developed nonunion of the lateral column lengthening osteotomy. No patient required conversion to talonavicular or subtalar fusion. CONCLUSION: This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation. LEVEL OF EVIDENCE: Level IV, case series.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches.

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options.

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. Level of Evidence: Level V, review article/expert opinion.

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.

Fiber-reinforced fixation implant for proximal interphalangeal joint arthrodesis shows advanced implant bio-integration at 2-year follow-up.

BACKGROUND: A bio-integrative fiber-reinforced implant (OSSIOfiber® Hammertoe Fixation Implant, OSSIO Ltd., Caesarea, Israel) for proximal interphalangeal joint (PIPJ) correction-arthrodesis showed partial bio-integration at 1-year follow-up (1FU) in a previous study. The study was prolonged to assess the bio-integration at 2-year-follow-up (2FU). METHODS: Twenty-four patients with proximal interphalangeal joint (PIPJ) correction-arthrodesis using the fiber-reinforced implant and analysed at 1FU, completed 2FU. Follow-up included clinical examination, patient reported outcomes, radiographs, MRI and bio-integration scoring. Results were compared between the 1FU and 2FU (paired t-test). RESULTS: Radiographs confirmed fusion in 96 % (n = 23) at 2FU (1FU, 92 % (n = 22)). Implant was no longer visible in 21 % (n = 5), partially visible in 33 % (n = 8), and fully visible in 46 % (n = 11)(1FU, fully visible 100 % (n = 24)). The border between implant and surrounding bone was scored not visible in 88 % (n = 21) and partially visible in 12 % (n = 3) (1FU, border partially visible 100 % (n = 24)). There were no cyst formation or fluid accumulation findings 1FU/2FU. Mild bone edema was detected in 4 % (n = 1) (1FU, 29 % (n = 7)). None of the edema findings were considered as adverse implant related. The mean bio-integration score was 9.71 ± 0.69 at 2FU (1FU, 7.71 ± 0.46). The parameters of border between implant and bone and bone edema further improved at the 2FU compared to the 1FU, total bio-integration score was also higher at 2FU than 1FU (each p < 0.05). CONCLUSIONS: This study demonstrates 96 % PIPJ fusion rate and increased bio-integration from 1FU to 2FU, reaching advanced bio-integration of the fiber-reinforced implant at 2FU.

Imaging Techniques for Assessment of Dynamically Unstable Sports Related Foot and Ankle Injuries.

Foot and ankle instability can be seen both in acute and chronic settings, and isolating the diagnosis can be difficult. Imaging can contribute to the clinical presentation not only by identifying abnormal morphology of various supporting soft tissue structures but also by providing referring clinicians with a sense of how functionally incompetent those structures are by utilizing weight-bearing images and with comparison to the contralateral side. Loading the affected joint and visualizing changes in alignment provide clinicians with information regarding the severity of the abnormality and, therefore, how it should be managed.

Sagittal Tibiotalar Alignment May Not Affect Functional Outcomes in Fixed-Bearing Total Ankle Replacement: A Retrospective Cohort Study.

BACKGROUND: In total ankle replacement (TAR), correct positioning of the implant is crucial. Malposition of the components may increase contact pressures and diminish prosthesis survival. The effect of sagittal tibiotalar alignment on functional outcomes after fixed-bearing TAR remains unclear, however, and no studies have compared fixed-bearing implants with respect to the anteroposterior (AP) position of the talar component. QUESTIONS/PURPOSE: The purposes of this study were (1) to evaluate the effect of sagittal tibiotalar alignment on functional outcomes in fixed-bearing TAR and (2) to compare post-operative sagittal tibiotalar alignment in two types of fixed-bearing implants. METHODS: In a retrospective analysis of 71 primary TARs performed at a single center, we studied the INBONE™ II Total Ankle System and the Salto Talaris® Ankle. Radiographic measurements of the tibial axis-talus (T-T) ratio and the AP offset ratio were performed before and after surgery, respectively, and we evaluated Foot and Ankle Outcome Scores (FAOSs) and the 12-item Short Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scales pre-operatively and at 2 years after surgery. The Pearson correlation and independent-samples t test were used to evaluate differences in FAOSs, SF-12 MCS scores, and SF-12 PCS scores regarding post-operative sagittal alignment. RESULTS: Post-operative sagittal tibiotalar alignment was neutral in 39 ankles and anterior in 32 ankles. We observed no significant between-group differences in clinical outcome scores. Patients with a Salto Talaris Ankle prosthesis had a greater AP offset ratio (0.12) than patients with an INBONE II implant (0.05). However, the greater translation did not correlate with outcome scores. CONCLUSION: At the 2-year follow-up, no correlation between the post-operative AP offset ratio and functional outcome scores was observed between the two fixed-bearing-implant groups. Further studies with longer follow-up are needed to determine whether the difference in sagittal alignment has an effect on functional outcomes in the long term.

Position of the Posteromedial Ankle Structures in Patients Indicated for Total Ankle Replacement.

BACKGROUND: The posteromedial ankle structures are at risk during total ankle replacement (TAR). The purpose of our study was to investigate the distance of these structures from the posterior cortex of the tibia and talus in order to determine their anatomy at different levels of bone resection during a TAR and whether plantarflexion of the ankle reliably moved these structures posteriorly. METHODS: Ten feet in 10 patients with end-stage tibiotalar arthritis indicated for a TAR were included. Preoperative magnetic resonance images were obtained with the foot in a neutral position as well as in maximum plantarflexion to measure the distance of posteromedial ankle structures to the closest part of the posterior cortex of the tibia or talus. Wilcoxon signed-rank rests were used to investigate differences in these distances. RESULTS: The mean distance from the posterior tibial cortex to the tibial nerve at 14 and 7 mm above the tibial plafond was 8.7 mm (range 5.0-11.8 mm) and 6.7 mm (range 2.7-10.6 mm), respectively, which represented a statistically significant movement anteriorly (P = .021). The posterior tibial artery was, on average, 8.0 mm (range 3.6-13.9 mm) and 7.2 mm (range 3.1-9.4 mm) from the posterior tibial cortex at 14 and 7 mm above the tibial plafond, respectively. Distal to the tibial plafond, the posterior tibial artery and flexor digitorum longus tendons moved posteriorly by less than 1 mm in plantarflexion (all P < .05); otherwise, plantarflexion of the ankle did not affect the position of the tibial nerve, posterior tibial tendon, or flexor hallucis longus. CONCLUSION: In patients with end-stage ankle arthritis, the tibial nerve and posterior tibial artery lie, on average, between 6.5 and 10 mm from the posterior tibial and talar cortices. Plantarflexion of the ankle did not reliably move the posteromedial ankle structures posteriorly. LEVEL OF EVIDENCE: Level IV, case series, therapeutic.

Imaging of Bone Perfusion and Metabolism in Subjects Undergoing Total Ankle Arthroplasty Using 18F-Fluoride Positron Emission Tomography.

BACKGROUND: Total ankle arthroplasty (TAA) continues to exhibit a relatively high incidence of complications and need for revision surgery compared to knee and hip arthroplasty. One common mode of failure in TAA is talar component subsidence. This may be caused by disruption in the talar blood supply related to the operative technique. The purpose of this study was to quantify changes in talar bone perfusion and turnover before and after TAA with the INBONE II system using 18F-fluoride positron emission tomography / computed tomography (PET/CT). METHODS: Nine subjects (5 M/4 F) aged 68.9 ± 8.2 years were enrolled for 18F-fluoride PET/CT imaging before and 3 months after TAA. Regions of interest (ROI) were placed on the postoperative CT images in the body of the talus beneath the talar component and overlaid on the fused static PET images. Standard uptake values (SUVs) along with dynamic K1 (bone blood flow) and ki (bone metabolism or osteoblastic turnover) were calculated. RESULTS: The SUV underneath the talar component compared to that measured at baseline before surgery was 1.93 ± 0.29 preoperatively vs 2.47 ± 0.37 postoperatively (P > .05). K1 was 0.84 ± 0.16 mL/min/mL preoperatively vs 1.51 ± 0.23 mL/min/mL postoperatively (P = .026). ki was constant at 0.09 ± 0.03 mL/min/mL preoperatively vs 0.12 ± 0.03 mL/min/mL postoperatively (P > .05). CONCLUSION: Our study was the first to link 18F-fluoride PET/CT with pre-post evaluation of total ankle replacements. The study quantified perfusion within the talus beneath the TAA implant supporting the hypothesis that perfusion of the talus remained intact after surgery. LEVEL OF EVIDENCE: Level II, prospective cohort study with development of diagnostic criteria.

Comparison of Tibial and Talar Bone Density in Patients Undergoing Total Ankle Replacement vs Non-Ankle Arthritis Matched Controls.

BACKGROUND: Bone quality in the distal tibia and talus is an important factor contributing to initial component stability in total ankle replacement (TAR). However, the effect of ankle arthritis on bone density in the tibia and talus remains unclear. The objective of this study was to compare bone density of tibia and talus in arthritic and nonarthritic ankles as a function of distance from ankle joint. METHODS: We retrospectively reviewed 93 end-stage ankle arthritis patients who had preoperative nonweightbearing ankle computed tomography (CT) and identified a cohort of 83 nonarthritic ankle patients as a demographic-matched control group. A region of interest tool was used to calculate Hounsfield unit (HU) values in the cancellous region of the tibia and talus. Measurements were obtained on axial cut CTs from 6 to 12 mm above the tibial plafond, and 1 to 4 mm below the talar dome. HU measurements between groups and the decrease of HU at the relative level in each group were compared. RESULTS: Arthritic ankles demonstrated significantly greater mean bone density than nonarthritic ankles at between 6 and 10 mm above the joint in the tibia (P < .05). No significant difference in bone density between 10 and 12 mm from the joint in the tibia nor at any level of the talus was found between groups. In both groups, bone density decreased significantly at each successive level away from the ankle joint. CONCLUSION: Ankle arthritis patients demonstrated greater or equal bone density in both the tibia and talus compared to demographic-matched controls. In both groups, bone density decreased with increasing distance away from the articular surface. In TAR, tibial bone resection between 6 and 8 mm may provide improved initial implant stability. LEVEL OF EVIDENCE: Level III, comparative study.

Assessment of Various Measurement Methods to Assess First Metatarsal Elevation in Hallux Rigidus.

BACKGROUND: While metatarsus primus elevatus (MPE) has been implicated in the development of hallux rigidus, previous studies have presented conflicting findings regarding the relationship between MPE and arthritis. This may be due to the variety of definitions for MPE and the radiographic measurement techniques that are used to assess it. Additionally, previous studies have only assessed elevation of the first metatarsal with respect to the floor or the second metatarsal, and not with respect to the proximal phalanx. The aim of this study was to examine the reliability of new radiographic measurements that consider the elevation of the first metatarsal in relation to the proximal phalanx, rather than in relation to the second metatarsal as previously described, to assess for MPE. In addition, we aimed to determine whether the elevation of the first metatarsal was significantly different in patients with hallux rigidus than in a control population. METHODS: A retrospective chart review was conducted from prospectively collected registry data at the investigators' institution to identify patients with hallux rigidus (n = 65). A size-matched control cohort of patients without evidence for first metatarsophalangeal (MTP) joint arthritis was identified (n = 65). Patients with a previous history of foot surgery, rheumatoid arthritis, or hallux valgus were excluded. Five blinded raters of varying levels of training, including 2 research assistants, 1 senior orthopedic resident, 1 foot and ankle fellowship-trained orthopedic surgeon, and 1 attending musculoskeletal fellowship-trained radiologist, evaluated 7 radiographic measurements for their reliability in assessing for MPE in hallux rigidus and control groups. Four of the 7 were newly designed measurements that include the relationship of the first MTP joint. Inter- and intrarater reliability were calculated using intraclass correlation coefficients (ICCs) and categorized by Landis and Koch reliability thresholds. The measurements between the hallux rigidus and control populations were compared using an independent t test. RESULTS: Six of the 7 radiographic measurements were found to have substantial to almost perfect interrater reliability (ICC, 0.800-0.953) between all levels of training, except for the proximal phalanx-first metatarsal angle, which showed moderate reliability (ICC, 0.527). Substantial to almost perfect intrarater reliability (ICC, 0.710-0.982) was demonstrated by the measurements performed by research assistants. All 7 of the measurements taken by the musculoskeletal fellowship-trained radiologist demonstrated significant differences in first metatarsal elevation between the hallux rigidus and control populations, with the hallux rigidus group showing increased elevation (P < .001-.019). CONCLUSION: This study confirmed the reliability of 7 radiographic measurements used to assess for MPE, including 3 previously established and 4 newly described measurements. Observers across all levels of training were able to demonstrate reliable measurements. In addition, the measurements were used to show that patients with hallux rigidus were more likely to have MPE compared with patients without radiographic evidence for first MTP arthritis. These measurements could be used in future work to examine how the presence of MPE relates to the etiology and progression of hallux rigidus, and how it affects the results of operative treatment. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Assessing the Ankle Joint Line Level Before and After Total Ankle Arthroplasty With the "Joint Line Height Ratio".

BACKGROUND: Restoring the joint line is an important principle in total knee arthroplasty. However, the effect of joint line level on patient outcomes after total ankle arthroplasty (TAA) remains unclear, as there is no established method for measuring ankle joint level in TAA. The objective of this study was to develop a reliable radiographic ankle joint line measurement method and to compare ankle joint line level measured pre-TAA, post-TAA, and in nonarthritic ankles. METHODS: A total of 112 radiographic sets were analyzed. Each set included weightbearing anteroposterior radiographs of the operative ankle taken preoperatively, 1-year postoperatively, and of the contralateral ankle. Measurements of vertical intermalleolar distance (VIMD) and vertical joint line distance (VJLD) at pre-TAA, post-TAA, and of the contralateral ankle were recorded by 2 authors on 2 separate occasions. The ratio of VJLD to VIMD was defined as the joint line height ratio (JLHR). Reliability of measurements and correlation between VIMD and VJLD were assessed. Pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHR were compared and considered significantly different if P <.05. RESULTS: The inter- and intrarater reliability of radiographic measurements was excellent (r > 0.9). There were strong positive correlations of VIMD and VJLD, r = 0.809 (pre-TAA)/0.756 (post-TAA), P < .001. Mean (SD) pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHRs were 1.54 (0.31), 1.39 (0.26), and 1.62 (0.49), respectively. Pre- and post-TAA JLHRs were significantly higher compared to the nonarthritic contralateral ankle (P < .05). JHLR was not significantly different between pre- and post-TAA (P = .15). CONCLUSION: The JLHR was reliable and could be a clinically applicable method for assessing ankle joint line level in patients undergoing TAA. End-stage ankle arthritis demonstrated elevated joint line level compared with nonarthritic ankles, and the joint line level post-TAA remained elevated compared with nonarthritic ankles. Further studies are needed to understand the effect of joint line elevation on clinical outcomes after TAA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Post-treatment Follow-up, Imaging, and Outcome Scores: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are 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 based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Post-treatment Follow-up, Imaging and Outcome Scores developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. 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 on 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%; unanimous, 100%. RESULTS: A total of 12 statements on Post-treatment Follow-up, Imaging, and Outcome Scores reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 12 statements reached strong consensus (greater than 75% agreement). CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with post-treatment follow-up, imaging, and outcome scores after management of a cartilage injury of the ankle in the general population. Moreover, healing, rehabilitation, and final outcomes can be optimized for the individual patient.

Comparison of Juvenile Allogenous Articular Cartilage and Bone Marrow Aspirate Concentrate Versus Microfracture With and Without Bone Marrow Aspirate Concentrate in Arthroscopic Treatment of Talar Osteochondral Lesions.

BACKGROUND: The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate (JACI-BMAC) for treatment of talar osteochondral lesions with those of patients who underwent microfracture (MF). METHODS: A total of 30 patients who underwent MF and 20 who received DeNovo NT for JACI-BMAC treatment between 2006 and 2014 were included. Additionally, 17 MF patients received supplemental BMAC treatment. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score and Visual Analog pain scale. Postoperative magnetic resonance images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Average follow-up for functional outcomes was 30.9 months (range, 12-79 months). Radiographically, average follow-up was 28.1 months (range, 12-97 months). RESULTS: Both the MF and JACI-BMAC showed significant pre- to postoperative improvements in all Foot and Ankle Outcome Score subscales. Visual Analog Scale scores also showed improvement in both groups, but only reached a level of statistical significance ( P < .05) in the MF group. There were no significant differences in patient reported outcomes between groups. Average osteochondral lesion diameter was significantly larger in JACI-BMAC patients compared to MF patients, but size difference had no significant impact on outcomes. Both groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group had more patients with hypertrophy exhibited on magnetic resonance imaging (MRI) than the MF group ( P = .009). CONCLUSION: JACI-BMAC and MF resulted in improved functional outcomes. However, while the majority of patients improved, functional outcomes and quality of repair tissue were still not normal. Based on our results, lesions repaired with DeNovo NT allograft still appeared fibrocartilaginous on MRI and did not result in significant functional gains as compared to MF. LEVEL OF EVIDENCE: Level III, comparative 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.

Technical Considerations: Best Practices for MR Imaging of the Foot and Ankle.

There are many challenges involved in obtaining diagnostic MR images of the foot and ankle. The complex anatomy and morphology, with curved and angular structures localized to the periphery of the body, make for an inherent challenge, let alone if an added level of complexity, such as orthopedic instrumentation, is added. This review outlines the technical considerations best designed to produce diagnostic images of the foot and ankle, with an emphasis on the postoperative state, including imaging in the presence of metal.

Effects on the Tarsal Tunnel Following Malerba Z-type Osteotomy Compared to Standard Lateralizing Calcaneal Osteotomy.

BACKGROUND: Tarsal tunnel syndrome is a known complication of lateralizing calcaneal osteotomy. A Malerba Z-type osteotomy may preserve more tarsal tunnel volume (TTV) and decrease risk of neurovascular injury. We investigated 2 effects on the tarsal tunnel of the Malerba osteotomy compared to a standard lateralizing osteotomy using a cadaveric model: (1) the effect on TTV as measured by magnetic resonance imaging (MRI) and (2) the proximity of the osteotomy saw cuts to the tibial nerve. METHODS: Ten above-knee paired cadaveric specimens underwent MRI of the ankle to obtain a baseline measurement of TTV. One foot in each pair received a standard lateralizing calcaneal osteotomy, with the other foot receiving a Malerba osteotomy. MRIs were performed after each of 3 increasing amounts of lateral displacement, which were accompanied by increasing amounts of wedge resection in the Malerba osteotomy group. TTV was measured on MRI using previously described and validated parameters. Differences in TTV with osteotomy type, displacement, and their interaction were assessed with generalized estimating equations. After all MRIs were completed, each specimen was dissected and the nearest distance of tibial nerve branches to the osteotomy site was measured. RESULTS: Baseline TTV averaged 13 229 ± 2354 mm(3) and did not differ between groups (P = .386). TTV decreased on average by 7% after the first translation, 14% after the second, and 27% after the third (P < .005 for each). The magnitude of the decrease in TTV did not differ between those specimens with standard osteotomies versus those with Malerba osteotomies (P = .578). At least one of the major branches of the tibial nerve crossed the osteotomy site in 5 of 5 specimens that received the Malerba osteotomy versus 2 of 5 that received a standard osteotomy. CONCLUSION: Regardless of osteotomy type, lateralizing calcaneal osteotomy decreased TTV. In all specimens, the osteotomy was at the level of branches of the tibial nerve. CLINICAL RELEVANCE: Our results demonstrate that lateralizing calcaneal osteotomies must be performed with care to avoid excessive lateral translation as well as direct nerve injury on the nonvisualized medial side of the calcaneus.

MRI Evaluation of Achilles Tendon Rotation and Sural Nerve Anatomy: Implications for Percutaneous and Limited-Open Achilles Tendon Repair.

BACKGROUND: Limited-open and percutaneous Achilles tendon (AT) repair techniques have limited visibility, which may result in sural nerve violation and poor tendon targeting. The goal of this study was to assess the in vivo rotation of the AT and its distance to the sural nerve in ruptured and nonruptured ATs to develop guidelines to aid in limited-open and percutaneous repair techniques. METHODS: A retrospective review was conducted to identify magnetic resonance imaging (MRI) studies of patients with ruptured and healthy (nonruptured) ATs. AT rotation and distance to the sural nerve in the anterior-posterior (A-P) and medial-lateral (M-L) planes were measured at the level of and proximal to the ankle. RESULTS: The AT was externally rotated in both ruptured and nonruptured cohorts. Ruptured ATs showed greater external rotation than nonruptured ATs at the ankle (15.8 ± 16.2 degrees vs 5.9 ± 9.0 degrees, P = .008) but not at 10 cm proximal to the tendon's insertion (10.9 ± 10.9 degrees vs 6.1 ± 8.4 degrees, P = .139). Proximal AT rotation was negatively correlated with rupture height (r = -0.477, P = .029). At 4 cm proximal to the AT insertion, the sural nerve was closer anteriorly to and farther laterally from the AT in ruptures than in nonruptures (P < .001). At 10 cm proximal to the AT insertion, the sural nerve was farther posteriorly and laterally from the AT in ruptures than in nonruptures (P = .027 and P < .001, respectively). CONCLUSION: We found that the AT was more externally rotated in ruptured than in nonruptured tendons at the ankle and that its distance to the sural nerve differed between the 2 cohorts in the A-P and M-L planes, likely due to increased AT rotation and swelling with ruptures. To minimize sural nerve injury and improve tendon targeting, we suggest an external rotation of 11 degrees at the proximal end of the rupture and 16 degrees at the distal end when using percutaneous and limited-open AT repair devices to try to minimize sural nerve violation and increase tendon capture, which can decrease rates of complication and rerupture. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

High Rate of Recurrence Following Proximal Medial Opening Wedge Osteotomy for Correction of Moderate Hallux Valgus.

BACKGROUND: The proximal medial opening wedge (PMOW) osteotomy has become more popular to treat moderate to severe hallux valgus with the recent development of specifically designed, low-profile modular plates. Despite the promising results previously reported in the literature, we have noted a high incidence of recurrence in patients treated with a PMOW. The purpose of this study was to report the clinical and radiographic outcomes of an initial cohort of patients treated with a PMOW osteotomy for moderate hallux valgus. METHODS: We retrospectively analyzed prospectively gathered data on a cohort of 17 consecutive patients who were treated by the senior author using a PMOW osteotomy for moderate hallux valgus deformity. Average time to follow-up was 2.4 years (range, 1.0-3.5 years). The intermetatarsal angle (IMA), the hallux valgus angle (HVA), and the distal metatarsal articular angle (DMAA) were assessed on standard weightbearing radiographs of the foot preoperatively and at all follow-up visits. The Foot and Ankle Outcome Score (FAOS) was collected on all patients preoperatively and at final follow-up. RESULTS: Despite demonstrating good correction of their deformity initially, 11 of the 17 patients (64.7%) had evidence of recurrence of their hallux valgus deformity at final follow-up. Patients who recurred had a greater preoperative HVA (P = .023) and DMAA (P = .049) than patients who maintained their correction. Improvement in the quality-of-life subscale of the FAOS was noted at final follow-up for all patients (P = .05). There was no significant improvement in any of the other FAOS subscales. CONCLUSIONS: There was a high rate of recurrence of the hallux valgus deformity in this cohort of patients. Recurrence was associated with greater preoperative deformity and an increased preoperative DMAA. The PMOW without a concomitant distal metatarsal osteotomy may be best reserved for patients with mild hallux valgus deformity without an increased DMAA. LEVEL OF EVIDENCE: Level IV, retrospective case series.