Modified Anatomic Hamstring Graft Reconstruction for Revision and Severe Cases of Lateral Ligament Instability

Category: Ankle Introduction/Purpose: Treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined. Results after ankle stabilization techniques involving non-anatomic reconstruction have historically been suboptimal, and newer techniques have limited presence in the literature. The purpose of this study is to report clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in patients with severe ankle instability or failed previous ankle stabilization. A novel technique for ligament reconstruction is also presented that is hypothesized to restore functional and radiographic ankle stability. Methods: A retrospective chart review was performed on all patients that had undergone modified anatomic lateral ligament reconstruction by a single surgeon between 2011 and 2015 with at least 6 months follow-up. Indications for modified anatomic reconstruction included failure of previous ankle stabilization or severe laxity with greater than 20 degrees of talar tilt or anterior drawer greater than 15 mm on stress radiographs. Patients completed routine pre- and post-operative functional outcome scores including Foot and Ankle Outcome Score (FAOS), Short Form 12 Health Survey (SF-12), and Visual Analog Scale (VAS). Patients underwent pre- and post-operative stress radiographs using the Telos Stress Device (Hungen, Germany). Thirty-four patients (35 ankles) were included with average follow-up of 26.7 months. Average age was 34.2 years, and there were 29 female patients and 5 male patients. Hamstring autograft was utilized in 31 ankles and hamstring allograft in 4 ankles. Results: Indications for surgery included failure of previous ankle stabilization in 13 patients and severe ankle instability in 22 patients. All functional outcome scores improved; VAS increased from 5.3 to 1.0 points (p < 0.0001), SF-12 increased from 64 to 89 points (p < 0.0001), and FAOS scores increased in all categories (p < 0.05). Radiographic measurements of instability also improved; anterior drawer decreased by 3 mm (p = 0.0002) and talar tilt decreased by 11 degrees (p < 0.0001) (see Table 1). One patient (3%) returned to the operating room for removal of hardware after over 2 years. There were 4 patients (12%) with delayed wound healing, 2 patients (6%) with neurologic complications, and 2 patients (6%) with venous thromboembolic events. Conclusion: Patients demonstrated significant improvement in functional outcome scores as well as radiographic measures of ankle stability following modified anatomic lateral ligament reconstruction in a population with severe or recurrent instability. This is the largest series to date of ankle ligament reconstruction using autograft, and it is associated with high patient satisfaction, reduced pain, improved objective stability, and low morbidity. Further study is warranted to develop well-defined guidelines on the management of patients with severe or recurrent instability

Arthroscopically Assisted Open Reduction–Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign

Standalone open reduction–internal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith &amp; Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign

Comparison of Juvenile Allogenous Articular Cartilage and Bone Marrow Aspirate Concentrate versus Microfracture in Arthroscopic Treatment of Talar Osteochondral Lesions

Category: Ankle Introduction/Purpose: There are few prior investigations that report the clinical and radiographic outcomes of juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate in the ankle. Reports that do exist have offered conflicting results and suggest that this relatively new technique has no significant advantage over current repair techniques. 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 for treatment of talar osteochondral lesions with those of patients who underwent microfracture. Methods: After approval was obtained from our institutional review board, the institution’s foot and ankle registry was searched using relevant Current Procedural Terminology codes for all patients who underwent either microfracture or juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate for an osteochondral lesion of the talus between 2006 and 2014. Ninety-six patients fit the inclusion criteria and composed the study cohort. Of these 96 patients, 50 had undergone microfracture treatment and 46 had received DeNovo NT for juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate treatment, composing the microfracture (MF) and JACI-BMAC groups, respectively. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Postoperative magnetic resonance (MR) images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Results: The average followup was 40.0 (range 5.0 to 113.6) months with the MF group having an average followup of 40.3 months (range 5 to 133.6) and the JACI-BMAC group averaging a 18.6 month followup (range 9.1 to 39.6). Both the JACI-BMAC and MF groups had significant pre-to-postoperative improvements in Pain, Daily Activities, Sports, Quality of Life, and overall FAOS Scores; however, there were no significant differences in any patient reported outcomes between the groups. SF-12 scores were improved in both JACI-BMAC and MF groups, however the MF change from pre- to-postoperative did not reach significance (p = 0.214). Radiographically, both the JACI-BMAC and MF groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group tended to have more patients with hypertrophy exhibited on MR imaging than the MF group (p = 0.030). Conclusion: Juvenile allogenic chondrocyte implantation and microfracture resulted in improved functional outcomes. However, none of the differences in FAOS scores between groups achieved the minimal clinically important difference, suggesting there may not be enough of a difference between these treatments to distinguish them in terms of patient outcomes in the short term. Both techniques produced reparative tissue that exhibited fibrocartilage composition radiographically. Based on our results, juvenile allogenous cartilage has not demonstrated a significant advantage over the microfracture technique in the treatment of talar osteochondral lesions. Longer term studies will be needed to see if these findings are maintained over time

Can Fifth Metatarsal Morphology Predict Proximal Fifth Metatarsal Fracture Risk? A Radiographic Analysis of National Football League Players

Category: Sports. Introduction/Purpose: Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Unfortunately, optimal treatment is often challenging, as the repetitive stresses endured by the fifth metatarsal can lead to delayed union and refracture following treatment. We therefore performed a radiographic analysis of fifth metatarsal morphology and foot type in NFL players, in search of morphologic risk factors for these injuries. Methods: NFL players treated by the senior authors between 1992 and 2012, as well as participants in the 2014 NFL Combine were evaluated. A total of 96 feet (51 athletes) were included. Fractures were present in 15 of the feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior (AP), lateral and oblique radiographs, after receiving measurement training by the senior authors. Table 1 lists the specific parameters studied. Reviewers’ measurements were averaged, as were those from the radiographic series for each athlete. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined via Student’s t-test analysis. Results: Athletes had an average height of 6’2” (range 5’8” to 6’8”) ft’in”, weight of 251 (range 184 to 336) lbs, and age of 22.4 (range 21.0 to 26.0) years. Reviewers’ inter-observer reliability was generally good to very good. On AP radiographs, statistically significant differences in apex medullary canal width, 4-5 intermetatarsal angle, 5th metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet (p=0.001, 0.003, 0.004, 0.008, respectively; Table 1). On lateral radiographs, statistically significant differences in the 5th metatarsal length, distance to apex, apex height, 5th metatarsal angle, and talocalcaneal angle were observed between fractured and non-fractured feet (p=0.04, 0.01, 0.02, 0.01, 0.01, respectively; Table 1). On oblique radiographs, a statistically significant difference was observed in apex height between fractured and non-fractured feet (p=0.002; Table 1). Conclusion: This investigation elucidates the relationship between fifth metatarsal morphology, foot type and proximal fifth metatarsal fractures. Specifically, individuals with long, straight and narrow fifth metatarsals, with an adducted forefoot are most at risk. Given athletes’ predisposition to refracture and nonunion following treatment of proximal fifth metatarsal fractures, which is at times career threatening, we believe that these findings are clinically relevant. With such insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at-risk. Admittedly, future research must evaluate the utility of such interventions

The Tarsal Navicular Stress Fracture Revisited

Category: Sports. Introduction/Purpose: The purpose of this paper is to both refute and condemn the current practice of open reduction and internal fixation in the treatment of both uncomplicated partial and complete tarsal navicular stress fractures. It will deal with issues that have violated the basic principals of clinical based evidence and resulted in unnecessary surgery, patient injury, and excessive costs. Methods: Ten cases managed by the senor author as well as a meta-analysis 250 cases in 19 published reports in the peer reviewed literature will be reported vis-a- vis surgical vs. conservative management. Management of the dorsal transverse fragment will be discussed, The large cost disparity between operative and non-operative management will be emphasized. The vascular and biomechanical factors will be presented. Results: The 10 cases of TNSF reported & treated by the senior author successfully healed by non-surgical, non-weight management. The meta-analysis of 250 reported cases treated conservatively had 96% successful outcomes. Conversely, those cases treated surgically with screw fixation had a 19% to 26% failure / major complication rates with repeat surgery and some with years of disability, Conclusion: Surgical management of TNSFs has resulted in a 19% to 26% non-union +/or morbidity rate, a marked increase in costs and is contra-indicated in the management of all non-displaced lesions. Non-weight bearing immobilization is indicated for both partial and complete sagittal fractures. Treatment should be based on established evidence based data and not on economic or remuneration factors. Orthopedic surgeons should subscribe to the concept of self regulation in dealing with this situation