Christopher J. Pearce

Return to Training and Playing After Posterior Ankle Arthroscopy for Posterior Impingement in Elite Professional Soccer

Background Posterior ankle impingement syndrome (PAIS) was first described in ballet dancers but is increasingly being diagnosed in other sports. Operative treatment may be indicated when nonoperative measures have failed. Traditionally, operative treatment has involved an open approach; more recently, posterior ankle arthroscopy has been employed. Purpose This study was conducted to describe the factors that influence return to play in professional athletes after posterior ankle arthroscopy for posterior ankle impingement syndrome. Study Design Case series; Level of evidence 4. Methods A consecutive series of 28 elite professional soccer players who had clinically and radiologically diagnosed posterior ankle impingement syndrome that failed to respond to nonoperative treatment underwent posterior ankle arthroscopy for bony or soft tissue posterior ankle impingement syndrome over 5 years. Results Of the 28 players, 27 were available for follow-up. Five had a diagnosis of soft tissue impingement and underwent debridement with flexor hallucis longus release, 13 had a symptomatic os trigonum that was excised arthroscopically, and 9 had removal of a bony avulsion fragment from the posterior ankle ligament complex. The mean length of time to return to training postoperatively was 34 days and return to playing was 41 days (range, 29-72 days). The duration of symptoms before surgery and excision of bony impingement were significantly correlated with the time to return to training and playing. There were no major complications and no reoperations at an average of 23 months of follow-up (range, 15-49 months). Conclusion Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player, with return to training expected at an average of 5 weeks.

The transverse acetabular ligament may be used to align the acetabular cup in total hip arthroplasty

Accurate positioning of the acetabular component in total hip arthroplasty is essential to minimise the risk of dislocation and preserve the range of movement of the hip. It also affects polyethylene wear and the rate of osteolysis. Although there are many tools available to the surgeon to aid placement of the acetabular component, errors still occur, especially in version. We conducted a study of 14 cadaveric hips to investigate whether the transverse acetabular ligament can be used to align implanted cups with the correct degree of anteversion. Radiographic measurement revealed that all of the implanted cups were found to lie within the safe zone for anteversion, when aligned with the ligament.

Continuous Infusion Versus Single Bolus Popliteal Block Following Major Ankle and Hindfoot Surgery: A Prospective, Randomized Trial

Background: Popliteal sciatic nerve blockade is a commonly used technique employed in the management of postoperative pain following foot and ankle surgery. Recent studies have shown that for outpatient surgery, for moderately painful procedures, a continuous infusion of local anesthesia via an indwelling catheter for 48 to 72 hours leads to reduced opiate analgesic requirements and improved pain and patient satisfaction scores. Materials and Methods: A prospective, randomized, double blind, placebo-controlled trial of a continuous infusion of bupivacaine verses normal saline via a popliteal catheter after a single bolus popliteal block for 72 hours after major ankle and hind foot surgery was performed in 54 patients. Results: The average pain scores overall were low (range, 1.1 to 3.6 on a Visual Analogue Scale of 0 to 10) throughout the study period. Statistically significantly lower pain scores with significantly less requirement for supplementary opiate analgesic agents were seen in the treatment group. Conclusion: Despite the statistically significant findings, with such low pain scores in both groups, we believe it remains debatable whether the extra time and cost involved warrants the use of a continuous popliteal blockade over a single bolus injection. Level of Evidence: I, Prospective, Randomized, Controlled Trial

Is Apoptosis the Cause of Noninsertional Achilles Tendinopathy

Background The pathogenesis of chronic tendinopathy is unclear but it does not appear to be an inflammatory process. Apoptosis may lead to degenerate tissue through a nitric oxide–mediated pathway. Increased levels of nitric oxide have been demonstrated in Achilles tendinopathy. Hypothesis Nitric oxide–mediated apoptosis is an important mechanism in the development of Achilles tendinopathy. Study Design Controlled laboratory study. Methods Samples were obtained from the Achilles tendons of 14 patients with noninsertional Achilles tendinopathy. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on magnetic resonance imaging. Immunohistochemical techniques identified the expression of inducible and endothelial nitric oxide synthase as markers of nitric oxide production. Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and the demonstration of caspase-3 activation. Results Significant differences were found between the diseased tendon and the controls for all parameters. The mean caspase-3 cell count for diseased tendon was 51.9 versus 28.3 for the controls (P < .001). The mean TUNEL cell count for diseased tendon was 24.1 compared with 14.8 (P < .001). Inducible nitric oxide synthase (iNOS) densitometry revealed a mean of 26.1 for the diseased tissue versus 15.0 for the controls (P < .001) and the values for endothelial nitric oxide synthase (eNOS) were 48.3 and 23.7, respectively (P = .015). Conclusion Apoptosis may play a role in the development of noninsertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels. Clinical Relevance A clearer understanding of the tendinopathic process may lead to new treatment strategies aimed at modulating apoptosis.

Sciatic Nerve Blockade: A Survey of Orthopaedic Foot and Ankle Specialists in North America and the United Kingdom:

Background: Sciatic nerve blocks are used to reduce postoperative pain and allow early discharge for patients undergoing foot and ankle surgery. This study aimed to identify the utilization of this procedure in the US and UK and to establish the standard of care with respect to the level of anesthesia that the patient is under and use of ultrasound localization when performing sciatic nerve blocks. Materials and Methods: A survey of current committee members of AOFAS and members of BOFAS. Results: Two hundred sixty-three surgeons were contacted with a response rate of 44%. Eighty-two percent commonly used a sciatic nerve blockade. Sixty-nine percent never or only sometimes used ultrasonography and variable levels of nerve stimulation were used. Forty-two percent where happy to have the block performed under full anesthesia. There were significant differences between British and American practices regarding the level of nerve stimulation and the level of anesthesia used. The most common complication cited was prolonged anesthesia of which the vast majority spontaneously resolved. Performing blocks awake or sedated did not seem to alter number of complications seen. Conclusion: This study represents a current practice review of sciatic nerve blocks performed amongst senior foot and ankle surgeons. Although no absolute consensus has been reached as to the use of ultrasound or whether the patient needs to be awake for the procedure, it is clear that the standard of care does not mandate either of these. The differences between US and UK practice are probably cultural and do not appear to affect the number of complications encountered.

Osteochondral Allograft: 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 is 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 “Osteochondral Allograft” 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 upon 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%; and unanimous, 100%. Results: A total of 15 statements on osteochondral allograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 14 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with osteochondral allograft as a treatment strategy for osteochondral lesions of the talus.

Fixation Techniques: 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 is 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 “Fixation Techniques” 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 upon 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%; and unanimous, 100%. Results: A total of 15 statements on fixation techniques reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 15 statements achieved strong consensus, with at least 82% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with using fixation techniques in the treatment of osteochondral lesions of the talus.

Revision and Salvage Management: 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 was to report on the consensus statements on “Revision and Salvage Management” 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 8 statements on revision and salvage management reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with revision and salvage management in the cartilage repair of the ankle.

Subchondral Pathology: 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 “Subchondral Pathology” 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 upon 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 9 statements on subchondral pathology reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. No statements achieved unanimous support, but all statements reached strong consensus (greater than 75% agreement). All statements reached at least 81% agreement. Conclusions: This international consensus statements regarding subchondral pathology of the talus derived from leaders in the field will assist clinicians in the assessment and management of this difficult pathology.

Scaffold-Based Therapies: 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 “Scaffold-Based Therapies” 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 upon 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 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus. Level of Evidence: Level V, expert opinion.