Eric Giza

Matrix-induced autologous chondrocyte implantation of talus articular defects.

Background: Osteochondral injury of the talus can be challenging to treat because the damaged articular cartilage has a poor intrinsic reparative capability. Autologous Chondrocyte Implantation has become an effective means for treating persistent cartilage lesions that fail to respond to routine ankle arthroscopy. The purpose of this study was to assess the results of Matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the talar dome using a technique which does not require an osteotomy of the tibia or fibula. Materials and Methods: A prospective investigation of MACI was performed on ten patients with full-thickness lesions of the talus. The patients had a documented talus lesion on MRI, failure of conservative treatment and arthroscopic debridement/curettage, persistent ankle pain and swelling, the absence of tibiotalar arthritis and a stable ankle. Five males and five females, with an average of 1.7 previous procedures prior to Matrix-induced autologous implantation, were included in this study. All patients were available for followup at 1 and 2 years. Lesions were graded during the harvesting procedure using the Cheng-Ferkel grading system, the Outerbridge classification, and the International Cartilage Repair Society system. Clinical and functional evaluation was done preoperatively, and at 1 and 2 years postoperatively using the AOFAS hindfoot evaluation and the SF-36 Health Survey. Results: Preoperative AOFAS hindfoot scores were 61.2 (range, 42 to 76) which improved 1 year postoperatively to 74.7 (range, 46 to 87) (p < 0.05) and 2 years postoperatively to 73.3 (range, 42 to 90) (p = 0.151). At both 1 and 2 years postoperatively, the results of the SF36 evaluation demonstrated a significant improvement in the Physical Functioning (p = 0.002) and Bodily Pain (p < 0.001) components. Subjectively, all ten patients believed this procedure helped them. Conclusion: The results of this study suggest that MACI may be an effective way to treat full-thickness lesions of the talus using harvested chondrocytes from the talus without malleolar osteotomy. We recommend it for patients who do not respond to initial curettage and microfracture. Level of Evidence: IV, Retrospective Case Series

Arthroscopic Suture Anchor Repair of the Lateral Ligament Ankle Complex A Cadaveric Study

Background: Operative treatment of mechanical ankle instability is indicated for patients with multiple sprains and continued episodes of instability. Open repair of the lateral ankle ligaments involves exposure of the attenuated ligaments and advancement back to their anatomic insertions on the fibula using bone tunnels or suture implants. Hypothesis: Open and arthroscopic fixation are equal in strength to failure for anatomic Broström repair. Study Design: Controlled laboratory study. Methods: Seven matched pairs of human cadaveric ankle specimens were randomized into 2 groups of anatomic Broström repair: open or arthroscopic. The calcaneofibular ligament and anterior talofibular ligament were excised from their origin on the fibula. In the open repair group, 2 suture anchors were used to reattach the ligaments to their anatomic origins. In the arthroscopic repair group, identical suture anchors were used for repair via an arthroscopic technique. The ligaments were cyclically loaded 20 times and then tested to failure. Torque to failure, degrees to failure, initial stiffness, and working stiffness were measured. A matched-pair analysis was performed. Power analysis of 0.8 demonstrated that 7 pairs needed to show a difference of 30%, with a 15% standard error at a significance level of α = .05. Results: There was no difference in the degrees to failure, torque to failure, or stiffness for the repaired ligament complex. Nine of 14 specimens failed at the suture anchor. Conclusion: There is no statistical difference in strength or stiffness of a traditional open repair as compared with an arthroscopic anatomic repair of the lateral ligaments of the ankle. Clinical Relevance: An arthroscopic technique can be considered for lateral ligament stabilization in patients with mild to moderate mechanical instability.

Treatment of Osteochondral Lesions of the Talus With Particulated Juvenile Cartilage

Background: Numerous modalities are used today to treat symptomatic osteochondral lesions in the ankle. However, there are ongoing challenges with the treatment of certain lesions, and concerns exist regarding long-term effectiveness. Methods: The purpose of the study was to collect clinical outcomes of pain and function in retrospectively and prospectively enrolled patients treated with particulated juvenile cartilage for symptomatic osteochondral lesions in the ankle. This study collected outcomes and incidence of reoperations in standard clinic patients. The analysis presented here includes final follow-up to date for 12 males and 11 females representing 24 ankles. Subjects had an average age at surgery of 35.0 years and an average body mass index of 28 ± 5.8. Fourteen ankles had failed at least 1 prior bone marrow stimulation procedure. The average lesion size was 125 ± 75 mm2, and the average depth was 7 ± 5 mm. In conjunction with the treatment, 9 (38%) ankles had 1 concomitant procedure and 9 (38%) had more than 1 concomitant procedure. Clinical evaluations were performed with an average follow-up of 16.2 months. Results: Average outcome scores at final follow-up were American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale 85 ± 18 with 18 (78%) ankles demonstrating good to excellent scores, Short-Form 12 Health Survey (SF12) physical composite score 46 ± 10, SF12 mental health composite score 55 ± 7.1, Foot and Ankle Ability Measure (FAAM) activities of daily living 82 ± 14, FAAM Sports 63 ± 27, and 100-mm visual analog scale for pain 24 ± 25. Outcomes data divided by lesion size demonstrated 92% (12/13) good to excellent results in lesions 10 mm or larger and those smaller than 15 mm. To date, 1 partial graft delamination has been reported at 16 months. Conclusions: Preliminary data from a challenging clinical population with large, symptomatic osteochondral lesions in the ankle suggest that treatment with particulated juvenile cartilage could improve function and decrease pain. Longer follow-up and additional subjects are needed to evaluate improvement level and ideal patient indications. Level of Evidence: Level IV, case series.

Diagnosis and treatment of acute Achilles tendon rupture.

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.

Cartilage transplantation techniques for talar cartilage lesions.

Talar articular cartilage is known to differ significantly from knee cartilage. Even so, recommendations for the treatment of talar cartilage lesions have been based on strategies for the knee. Arthroscopic management of osteochondral lesions of the talus is well documented. Results have been favorable with reparative techniques such as débridement with curettage and débridement with drilling, whether undertaken via early open techniques or more recent arthroscopic procedures. Salvage of failed reparative techniques is controversial. Early efforts to salvage failed débridement focused on osteochondral allografts and autografts that used the knee as a donor site. Results of these restorative techniques have been favorable, but concerns have been raised regarding knee donor site morbidity, the use of malleolar osteotomy, and incomplete restoration of the talar articular surface. More recent restorative techniques developed for the knee have been adapted for the ankle, such as autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation.

Posterior Impingement Of The Ankle Caused By Anomalous Muscles: A Report Of Four Cases

P osterior impingement of the ankle results from the compression of the talus and surrounding soft tissue between the tibia and the calcaneus and has been likened to a “nut in a nutcracker.”1 It is produced by repetitive or forced plantar flexion of the foot and has been described in female ballet dancers, athletes, and in nonathletes after an ankle sprain1-4. Patients have pain in the posterolateral or posteromedial aspect of the ankle with activity, particularly plantar flexion. Often there is tenderness medial or lateral to the Achilles tendon, and soft-tissue thickening may be palpated. A positive posterior impingement test consists of reproduction of the symptoms with forced plantar flexion of the ankle2. The diagnosis is made on the basis of the history and physical examination of the patient and the clinical judgment of the surgeon and is supported if the symptoms are temporarily relieved by an injection of a local anesthetic and steroid into the region of the posterior process of the talus through a posterolateral approach2. Structures implicated in the etiology of posterior impingement of the ankle include an os trigonum5, an enlarged lateral process of the talus2, an enlarged posterior process of the calcaneus1, the posterior intermalleolar ligament6, soft-tissue impingement7, a gouty os trigonum8, loose bodies, ganglia, calcified inflammatory tissue, and a low-lying flexor hallucis longus muscle belly1,2. The surgical resection of symptomatic structures can be a successful treatment even in the high-level athlete2. Anomalous muscles about the ankle have been documented since the nineteenth century9-11. The peroneus quartus has been reported most frequently, and studies involving anatomical dissection of cadavera have shown that the prevalence …

Strength of Bone Tunnel Versus Suture Anchor and Push-Lock Construct in Broström Repair

Background: Operative treatment of mechanical ankle instability is indicated for patients who have had multiple sprains and have continued episodes of instability despite bracing and rehabilitation. Anatomic reconstruction has been shown to have improved outcomes and return to sport as compared with nonanatomic reconstruction. Hypothesis: The use of 2 suture anchors and a push-lock anchor is equal to 2 bone tunnels in strength to failure for anatomic Broström repair. Study Design: Controlled laboratory study. Methods: In 7 matched pairs of human cadaver ankles, the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) were incised from their origin on the fibula. A No. 2 Fiberwire suture was placed into the CFL and a separate suture into the ATFL in a running Krackow fashion with a total of 4 locking loops. In 1 ankle of the matched pair, the ligaments were repaired to their anatomic insertion with bone tunnels. In the other, 2 suture anchors were used to reattach the ligaments to their anatomic origins, and a push-lock was used proximally to reinforce these suture anchors. The ligaments were cyclically loaded 20 times and then tested to failure. Torque to failure, degrees to failure, and stiffness were measured. The authors performed a matched pair analysis. An a priori power analysis of 0.8 demonstrated 6 pairs were needed to show a difference of 30% with a 15% standard error at a significance level of .05. Results: There was no difference in the degrees to failure, torque to failure, and stiffness. A post hoc power analysis of torque to failure showed a power of .89 with 7 samples. Power for initial stiffness was .97 with 7 samples. Eleven of 14 specimens failed at either the suture anchor or the bone tunnel. Conclusion: There is no statistical difference in strength or stiffness for a suture anchor and push-lock construct as compared with a bone tunnel construct for an anatomic repair of the lateral ligaments of the ankle. Clinical Relevance: The use of suture anchors in lateral ligament stabilization allows for a smaller incision, less surgical dissection, and improved surgical efficiency. It is up to the discretion of the performing surgeon based on preference, ease of use, operative time, and cost profile to choose either of these constructs for anatomic repair of the lateral ligaments of the ankle. The suture repair at the ligament was significantly strong enough such that the majority of ankles failed at the bone interface.

Peroneal Tendon Disorders

Peroneal tendon pathology is often found in patients complaining of lateral ankle pain and instability. Conditions encountered include tendinosis; tendinopathy; tenosynovitis; tears of the peroneus brevis, peroneus longus, and both tendons; subluxation and dislocation; and painful os peroneum syndrome. Injuries can be acute as a result of trauma or present as chronic problems, often in patients with predisposing structural components such as hindfoot varus, lateral ligamentous instability, an enlarged peroneal tubercle, and a symptomatic os peroneum. Treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good.

First Metatarsophalangeal Hemiarthroplasty for Grade III and IV Hallux Rigidus

The BIOPRO® first metatarsophalangeal hemiarthroplasty is a reliable alternative to fusion of the first metatarsophalangeal for patients with grade III or IV hallux rigidus. The implant was introduced in 1952, and Townley reported 93% good or excellent results on 279 implants with an 8-month to 33-year follow-up. One hundred three first metatarsophalangeal hemiarthroplasties have been performed at our center over 4 years, and we report no cases of deep infection or loosening. Postoperative arthrofibrosis is the most common complication and is addressed with manipulation, which restores functional dorsiflexion. A structured postoperative physical therapy program is important to maintain range of motion and favorable outcomes. A prospective, long-term follow-up study is currently underway.

Arthroscopic Treatment of Talus Osteochondral Lesions With Particulated Juvenile Allograft Cartilage

Osteochondral lesions of the talus (OLT) are commonly associated with traumatic injury to the ankle joint. Treatment options depend on the grade, location, and size of the lesion. Operative intervention is frequently required with initial management involving marrow stimulation techniques, such as microfracture/curettage. Larger lesions often require a secondary procedure, such as osteochondral transplantation or autologous chondrocyte implantation. The advent of particulated juvenile articular cartilage (PJAC) provides an alternative method for OLTs refractory to traditional treatments. This article describes the technique of PJAC transplantation for the treatment of osteochondral lesions of the talus. Level of Evidence: Level V, expert opinion.