Gregory R. Applegate

Autologous chondrocyte implantation of the ankle: a 2- to 5-year follow-up.

Background Treatment of full-thickness talar cartilage defects that have failed previous surgery is problematic without a definitive solution. Purpose To report the first US prospective study of autologous chondrocyte implantation of the talus. Study Design Case series; Level of evidence, 4. Methods Eleven patients (6 women and 5 men; mean age, 33 years) underwent autologous chondrocyte implantation of the talus after previous failed surgical management. There were 9 medial and 2 lateral lesions, with a mean size of 21 × 13 mm (273 mm2). Five patients underwent autologous chondrocyte implantation of the talus alone; 6 had it with a “sandwich procedure.” Ten patients underwent a second-look arthroscopy with screw removal. Results Mean follow-up was 38 months. Preoperatively, 10 patients rated their ankles as poor and 1 as fair, using the simplified symptomatology evaluation. At latest follow-up, 3 patients were classified as excellent, 6 as good, and 2 as fair. Tegner activity level improved from 1.3 ± 1.0 (mean ± SE) preoperatively to 4.0 ± 1.6 (P <. 002) postoperatively. The Finsen score (modified Weber score) showed significant improvement in the total score (P <. 001). There was also overall agreement between the Finsen score and the American Orthopaedic Foot and Ankle Society ankle hindfoot score, with significant improvement from 47.4 ± 17.4 preoperatively to 84.3 ± 8.1 postoperatively (P <. 001). At repeat arthroscopy, complete coverage of the defect was seen in all patients. Conclusion Autologous chondrocyte implantation of the talus yields significant functional improvement; however, further investigation is necessary to determine the long-term structural and biomechanical properties of the repair tissue.

The MR appearance of cruciate ganglion cysts: a report of 16 cases

Intra-articular ganglion cysts arising from the cruciate ligaments are unusual lesions, there being only nine previously reported cases. We report 16 cases and describe their MR appearance. Nine ganglia originated from the posterior cruciate ligament, most often appearing as well-defined multilocular lesions. The seven ganglia arising from the anterior cruciate ligament most often appeared as fusiform cystic lesions extending along and interspersed within the fibers of the ligament. Although uncommon, intra-articular ganglion cysts arising from the knee appear to have a distinctive MR appearance which should allow their correct diagnosis.

Autologous chondrocyte implantation of the ankle: 2- to 10-year results.

Background: The treatment of osteochondral lesions of the talus after failed surgery is challenging, with no clear solution. Short-term results using autologous chondrocyte implantation have been promising. Purpose: To report the long-term outcomes of patients who underwent autologous chondrocyte implantation (ACI) of the talus after failed marrow stimulation techniques for osteochondral lesions of the talus (OLTs). Study Design: Case series; Level of evidence, 4. Methods: Thirty-two consecutive patients underwent ACI of the talus, and 29 patients (15 male, 14 female; mean age, 34 years [range, 16-54 years]) were available for follow-up. There were 23 medial and 6 lateral lesions, with a mean size of 18 × 11 mm (198 mm2; range, 80-500 mm2). Twenty patients underwent ACI of the talus alone; 9 underwent ACI with bone grafting of underlying cysts. Follow-up was performed at a mean of 70 months (range, 24-129 months). Patient outcomes were evaluated using the simplified symptomatology score, Tegner activity score, Finsen score, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Twenty-five patients (86%) underwent second-look arthroscopic surgery at the time of hardware removal and were assessed with the International Cartilage Repair Society (ICRS) score. Postoperative magnetic resonance imaging (MRI) was performed on 24 patients (83%) and compared with preoperative MRI scans. Results: Preoperatively, 26 patients rated their ankles as poor and 3 as fair using the simplified symptomatology score. At last follow-up, 9 were classified as excellent, 14 as good, 5 as fair, and 1 as poor using the same score. The mean AOFAS score improved from 50.1 to 85.9 (range, 65-100). The mean Tegner activity score improved from 1.6 to 4.3 (P < .0001). The mean Finsen score (modified Weber score) showed significant improvement from 13.7 to 5.1 (P < .0001). Conclusion: Autologous chondrocyte implantation of the talus yields improvement in all parameters tested with enduring long-term results in patients who have failed previous surgery for OLTs.

MRI evaluation of anterolateral soft tissue impingement of the ankle.

Background: The usefulness of magnetic resonance imaging (MRI) has been questioned in evaluating patients with chronic ankle sprain pain. The purpose of this study was to determine the effectiveness and reliability of routine MR imaging in the diagnosis of anterolateral soft tissue impingement. Materials and Methods: Inclusion criteria required that the MR examinations be performed by the same musculoskeletal radiologist after the most recent scanner upgrade and using a dedicated ankle/hindfoot coil. The surgical and MRI reports of 24 patients who had an arthroscopic diagnosis of anterolateral soft tissue impingement of the ankle were tabulated and categorized. Unlike previous studies, sagittal T1 and Short Tau Inversion Recovery (STIR) images were used primarily in the diagnosis of these lesions. Results: Using this technique, we report a 78.9% accuracy in diagnosis, a sensitivity of 83.3% and a specificity of 78.6%. Fifty-eight percent of patients had an associated diagnosis, which in 33% of patients altered our surgical plan. Conclusion: Although not indicated in all cases of anterolateral ankle impingement, we advocate the use of MR imaging in complicated clinical presentations where the exclusion of additional pathology in the ankle or subtalar joint, and the confirmation of anterolateral soft tissue impingement would be beneficial. Level of Evidence: III, Case Control Study

The “LIFT” Lesion: Lateral Inverted Osteochondral Fracture of the Talus

PURPOSE The purpose of this study was to assess a series of lateral inverted osteochondral fractures of the talus. METHODS Over a 17-year period, 10 patients with an acute lateral inverted osteochondral fracture of the talus after an inversion injury to the ankle were identified. Diagnosis was made by physical examination, radiographs, magnetic resonance imaging, and/or computed tomography scan. Arthroscopy was initially performed on all patients. All patients had an inverted osteochondral fragment. In 8 of 10 patients the fragment was reattached in an open manner in conjunction with lateral ligament reefing. The fragment was excised in 2 patients. The mean age of the patients was 17.2 years. They were evaluated with the Single Assessment Numeric Evaluation, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, modified Weber score, Berndt and Harty score, and Short Form 36 version 2 score. Physical and radiographic examination was also performed. The mean time to follow-up was 112.3 months (9.3 years). RESULTS The mean American Orthopaedic Foot and Ankle Society score improved from 18.9 preoperatively to 86.9 postoperatively (P ≤ .0001). The mean Single Assessment Numeric Evaluation and modified Weber scores were 81.6 and 81.5, respectively. On the Berndt and Harty scale, 6 patients had a good to excellent rating; 3, fair; and 1, poor. The mean Short Form 36 version 2 scores corresponded to national averages for healthy populations. Mean loss of motion for dorsiflexion and plantarflexion was 6.8° and 3.0°, respectively, when compared with the contralateral side. All patients showed some osteophyte formation on follow-up radiographs. CONCLUSIONS An inverted osteochondral fracture of the lateral talus (lateral, inverted, fracture, talus [LIFT lesion]) can occur after a twisting injury to the ankle. Clinical suspicion should be high, especially in the younger athlete. This injury can be successfully managed with a combined arthroscopic and open approach. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Shoulder Arthroscopy and MRI Techniques

General Part: Shoulder Arthroscopy: Struggles and Successes OR-Set Up Knot Tying Techniques Arthroscopical Anatomy and Norm Variants Arthroscopical Findings versus Preoperative MRI Portals.- Special Part: Instability of the Glenohumeral Joint Pathology of the Long Head of the Biceps Rotator Cuff Pathology Intraarticular Ganglion Cysts and Nerve Entrapment Pathology of the Subacromial Space AC-Joint Pathology Arthroscopic Treatment of Primary and Secondary Frozen Shoulder Management of Loose Bodies Anterosuperior Impingement Posterosuperior Impingement Arthroscopic Osteosynthesis of Glenoid Fractures.

Correlation of MRI Appearance of Autologous Chondrocyte Implantation in the Ankle with Clinical Outcome

The objective of this study was to characterize magnetic resonance imaging (MRI) findings and correlate with clinical results in patients who underwent autologous chondrocyte implantation (ACI) of osteochondral lesions of the talus (OLT). Methods. Twenty-four grafts were evaluated at a mean 65.8 months after ACI for OLT. MRI was performed on a 1.5-T GE scanner using multiple sequences. Graft appearance was compared with preoperative MRI and evaluated for 6 criteria: defect fill, surface regularity, signal pattern, bone marrow edema, subchondral plate irregularity, and presence of cystic lesions. Clinical outcome was measured with the American Orthopaedic Foot and Ankle Society (AOFAS) clinical outcome score. Results. Of 24 grafts, 22 (92%) demonstrated >75% defect fill. Eighteen (75%) had a mildly irregular and 6 (25%) had a moderately irregular articular surface. The signal pattern of the repair tissue was heterogenous in 23 (96%); 14 (58%) layered and 9 (38%) mottled. Fourteen grafts (58%) showed decreased amount of bone marrow edema while 4 (17%) had no change and 5 (21%) had an increase in the amount of bone marrow edema. The subchondral bone plate was abnormal in most grafts, with focal defects seen in 10, slight depression in 7, and both in 5. Seven had an increase in cystic lesions while the others had no change, decrease or no cysts seen. Mean postoperative AOFAS score was 87.5 with mean improvement of 39.4. Conclusions. At 66-month mean follow-up, MRI appearance of the ACI grafts show imaging abnormalities but demonstrate good clinical results. While MRI is an important tool in the postoperative assessment of ACI grafts, the various variations from a normal/nonoperative ankle must be interpreted with caution.