Keir A. Ross

Osteochondral Lesions of the Talus: A Current Concepts Review and Evidence-Based Treatment Paradigm

Osteochondral lesions of the talar dome are increasingly diagnosed and are a difficult pathology to treat. Conservative treatment yields best results in pediatric patients, often leaving surgical options for adult populations. There is a paucity of long-term data and comparisons of treatment options. Arthroscopic bone marrow stimulation is a common first-line treatment for smaller lesions. Despite promising short to medium term clinical results, bone marrow stimulation results in fibrocartilagenous tissue that incurs differing mechanical and biological properties compared with normal cartilage. Autologous osteochondral transplantation has demonstrated promising clinical results in the short to medium term for larger, cystic lesions and can restore the contact pressure of the joint. However, concerns remain over postoperative cyst formation and donor site morbidity. Recent developments have emphasized the usefulness of biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate, as well as particulate juvenile cartilage, in augmenting reparative and replacement strategies in osteochondral lesion treatment. The purpose of this article is to review diagnosis and treatment of talar osteochondral lesions so that current practice guidelines can be more efficiently used given the available treatment strategies. A treatment paradigm based on current evidence is described. Levels of Evidence: Therapeutic, Level V, Expert Opinion

Arthroscopic Bone Marrow Stimulation and Concentrated Bone Marrow Aspirate for Osteochondral Lesions of the Talus: A Case-Control Study of Functional and Magnetic Resonance Observation of Cartilage Repair Tissue Outcomes.

PURPOSE This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. METHODS Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. RESULTS The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively). CONCLUSIONS BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.

The Biology of Ewing Sarcoma

Objective. The goal of this study was to review the current literature on the biology of Ewings sarcoma, including current treatments and the means by which an understanding of biological mechanisms could impact future treatments. Methods. A search of PubMed and The Cochrane Collaboration was performed. Both preclinical and clinical evidence was considered, but specific case reports were not. Primary research articles and reviews were analyzed with an emphasis on recent publications. Results. Ewing sarcoma is associated with specific chromosomal translocations and the resulting transcripts/proteins. Knowledge of the biology of Ewing sarcoma has been growing but has yet to significantly impact or produce new treatments. Localized cases have seen improvements in survival rates, but the same cannot be said of metastatic and recurrent cases. Standard surgical, radiation, and chemotherapy treatments are reaching their efficacy limits. Conclusion. Improving prognosis likely lies in advancing biomarkers and early diagnosis, determining a cell(s) of origin, and developing effective molecular therapeutics and antiangiogenic agents. Preclinical evidence suggests the utility of molecular therapies for Ewing sarcoma. Early clinical results also reveal potential for novel treatments but require further development and evaluation before widespread use can be advocated.

Investigating the Relationship Between Ankle Arthrodesis and Adjacent-Joint Arthritis in the Hindfoot. A Systematic Review.

BACKGROUND Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis. METHODS A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis. RESULTS The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed. CONCLUSIONS There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Functional and MRI Outcomes After Arthroscopic Microfracture for Treatment of Osteochondral Lesions of the Distal Tibial Plafond

BACKGROUND Osteochondral lesions of the distal tibial plafond are uncommon compared with talar lesions. The objective of this study was to assess functional and magnetic resonance imaging (MRI) outcomes following microfracture for tibial osteochondral lesions. METHODS Thirty-one tibial osteochondral lesions in thirty-one ankles underwent arthroscopic microfracture. The Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire were used to obtain patient-reported functional outcome scores preoperatively and postoperatively. MRI scans were assessed postoperatively with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for twenty-three ankles. RESULTS The average age was thirty-seven years (range, fifteen to sixty-eight years), and the average lesion area was 38 mm(2) (range, 7.1 to 113 mm(2)). Twelve ankles had a kissing lesion on the opposing surface of the talus, and two ankles had a concomitant osteochondral lesion elsewhere on the talus. FAOS and SF-12 scores were significantly improved (p < 0.01) at the time of follow-up, at an average of forty-four months. The average postoperative MOCART score was 69.4 (range, 10 to 95), with a lower score in the ankles with kissing lesions (62.8) than in the ankles with an isolated lesion (73.6). Increasing age negatively impacted improvement in SF-12 (p < 0.01) and MOCART (p = 0.04) scores. Increasing lesion area was negatively correlated with MOCART scores (p = 0.04) but was not associated with FAOS or SF-12 scores. Lesion location and the presence of kissing lesions showed no association with functional or MRI outcomes. CONCLUSIONS Arthroscopic microfracture provided functional improvements, but the optimal treatment strategy for tibial osteochondral lesions remains unclear. The repair tissue assessed on MRI was inferior to normal hyaline cartilage. The MRI outcomes appeared to deteriorate with increasing lesion area, and both functional and MRI outcomes appeared to deteriorate with increasing age. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Double-Plug Autologous Osteochondral Transplantation Shows Equal Functional Outcomes Compared With Single-Plug Procedures in Lesions of the Talar Dome A Minimum 5-Year Clinical Follow-up

Background: Autologous osteochondral transplantation (AOT) is used for large (>100-150 mm2) or cystic osteochondral lesions (OCLs) of the talus. Larger lesions may require using more than 1 graft to fill the defect. While patients with larger OCLs treated with microfracture exhibit inferior clinical outcomes, there is little evidence regarding the effect of lesion size and number of grafts required on clinical and radiological outcomes after AOT. Hypothesis: Larger OCLs of the talar dome treated by double-plug AOT (dp-AOT) have inferior clinical and radiological MRI outcomes compared with smaller OCLs requiring single-plug AOT (sp-AOT). Study Design: Cohort study; Level of evidence, 3. Methods: Fourteen consecutive patients with a large OCL (mean, 208 ± 54 mm2) treated using dp-AOT with a minimum 5-year follow-up were matched by age and sex to a control cohort of 28 patients who underwent sp-AOT for a smaller OCL (mean, 74 ± 26 mm2) over the same period. Functional outcomes were assessed both pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form–12 (SF-12) general health questionnaire. Mean follow-up was 85 months (range, 65-118 months). Latest postoperative MRI was evaluated with modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Results: There was no significant difference between groups demographically (P > .05). All patients with dp-AOT and sp-AOT showed a significant pre- to postoperative increase in FAOS and SF-12 scores (P < .001). When comparing preoperative scores for both groups, there was no statistical significance between sp-AOT and dp-AOT scores (FAOS, P = .719; SF-12, P = .947). There was no significant difference in functional scores between the 2 groups postoperatively for both FAOS (P = .883) and SF-12 (P = .246). Mean MOCART scores did not exhibit any statistically significant difference between groups (P = .475). Two patients complained of knee donor site stiffness (4.8%), which later resolved. Conclusion: Patients with large OCLs treated using a dp-AOT procedure did not show inferior clinical or radiological outcomes compared with those treated with sp-AOT at a minimum 5-year follow-up. The dp-AOT procedure is as effective as sp-AOT in treating larger OCLs of the talar dome in the intermediate term, with similar high postoperative clinical and radiological outcomes.

A Plantar Closing Wedge Osteotomy of the Medial Cuneiform for Residual Forefoot Supination in Flatfoot Reconstruction

Background: Residual forefoot supination is commonly encountered during a flatfoot reconstruction, and a new technique for its treatment is described. Contrary to the standard Cotton osteotomy, a plantar closing wedge osteotomy of the medial cuneiform (PCWOMC) was performed, which has a number of advantages. Methods: We followed 10 feet in 9 patients who had a PCWOMC performed as the last step of a standard flatfoot reconstruction for the correction of residual forefoot supination. These patients were evaluated pre- and postoperatively by standardized radiographic parameters, Short Form-12 (SF-12), and Foot and Ankle Outcome Score (FAOS). Results: Patients were followed for an average of 25.8 months with final radiographic analysis performed at an average of 9.9 months. A significant difference (P < .001) between pre- and postoperative parameters was demonstrated for both lateral talus–first metatarsal angle and medial-cuneiform-to-ground distance. Likewise, there was a statistically significant improvement in the SF-12 score and 4 out of 5 components of the FAOS. One patient developed internal hardware–related symptoms, which were relieved following implant removal. All osteotomies healed uneventfully. Conclusion: A PCWOMC can be considered an alternative to the Cotton osteotomy for the treatment of forefoot supination deformity in adult flatfoot reconstruction. The main advantage of this technique over the Cotton osteotomy was simplicity, as an additional dorsal incision and bone graft were not required. Level of Evidence: Level IV, retrospective case series.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

Clinical and MRI Donor Site Outcomes Following Autologous Osteochondral Transplantation for Talar Osteochondral Lesions

Background: Autologous osteochondral transplantation (AOT) has an inherent risk of donor site morbidity (DSM). The reported rates of DSM vary from 0% to 50%, with few studies reporting clinical or imaging outcomes at the donor site as a primary outcome and even fewer report these outcomes when a biosynthetic plug backfill is employed. Although TruFit (Smith & Nephew, Andover, MA) plugs have been removed from the market for regulatory purposes, biphasic plugs (including TruFit plugs) have been used for several years and the evaluation of these is therefore pertinent. Methods: Thirty-nine patients who underwent forty AOT procedures of the talus, with the donor graft being taken from the ipsilateral knee, were included. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site graded with magnetic resonance observation of cartilage repair tissue (MOCART) scoring. Lysholm scores were collected preoperatively, at the time of magnetic resonance imaging (MRI), and again at 24 months and at final follow-up to assess clinical outcomes. Statistical analysis was performed to establish if there was any correlation between MRI assessment of the donor site and clinical outcomes. The mean patient age was 36.2 ± 15.7 years with a mean follow-up of 41.8 ± 16.7 months. Results: All patient donor site defects were filled with OBI TruFit biphasic plugs. DSM was encountered in 12.5% of the patient cohort at 24 months, and in these patients, the Lysholm score was a mean 87.2 ± 5.0. At final follow-up, DSM was reduced to 5%. Lysholm scores for the entire cohort were 98.4 ± 4.6 and 99.4 ± 3.1 at 24 months and final follow-up, respectively. MRI of the donor sites were taken at an average of 18.1 ± 13.5 (range, 3-48) months postoperatively and the mean MOCART score was 60.0 ± 13.5. No correlation was found between the MOCART score and Lysholm outcomes at the donor knee (P = .43, r = 0.13). Conclusion: Low incidence of DSM and good functional outcomes were achieved with AOT. Additionally, MRI findings did not predict clinical outcomes in our study. Level of Evidence: Level IV, retrospective case series.

Functional Outcomes of Tibialis Posterior Tendoscopy With Comparison to Magnetic Resonance Imaging

Background: The purpose of the current study was to report functional outcomes of tendoscopy for treatment of tibialis posterior tendon pathology as well as compare its diagnostic capability with magnetic resonance imaging (MRI). Methods: Clinical records and MRI of 12 patients who underwent tendoscopy of the tibialis posterior tendon (TPT) were retrospectively reviewed. Mean follow-up was 31 months (range, 26-43 months). Preoperative MRI findings were compared with tendoscopic findings to assess the diagnostic agreement between each modality. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) General Health Questionnaire pre- and postoperatively. Mean patient age was 43 years (range, 17-63 years). Mean duration of preoperative symptoms was 15.5 months (range, 3-36 months). Results: Pathologies addressed via tendoscopy included tenosynovitis, tendinosis, stenosis, tendon subluxation, and partial thickness tear (via mini-arthrotomy). Preoperative MRI findings were in agreement with tendoscopic findings in 8 of 12 cases (67%). Tendoscopy diagnosed and allowed access for treating pathology that was missed on MRI in the remaining four cases. The FAOS improved from a mean preoperative score of 58 (range, 36-78) to a mean postoperative score of 81 (range, 44-98) (P < .01). The SF-12 score improved from a mean preoperative score of 34 (range, 13-51) to a mean postoperative score of 51 (range, 21-76) (P = .01). Conclusions: Although MRI is considered an effective imaging technique for tendon pathology, tendoscopy may be a more sensitive diagnostic tool. Tendoscopy was an effective minimally invasive tool to diagnose and treat tibialis posterior tendon pathology resulting in functional improvements in the short-term for early stage TPT dysfunction. Further studies comparing tendoscopy with traditional open approaches are warranted. Level of Evidence: Level IV case series.