Travis J. Dekker

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury

Background: Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. Methods: We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients’ preoperative and postoperative sports involvement (primary and secondary sports, number of sports). Results: A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). Conclusions: Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ratio of Range of Motion of the Ankle and Surrounding Joints After Total Ankle Replacement: A Radiographic Cohort Study.

Background: This study attempted to identify where motion occurs after total ankle replacement, the difference in range-of-motion contributions between fixed-bearing and mobile-bearing total ankle replacements, and the contribution of abnormal peritalar motion. We hypothesized that sagittal plane radiographic assessment would demonstrate that actual ankle motion through the prosthesis is less than the total arc of ankle motion that may be observed clinically secondary to contributions from adjacent joints. Methods: Patients underwent routine standardized weight-bearing maximum dorsiflexion and plantar flexion sagittal radiographs. Sagittal plane ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the total arc of ankle motion, actual ankle motion through the prosthesis, motion through the subtalar and talonavicular joints, and midfoot motion. Motion radiographs were routinely made at 1 year postoperatively and at the time of the most recent follow-up. A minimum follow-up of 2 years was required of all patients. Results: There were 197 patients who met the inclusion criteria (75 INBONE, 52 Salto Talaris, and 70 STAR prostheses). The mean time to the latest radiographs (and standard deviation) was 42.9 ± 18.8 months. The mean actual ankle motion through the prosthesis was 25.9° ± 12.2°, which was significantly less (p < 0.001) than the mean total motion arc of 37.6° ± 12.0°. The motion of the ankle accounted for 68% of total range of motion, and motion of the peritalar joints accounted for 32%. There was no significant difference (p > 0.05) among the 3 prostheses or when comparing fixed and mobile-bearing designs for both ranges of motion. Conclusions: This study demonstrates that actual ankle motion after total ankle replacement is approximately 12° less than the total arc of motion that might be observed clinically because of increased midfoot and subtalar motion. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone Marrow Aspirate Concentrate for Bone Healing in Foot and Ankle Surgery

Autologous bone marrow aspirate concentrate (BMAC) has become a popular orthobiologic to augment bone healing. The potential benefit comes from osteoprogenitor cells and growth factors that can lead to new bone formation in the setting of foot and ankle arthrodesis procedures. BMAC has an excellent safety record and has demonstrated efficacy in animal models of bone healing. Although scant, the literature on the use of BMAC in foot and ankle surgery does demonstrate promise for this orthobiologic adjuvant.

Treatment of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus encompass a variety of pathological lesions, including osteochondral defects, osteochondritis dissecans, and osteochondral fractures. Articular cartilage has poor regenerative capacity, and the osseous blood supply to the talus is tenuous. Both of these issues make

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications

Introduction. Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support. Methods. Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications. Results. All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusions. The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing. Levels of Evidence: Level IV: Case series

Topical Review: MACI as an Emerging Technology for the Treatment of Talar Osteochondral Lesions:

Matrix-induced autologous chondrocyte implantation (MACI) is a viable procedure that can be used as both a primary or revision cartilage regenerative procedure in high-functioning individuals without tibiotalar arthritis. Both short-term and midterm follow-up results demonstrate clinical, radiographic, and functional improvements with high rates of return to full activities. Cost remains a chief concern with the use of this technique, but theoretical improvements in the durability of repair with type II cartilage replacement may offer long-term benefits. Level of Evidence: Level V, expert opinion.

Hindfoot Arthritis Progression and Arthrodesis Risk After Total Ankle Replacement

Background: The purpose of this study was to assess the radiographic progression of subtalar and talonavicular degenerative joint disease in a series of patients who had undergone TAA (total ankle arthroplasty) with minimum follow-up of 5 years. Methods: TAA patient radiographs from a single institution were analyzed for peritalar arthritic changes by extrapolating the modified Kellgren Lawrence (KL) grades of the knee to the subtalar and talonavicular joints. Patients were included if they had a minimum of 5 years of follow-up. Patients who had undergone prior arthrodesis of the talonavicular or subtalar joints were excluded. A total of 140 patients with average follow-up of 6.5 years (range, 5.0-8.9 years) were included. Results: Overall, 27% of patients advanced 1 KL grade at the subtalar joint and 31% of patients increased 1 KL grade at the talonavicular joint. Furthermore, 60% and 66% of patients showed no progression in the subtalar and talonavicular joints, respectively. Two patients progressed greater than 2 KL subtalar arthritis grades and only 2 patients with talonavicular arthritis progressed to the same extent. Sixteen patients went on to require a subtalar arthrodesis compared to 2 requiring a talonavicular fusion (P < .05). Conclusion: This study suggests a moderate but nominal radiographic increase in adjacent subtalar and talonavicular arthritis over a minimum of 5 years after TAA. Future studies require a comparative control group of ankle fusion, but these data may suggest the motion preserved with an arthroplasty diminishes the stresses and compensatory motion incurred during tibiotalar arthrodesis. Level of Evidence: Level IV, retrospective case series.

Efficacy of a Cellular Bone Allograft for Foot and Ankle Arthrodesis and Revision Nonunion Procedures

Background: Bone graft substitutes are often required in patients at risk for nonunion, and therefore, an allograft that most closely mimics an autograft is highly sought after. This study explored the utility and efficacy of a cellular bone allograft used for foot and ankle arthrodesis and revision nonunion procedures in a patient population at risk for nonunion. Methods: An institutional review board–approved retrospective review of consecutive patients who underwent arthrodesis and revision nonunion procedures with a cellular bone allograft was performed at a single academic institution. No external sources of funding were provided for this study. Inclusion criteria included patients who were more than 1 year after surgery or less than 1 year after surgery if they had undergone a second operative procedure for nonunion or if they had computed tomography–documented union. Forty operative procedures in 36 patients with a mean follow-up of 13 months (range, 6-25 months) were included for data analysis. All patients had at least one of the following risk factors associated with nonunion: current smoker, diabetes, avascular necrosis (AVN) of the involved bone, active same-site operative infection, history of nonunion, previous same-site surgery, or gap of 5 mm or greater after joint preparation. The primary outcome was radiographic union. Results: The union rate in this high-risk population was 83% (33/40). Univariate analysis demonstrated that the use of a cellular bone allograft helped mitigate the presence of risk factors known to cause nonunion. There was no significant difference in fusion rates among groups with current smoking, AVN of the involved bone, active same-site operative infections, history of nonunion, rheumatoid arthritis on medication, previous same-site operative procedures or infections, or a gap of 5 mm or greater after joint preparation. However, in this population, diabetic and female patients remained at a high risk of recurrent nonunion (P = .0015), despite the use of a cellular bone allograft. Chi-square analysis of patients with increasing numbers of risk factors directly correlated with an increased risk of nonunion (P = .025). Four wound complications were reported in this cohort that required irrigation and debridement (10%). Conclusion: These data demonstrated a union rate of 83% in patients with risk factors known to cause nonunion. The benefits of the use of a cellular bone allograft allowed for the avoidance of morbidity associated with autograft harvesting while still improving the local biology to facilitate fusion in a difficult patient population to attain a successful fusion mass. Level of Evidence: Level IV, retrospective case series.

Tendonitis and Tendinopathy: What Are They and How Do They Evolve?

The development of tendinitis and tendinopathy is often multifactorial and the result of both intrinsic and extrinsic factors. Intrinsic factors include anatomic factors, age-related factors, and systemic factors, whereas extrinsic factors include mechanical overload and improper form and equipment. Although tendinitis and tendinopathy are often incorrectly used interchangeably, they are in 2 distinct pathologies. Due to their chronicity and high prevalence in tendons about the ankle, including the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons, tendinitis and tendinopathies cause significant morbidity and are important pathologies for physicians to recognize.

Efficacy of a Cellular Allogeneic Bone Graft in Foot and Ankle Arthrodesis Procedures

A cellular allogeneic bone graft can be used in patients at high risk for nonunion after arthrodesis surgery. This study explores the utility and efficacy of MAP3 in foot and ankle arthrodesis procedures. Map3 is a cellular allogeneic bone graft that contains osteogenic, osteoconductive, osteoinductive, and angiogenic properties. A total of 23 mostly high-risk patients were included in this study. The overall fusion rate was 83%. Univariate analysis demonstrated diabetic patients remain at risk of recurrent nonunion (P<.001) despite supplementation with MAP3. These data demonstrate successful fusion in high-risk patients when MAP3 is used.