Arthroscopically detected intra-articular lesions associated with acute ankle fractures

The efficacy of autologous matrix-induced chondrogenesis (AMIC) for osteochondral lesions of the talus in the mid-long term: a systematic review and meta-analysis

PURPOSE

The objective of this study was to provide a comprehensive review of the existing literature regarding the treatment of osteochondral lesions of the talus (OLT) using autologous matrix-induced chondrogenesis (AMIC), while also discussing the mid-long term functional outcomes, complications, and surgical failure rate.

METHODS

We searched Embase, PubMed, and Web of Science for studies on OLT treated with AMIC with an average follow-up of at least 2 years. Publication information, patient data, functional scores, surgical failure rate, and complications were extracted.

RESULTS

A total of 15 studies were screened and included, with 12 case series selected for meta-analysis and 3 non-randomized controlled studies chosen for descriptive analysis. The improvements in the Visual Analog Scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot, and Tegner scores at the last follow-up were (SMD = - 2.825, 95% CI - 3.343 to  - 2.306, P < 0.001), (SMD = 2.73, 95% CI 1.60 to 3.86, P < 0.001), (SMD = 0.85, 95% CI 0.5 to 1.2, P < 0.001) respectively compared to preoperative values. The surgery failure rate was 11% (95% CI 8-15%), with a total of 12 patients experiencing complications.

CONCLUSION

The use of AMIC demonstrates a positive impact on pain management, functional improvement, and mobility enhancement in patients with OLT. It is worth noting that the choice of stent for AMIC, patient age, and OLT size can influence the ultimate clinical outcomes. This study provides evidences supporting the safety and efficacy of AMIC as a viable treatment option in real-world medical practice.

Fresh Osteochondral Allograft for Large Talar Osteochondral Lesions

Osteochondral lesions of the talus are being recognized as an increasingly common injury. Large osteochondral lesions have significant biomechanical consequences and often require resurfacing with both boney and cartilaginous graft. The current treatment options include osteochondral autograft transfer, mosaicplasty, autologous chondrocyte implantation, or osteochondral allograft transplantation. Allograft procedures have the advantage of no donor site morbidity and ability to match the defect line to line. Careful transportation, storage, and handling of the allograft are critical to success. The failure of nonoperative management, failure of arthroscopic treatment, or large defects are an indication for resurfacing.

Outcomes Following Repeat Ankle Arthroscopy and Microfracture for Osteochondral Lesions of the Talus

BACKGROUND

The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs.

METHODS

Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts.

RESULTS

We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5).

CONCLUSION

At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations.Level of Evidence: Level IV Case Series.

Distal Tibiofibular Syndesmosis Injuries in the National Football League (NFL): A Spectrum of Pathology That Correlates With Time to Return to Full Participation

BACKGROUND

Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially influencing return to full participation.

HYPOTHESIS

In National Football League (NFL) players, isolated high ankle sprains are rare and syndesmosis injuries with concomitant pathology will result in increased time to return to full participation.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Distal tibiofibular syndesmosis injuries sustained by NFL players between 2017 and 2019 were identified through NFL Injury Surveillance Database queries and verified with video analysis. Each injury underwent a comprehensive magnetic resonance imaging (MRI) review. Regression modeling was utilized to explore the influence of numerous imaging findings on time to return to full participation.

RESULTS

There were 83 external rotation ankle injuries involving the syndesmosis. Isolated distal tibiofibular syndesmosis injuries were rare (n = 11; 13%) and more often associated with other ligamentous injury (deltoid ligament and lateral ligamentous complex) and/or fractures. Regression modeling resulted in clustering of 3 injury pattern groups for time to return to full participation across numerous imaging findings: syndesmosis injury-fracture combinations (250 days [interquartile range [IQR,] 142-266 days]), syndesmosis injury with complete deep deltoid tear or acute diastasis (175 days [IQR, 20-248 days]), and all other syndesmosis injuries (27 days [IQR, 18-46 days]).

CONCLUSION

In NFL athletes with external rotation ankle injuries, isolated distal tibiofibular syndesmosis injuries were rare and more often associated with concomitant pathology. Time to return to full participation was affected by an associated fracture and complete deep deltoid ligament tear or diastasis but no other relevant MRI variables such as lateral ligament complex involvement or the presence of osteochondral lesions or bone contusions.

Comparative analysis of short-term efficacy between robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus

Objective

To investigate the short-term clinical efficacy of robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus (OCLT).

Methods

This study was divided into two groups: experimental group: robot-assisted retrograde drilling group; control group: arthroscopic microfracture group. A total of 6 OCLT patients who were treated with robot navigation-assisted retrograde drilling and 10 OCLT patients who were treated with arthroscopic microfracture between October 2020 and October 2021 were retrospectively analyzed. There were 11 males and five females, with a mean age of 36 years. The patients were followed up for 6-12 months to compare the changes in the OCLT lesion area by magnetic resonance imaging (MRI), visual analogue scale/score (VAS) and American Orthopedic Foot and Ankle Society score (AOFAS) before and after surgery.

Results

All 16 patients were followed up for an average of 8 months, and no complications such as joint infection, nerve injury, or active bleeding occurred during the follow-up period. Only one patient suffered discomfort involving transient postoperative pain in the operative area, but did not experience long-term numbness or chronic pain. Postoperative MRI revealed that none of the patients had severe signs of osteonecrosis, osteolysis or cystic changes of the talus, with lesion areas smaller than those before surgery. The difference was statistically significant (P < 0.01). The patients in the experimental group showed a more significant improvement in the last 3 months than in the first 3 months of the follow-up period. At the last follow-up, the VAS score was 3 points in the experimental group and 2.2 points in the control group, and the AOFAS score was 88.6 points in the experimental group and 88 points in the control group, all of which were significantly higher than those before operation, and the differences were statistically significant, but there was no statistically significant difference between the groups.

Conclusion

Both robot navigation-assisted retrograde drilling and arthroscopic microfracture for bone marrow stimulation (BMS) to treat OCLT in all patients obtained satisfactory effects in the short term. In addition, the follow-up revealed that with excellent efficacy and few complications, robot navigation-assisted retrograde drilling was safe and minimally invasive, and greatly reduced operative time. Consequently, robot navigation-assisted retrograde drilling for BMS was a safe and effective procedure for the treatment of OCLT.

Talus Osteochondral Defect Treatment With Biological Scaffold

Talus Osteochondral defects (OCDs) are challenging and there is no consensus in literature regarding which is the best method of treatment. New techniques coming from regenerative medicine are being considered good alternatives of treatment and are being used exponentially in orthopaedic surgery. Platelet-rich fibrin (PRF) is the second generation of platelet concentrates. It has a convenient method of acquisition and can be used to create a biological scaffold which is able to seal up cavitary lesions. In this article, the authors describe a talus OCD treated with a biological scaffold, reporting the technique details and its results clinical and radiological results. The case report objective is to portray the use of this kind of biological material, its advantages, and limitations.Level of Evidence: Level 5.

A Multi-Disciplinary MRI Assessment May Optimize the Evaluation of Chondral Lesions in Acute Ankle Fractures: A Prospective Study

Chondral lesions (CL) in the ankle following acute fractures are frequently overlooked immediately after the injury or diagnosed at a later stage, leading to persistent symptoms despite successful surgery. The literature presents a wide range of discrepancies in the reported incidence of CLs in acute ankle fractures. The objective of this prospective study is to provide a precise assessment of the occurrence of chondral lesions (CLs) in acute ankle fractures through MRI scans conducted immediately after the trauma and prior to scheduled surgery. Furthermore, the study aims to highlight the disparities in the interpretation of these MRI scans, particularly concerning the size and extent of chondral damage, between radiologists and orthopedic surgeons. Over the period of three years, all patients presenting with an unstable ankle fracture that underwent operative treatment were consecutively included in this single-center prospective study. Preoperative MRIs were obtained for all included patients within 10 days of the trauma and were evaluated by a trauma surgeon and a radiologist specialized in musculoskeletal MRI blinded to each other's results. The location of the lesions was documented, as well as their size and ICRS classification. Correlations and kappa coefficients as well as the p-values were calculated. A total of 65 patients were included, with a mean age of 41 years. The evaluation of the orthopedic surgeon showed CLs in 52.3% of patients. CLs occurred mainly on the tibial articular surface (70.6%). Most talar lesions were located laterally (11.2%). The observed CLs were mainly ICRS grade 4. According to the radiologist, 69.2% of the patients presented with CLs. The most common location was the talar dome (48.9%), especially laterally. Most detected CLs were graded ICRS 3a. The correlation between the two observers was weak/fair regarding the detection and classification of CLs and moderate regarding the size of the detected CLs. To enhance the planning of surgical treatment for ankle chondral lesions (CLs), it may be beneficial to conduct an interdisciplinary preoperative assessment of the performed scans. This collaborative approach can optimize the evaluation of ankle CLs and improve overall treatment strategies.

Arthroscopically assisted internal fixation for treatment of acute ankle fracture: A systematic review and meta-analysis of comparative studies

BACKGROUND

Arthroscopically assisted reduction and internal fixation (ARIF) allows for the assessment of joint congruity following anatomic reduction, identification of occult intra-articular lesions, and treatment of traumatic intra-articular pathologies. The aim of this systematic review and meta-analysis was to provide evidence on whether ARIF is an alternative treatment protocol for ankle fractures.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched independently by two investigators from the inception dates to October 9, 2022, for comparative studies. The risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials and the methodological index for non-randomized studies (MINORS) were used for assessing the methodological quality. Outcomes were evaluated in terms of the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, post-operative complications, arthroscopic findings, Visual Analogue Scale (VAS) score, and operation time. Cochrane Review Manager Software 5.4 was used to perform the statistical analysis.

RESULTS

A total of 10 trials involving 755 patients were included in this meta-analysis. The results revealed that ARIF for ankle fractures was superior regarding functional outcomes and VAS scores when compared with open reduction and internal fixation (ORIF). No significant difference was noted in the post-operative complication rate and the operation time between the ARIF and ORIF groups. A high incidence of chondral or osteochondral lesions (OCLs), ligamentous injuries, and loose bodies with ankle fractures was found by ankle arthroscopy.

CONCLUSIONS

ARIF for ankle fractures might be beneficial to offer superior functional outcomes and VAS score than ORIF. Orthopedic surgeons should take a high incidence of OCLs and ligamentous injuries into consideration for the treatment of acute ankle fractures. We believe that with the increase in surgical experience, the occurrence of post-operative complications and the extension of operation time will no longer be a potential concern for surgeons.

A Systematic Review of the Retrograde Drilling Approach for Osteochondral Lesion of the Talus: Questioning Surgical Approaches, Outcome Evaluation and Gender-Related Differences

BACKGROUND

Retrograde drilling (RD) is a minimally invasive surgical procedure mainly used for non-displaced osteochondral lesions (OCL) of the talus, dealing with subchondral necrotic sclerotic lesions or subchondral cysts without inducing iatrogenic articular cartilage injury, allowing the revascularization of the subchondral bone and new bone formation.

METHODS

This systematic review collected and analyzed the clinical studies of the last 10 years of literature, focusing not only on the clinical results but also on patients' related factors (gender, BMI, age and complications).

RESULTS

Sixteen clinical studies were retrieved, and differences in the type of study, follow-up, number and age of patients, lesion type, dimensions, grades and comparison groups were observed, making it difficult to draw conclusions. Nevertheless, lesions on which RD showed the best results were those of I-III grades and not exceeding 150 mm² in size, showing overall positive results, a good rate of patient satisfaction, improvements in clinical scores, pain reduction and return to daily activities and sports.

CONCLUSIONS

There are still few studies dealing with the issue of post-surgical complications and gender-related responses. Further clinical or preclinical studies are thus mandatory to underline the success of this technique, also in light of gender differences.

Arthroscopy for Traumatic Ankle Injuries

Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by way of treating intra-articular pathologies, leading to improved patient outcomes. While a majority of these injuries are not treated with concurrent arthroscopy, its addition may lead to more prognostic information to dictate the patient's course. This article has illustrated its use in managing malleolar fractures, syndesmotic injuries, pilon fractures and pediatric ankle fractures. While additional studies may be needed to further support AORIF, it may prove to play a vital role in the future.

Republication of "Osteochondral Lesions of the Talus: Current Concepts in Diagnosis and Treatment"

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Comparison of Visibility and Risk of Neurovascular Tissue Injury Between Portals in Needle Arthroscopy of the Anterior Ankle Joint: A Cadaveric Study

Background

For needle arthroscopy with 0° viewing, the visible range of intra-articular structures and the difference between portals remain unknown, as do the risks for neurovascular tissue at each portal.

Purpose

To clarify the visibility and safety of needle arthroscopy.

Study Design

Descriptive laboratory study.

Methods

Ten cadaveric ankle specimens were used. A needle arthroscope with a 1.9-mm diameter was inserted from 4 portals (anteromedial [AM], anterolateral [AL], medial midline [MM], and anterocentral [AC]). Visibility was assessed using a 15-point ankle arthroscopy checklist. In addition, the ankles were dissected to measure the distance between each portal and neurovascular tissues. The visibility of the ankle joint was compared between portals.

Results

The success rate of visibility in the deltoid ligament and the tip of the medial malleolus was 100% from the AM, MM, and AC portals and 10% from the AL portal, with significant differences between the portals (P < .01). The visibility success rates in the origin of the anterior talofibular ligament and the tip of the lateral malleolus were 20% for the AM portal, 90% for the MM and AC portals, and 100% for the AL portal, with significant differences between the portals (P < .01). All other points of the ankle joint were visualized from all the portals with a 100% success rate. The AC portal was in contact with the anterior neurovascular bundle in 4 of the 10 specimens.

Conclusion

When needle arthroscopy was performed from the AM or AL portal, the site opposite to the portal in the ankle joint was difficult to visualize. Conversely, most points of the ankle joint could be visualized from the MM and AC portals. Care should be taken when creating an AC portal because of its proximity to the anterior neurovascular bundle.

Clinical Relevance

The present study provides information regarding which portal should be selected to perform needle arthroscopy in the ankle joint, which will be beneficial for management of ankle injuries.

Talus bone: normal anatomy, anatomical variations and clinical correlations

Talus is a pivotal bone that assists in easy and correct locomotion and transfers body weight from the shin to the foot. Despite its small size, it is implicated in many clinical disorders. Familiarity with the anatomy of the talus and its anatomical variations is essential for the diagnosis of any disorder related to these variations. Furthermore, orthopedic surgeons must be fully aware by this anatomy during podiatry procedures. In this review, we attempt to present its anatomy in a simple, updated and comprehensive manner. We have also added the anatomical variations and some clinical points relevant to the unique and complex anatomy of talus. The talus has no muscle attachment. However, it does have many ligaments attached to it and others around it to keep it in place. Moreover, the bone plays a pig role in movements due to its involvement in many joints. Most of its surface is covered with articular cartilage. Therefore, its blood supply is relatively poor. This puts the talus at greater risk for poor healing as well as more complications in the event of injury than any other bone. We hope this review will make it easier for clinicians to pursue and understand the updated essential knowledge of one of the most complex bone anatomies that they need in their clinical practice.

Autologous Osteoperiosteal Transplantation for the Treatment of Large Cystic Talar Osteochondral Lesions

OBJECTIVE

The effectiveness of autologous osteoperiosteal transplantation (AOPT) for the treatment of large cystic talar osteochondral lesions (OCLs) should be further evaluated, and the postoperative cartilage coverage is questionable. The purpose of this retrospective observational study was to investigate the clinical outcomes of AOPT for the treatment of large cystic talar OCLs and to report second-look arthroscopic results.

METHODS

From June 1, 2017, to June 1, 2021, all talar OCLs at our center were reviewed. Painful cystic lesions treated with AOPT were included in the study. The American Orthopaedic Foot and Ankle Society (AOFAS; 0-100 points) ankle-hindfoot score, Foot Function Index (FFI; 0-100 points), visual analog scale (VAS; 0-10 points) score, and Tegner score (0-10 points) were used to describe pain and functional outcomes. Furthermore, complications, patient-reported satisfaction degrees, imaging results (including computed tomography and magnetic resonance), and second-look arthroscopic evaluation data were also collected for analysis.

RESULTS

A total of 29 cases were eligible for the study, and 26 responded to the latest follow-up request, with a mean follow-up duration of 30.2 (range, 12-57) months. The AOFAS score improved from 69.2 ± 10.9 preoperatively to 80.9 ± 10.0 at the latest follow-up (p = 0.000). The FFI score improved from 30.4 ± 18.4 preoperatively to 16.3 ± 14.0 at the latest follow-up (p = 0.000). The VAS pain score improved from 4.0 ± 2.1 preoperatively to 2.5 ± 2.0 at the latest follow-up (p = 0.001). No donor site morbidity was found. The mean postoperative MOCART score was 57.7 ± 9.5. Second-look arthroscopy showed a fibrillated cartilage-like surface at the lesion site in most cases, while two cases exhibited a nearly normal surface.

CONCLUSION

The transplantation of osteoperiosteal cylinder autografts taken from the iliac crest for the treatment of large cystic talar OCLs yielded acceptable clinical results. Good integration of the bony part was observed, but cartilage regeneration remained uncertain.

Pure Ankle Dislocation Without Associated Fracture: A Series of Cases and Our Clinical Experience

PURPOSE

Pure ankle dislocation without associated fracture is extremely rare. The current study reports eight cases of this type of injury, aiming to add some new material to the published data and present our clinical experience.

METHODS

Six open and two closed posteromedial tibiotalar dislocations without associated fractures treated in our department from 2015 to 2019 were retrospectively analyzed. Emergent reduction was performed for all patients followed by an average of 6 weeks of immobilization with external fixators in open cases and a short leg cast in closed cases. No patients underwent ligament or capsule repair except one case. The clinical data were recorded and analyzed.

RESULTS

At a mean follow-up of 33 months (range 13-61), the average AOFAS score was 91 (range 78-100) with five ankles rated as excellent and three rated as good. All of the eight patients returned to their prior daily life and the two closed patients with sports injuries resumed pre-injury activity level. The average range of motion (ROM) loss of the ankles was 9 degrees for plantarflexion and 3 degrees for dorsiflexion. Complications included superficial infection, moderate ankle stiffness, ankle degenerative change and residual numbness. None of the eight patients showed obvious ankle instability.

CONCLUSION

Pure ankle dislocation without associated fracture is a rare injury. Emergent reduction, appropriate wound care in open injuries and proper joint stabilisation with a cast or external fixator provide good clinical results and could be the mainstay of treatment.

Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified With Ankle Arthroscopy Following Rotational Ankle Fracture: A Systematic Review

A systematic literature search was performed using the PubMed, MEDLINE, and the Cochrane Library databases according to the Preferred Reporting Items for Systematic review and Meta-Analyses guidelines on May 20, 2019. The keywords used were: ankle, distal tibia, distal fibula, fracture, arthroscopic, cartilage, and chondral. The objective of this study is to systematically review the characterization of intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following ankle fracture. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures within any timeframe were included. The incidence of intra-articular chondral lesions was recorded, the location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. Fifteen studies with 1355 ankle fractures were included. About 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL). We compared incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < .05 was considered statistically significant. We found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy.

Triplane osteotomy combined with talar non-weight-bearing area autologous osteochondral transplantation for osteochondral lesions of the talus

Background

Traditional medial malleolar osteotomy combined with autologous osteochondral transplantation (AOT) is mostly used in the treatment of osteochondral lesions of the talus (OLTs), but with high osteotomy and donor site complications. We hypothesis a new triplane medial malleolar osteotomy combined with AOT from non-weight-bearing area of the talus could be a promising choice for OLTs.

Methods

We reviewed all the symptomatic OLTs patients who received AOT with triplane osteotomy of the medial malleolus between September 2015 and December 2017 in our department. According to the inclusion and exclusion criteria, 23 patients (23 ankles), including 14 males and 9 females, were included in the study. The mean age was 35.6 years. The mean size of the lesion area was 141.5 mm². According Ferkel’s classification, including 5 type I, 11 typeIIa and 7 typeIIb. The visual analog scale (VAS) for pain during walking and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for the pre- and postoperative evaluations. In addition, the incorporation of the grafts was assessed by computed tomography (CT).

Results

All patients had a minimum follow-up of 22 months, with an average of 37.1 months. The mean time from osteotomy to full weight-bearing activity was 8.1 ± 2.3 weeks (range, 5–12 weeks). The mean VAS score improved from 5.6 ± 0.7 preoperatively to 0.7 ± 1.0 postoperatively (P < 0.01). The AOFAS ankle-hindfoot score improved significantly in all domains (P < 0.01). Twenty-one patients returned to sport at their previous level, and 2 returned at a lower level compared with preinjury (mean return to play, 7.4 months). According to CT, the medial malleolus recovered in all patients, and the graft was incorporated well. One patient suffered from flexor hallucis longus tendon discomfort due to internal fixation screw irritation posteromedial to the ankle. The general complication rate was 4.3% (1/23).

Conclusions

These results indicate that AOT combined with medial malleolus triplane osteotomy maybe a viable option for OLTs. Patients could perform weight-bearing exercise and return to sport as early as possible, with a lower rate of complications at the osteotomy site and donor site. However, the large sample well-designed prospective comparative studies are still needed.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background:

Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time.

Purpose:

To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus.

Study Design:

Descriptive laboratory study.

Methods:

Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated.

Results:

Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm² (95% CI, 13.3-14.7 cm²), while the mean area visible via an open approach was 2.1 cm² (95% CI, 0.5-3.6 cm²). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%).

Conclusion:

These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate.

Clinical Relevance:

Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Osteochondritis dissecans of the talar dome in patients with tarsal coalition

OBJECTIVE

Tarsal coalition is known to cause abnormal talocrural stress, hindfoot malalignment, and ankle sprains. These can all be associated with osteochondritis dissecans (OCD) of the talar dome. We present the first detailed description of a series of talar OCDs occurring in patients with tarsal coalition, with the goal of determining whether there is an increased prevalence of OCDs among patients with tarsal coalition.

MATERIALS AND METHODS

We studied ankle MRIs in 57 patients with tarsal coalitions, excluding those with a reported inciting traumatic event. The MRIs were performed on magnetic field strengths ranging from 0.3 to 1.5 T and included axial, coronal, and sagittal T1 and T2 or PD fat-suppressed sequences. We evaluated the morphology and location of classically described OCDs in these patients, type and location of concomitant tarsal coalition, and, when available, the presence of pes planus and hindfoot valgus on weight-bearing radiographs. Chi-squared analysis was used to compare categorical variables and a Student's t test was used for parametric continuous variables. Additionally, logistic regression was used to compute the odds ratio of talar OCD associated with patient age, gender, laterality, pes planus status, hindfoot valgus status, and coalition type.

RESULTS

Eighty-nine percent of tarsal coalitions were non-osseous coalitions and the calcaneonavicular space was the most common site of abnormal tarsal connection (54.4%). In the 29 patients with tarsal coalitions and talar OCDs, OCDs commonly occurred medially (75.9%). In the sagittal plane, talar OCDs occurred centrally, with only one case sparing the central talar dome. The mean surface area of the 29 OCDs was 89.7 mm². Both osseous coalition and hindfoot valgus were associated with smaller talar OCD mean surface area (p = 0.015 and p = 0.0001, respectively). There was no association between depth and surface area of talar OCD with either coalition location or presence of pes planus (coalition location: p = 0.455 for depth and p = 0.295 for surface area; presence of pes planus: p = 0.593 for depth and p = 0.367 for surface area).

CONCLUSION

Talar OCD prevalence is higher in patients with tarsal coalition than that reported for the general population. This occurrence may relate to altered biomechanics and repetitive talocrural stress owing to altered subtalar motion, particularly given the findings of increased odds of talar OCD in older patients, as well as weak associations between OCD surface area and both non-osseous coalition and hindfoot alignment. However, we did not find any specific OCD morphologic features attributable to the precise location of the tarsal coalition.

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review

BACKGROUND

Arthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT.

METHODS

Two independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool.

RESULTS

AD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation.

CONCLUSIONS

There is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.

Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.

Osteochondral Lesions of the Tibial Plafond: A Systematic Review

Background:

There is a paucity of data regarding osteochondral lesions of the tibial plafond (OLTPs), in part because they are far less common than osteochondral lesions of the talus.

Purpose:

To evaluate the topographical characteristics of OLTPs and outcomes after surgical intervention, while analyzing the level of evidence (LOE) and quality of evidence (QOE) of the included studies.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting clinical data for OLTPs were included. The LOE and QOE of the included studies were evaluated using a 5-level grading system and the modified Coleman Methodology Score, respectively.

Results:

Included were 20 studies with 426 OLTPs; 4 studies were LOE 2 and 16 studies were LOE 4. Overall, 86.7% of OLTPs were associated with a traumatic history and/or previous ankle sprain. OLTPs were most commonly located in the centromedial region of the tibial plafond (30.4%), with the fewest number of OLTPs found in the anteromedial region of the tibial plafond (3.9%). In 17 of the studies, a total of 46.9% of OLTPs were associated with coexisting osteochondral lesions of the talus. The most frequently used surgical technique to treat OLTPs was microfracture, which resulted in good clinical outcomes at midterm follow-up.

Conclusion:

The results of this systematic review indicated that OLTPs are frequently preceded by ankle trauma and are often associated with coexisting osteochondral lesions of the talus. Clinical outcomes after arthroscopic intervention appear to produce good results in the midterm, but the low LOE, poor QOE, marked heterogeneity, and underreporting of the data confound any recommendation based on this systematic review.

Histological and Inflammatory Cytokine Analysis of Osteochondral Lesions of the Talus After Failed Microfracture: Comparison With Fresh Allograft Controls

Background:

The most common first-line treatment of osteochondral lesions of the talus (OLTs) is microfracture. Although many patients do well with this procedure, a number fail and require reoperation. The mechanism of failure of microfracture is unknown, and to our knowledge there has been no research characterizing failed microfracture regarding histological and inflammatory makeup of these lesions that may contribute to failure.

Purpose:

To characterize the structural and biochemical makeup of failed microfracture lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

Specimens from 8 consecutive patients with symptomatic OLTs after microfracture who later underwent fresh osteochondral allograft transplantation were analyzed. For each patient, the failed microfracture specimen and a portion of the fresh allograft replacement tissue were collected. The allograft served as a control. Histology of the failed microfracture and the allograft replacement was scored using the Osteoarthritis Research Society International (OARSI) system. Surface roughness was also compared. In addition, tissue culture supernatants were analyzed for 16 secreted cytokines and matrix metalloproteinases (MMPs) responsible for inflammation, pain, cartilage damage, and chondrocyte death.

Results:

The OARSI grade, stage, and total score as well as surface smoothness were significantly worse in the failed microfracture sample, indicating better cartilage and bone morphology for the allografts compared with the failed microfracture lesions. Analyzed cytokines and MMPs were significantly elevated in the microfracture tissue culture supernatants when compared with fresh osteochondral tissue supernatants.

Conclusion:

These data demonstrate a significantly rougher cartilage surface, cartilage and subchondral bone histology that more closely resembles osteoarthritis, and elevated inflammatory cytokines and MMPs responsible for pain, inflammation, cartilage damage, and chondrocyte death when compared with fresh osteochondral allografts used as controls.

Osteochondral lesions of the talar dome: an up-to-date approach to multimodality imaging and surgical techniques

Osteochondral lesions (OCLs) of the talar dome consist of a multifactorial pathology of the articular cartilage and subchondral bone and can result in persistent ankle pain and osteoarthritis (OA). Along with a physical examination and clinical history, an imaging evaluation plays a pivotal role in the diagnosis of these lesions and is fundamental for making treatment decisions and determining prognosis by providing information regarding the size, location, and cartilage and subchondral bone statuses as well as associated lesions and degenerative changes. Multiple surgical techniques for OCLs of the talar dome have been developed in recent decades, including cartilage repair, regeneration, and replacement strategies, and radiologists should be acquainted with their specific expected and abnormal postoperative imaging findings to better monitor the results and predict poor outcomes. The present article proposes a thorough review of the ankle joint anatomy and biomechanics, physiopathology, diagnosis, and treatment of OCLs of the talar dome, highlighting the radiological approach and imaging findings in both pre- and postoperative scenarios.

Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for Treatment of Ankle and Foot Osteochondral Lesions

BACKGROUND

The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid.

METHODS

Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner.

RESULTS

The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm² vs 133 mm²). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm² and 194 mm², respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures.

CONCLUSION

The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle.

CLINICAL RELEVANCE

This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BACKGROUND

Anatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes OBJECTIVES: The purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes.

RESULTS

Lauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions.

CONCLUSION

Second-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Current management of trimalleolar ankle fractures

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Correlation of stress radiographs to injuries associated with lateral ankle instability

BACKGROUND

Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability.

AIM

To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability.

METHODS

A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings.

RESULTS

A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (P = 0.043).

CONCLUSION

Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle instability.

Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation

Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Comparison of Arthroscopic Treatment Methods in Talar Osteochondral Lesions: A Multicenter, Prospective, Randomized Clinical Trial

BACKGROUND

The aim of the present study was to contribute new and updated information to the literature by comparing the clinical and radiologic results of arthroscopic microfracture, platelet-rich plasma (PRP) after arthroscopic microfracture, and BST-Cargel scaffold application after arthroscopic microfracture in the treatment of talar osteochondral lesions.

METHODS

Sixty-two talar osteochondral lesion patients (31 women and 31 men) who underwent ankle arthroscopy in two different centers were randomized into three groups. The first group consisted of patients who underwent only arthroscopic microfracture (MF) (n = 22); the second group consisted of patients who underwent the PRP procedure after arthroscopic MF (PRP; n = 19); and the third group consisted of patients who underwent the BST-Cargel procedure after arthroscopic MF was (BST-Cargel; n = 21). The talar osteochondral lesions in the three groups were classified according to magnetic resonance and arthroscopic images. American Orthopedic Foot and Ankle Society, Foot and Ankle Ability Measurement (overall pain, 15-minute walking, running function), and visual analog scale scores were evaluated preoperatively and postoperatively, and postoperative return time to sports activities was performed.

RESULTS

Compared to the preoperative score, postoperative American Orthopedic Foot and Ankle Society score increased 48.80 ± 9.60 in the BST-Cargel group, whereas there was an increase of 46.68 ± 3.65 in the PRP group and 29.63 ± 3.69 in the MF group, which were statistically significant (P < .05).There was a statistically significant postoperative change in the visual analog scale scores of the patients in all three groups compared to the preoperative scores (P < .05). At the end of the follow-up, the Foot and Ankle Ability Measurement overall pain, 15-minute walking, and running function results of all three groups increased significantly postoperatively compared to the preoperative values (P < .005).

CONCLUSIONS

BST-Cargel application with microfracture is a method that can be applied easily and safely with arthroscopy to lesions larger than 1.5 cm2 regardless of the size of the cartilage defect, and it has been found to be superior to the other two methods in terms of pain, functional score, radiologic recovery, and return to sports activities.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey

PURPOSE

Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons.

METHODS

A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency".

RESULTS

A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm.

CONCLUSION

The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options.

LEVEL OF EVIDENCE

Level IV.

High incidence of (osteo)chondral lesions in ankle fractures

PURPOSE

To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to 50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL).

METHODS

A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis-Weber and/or Lauge-Hansen classification) was calculated and pooled. Two-sided p values of less than 0.05 were considered statistically significant.

RESULTS

Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (n = 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge-Hansen categories (p = 0.049). Post hoc pairwise comparisons between Lauge-Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.).

CONCLUSION

OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45-47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery.

LEVEL OF EVIDENCE

IV.

Ankle Arthroscopy as an Adjunct to the Management of Ankle Fractures

BACKGROUND

Ankle fractures are one of the most common injuries managed by orthopedic surgeons. Although the etiology of posttraumatic osteoarthritis in anatomically reduced ankle fractures is not completely known, several studies suggest that undetected intra-articular pathology at the time of injury may play a role. The purpose of this study is to report the operative findings of ankle arthroscopy as an adjunct to ankle fracture open reduction and internal fixation.

METHODS

A retrospective review was performed of all ankle fractures treated consecutively at our institution by a single surgeon from August 2010 to October 2019, which were found using Current Procedural Terminology codes. A total of 84 patients met our inclusion criteria for whom patient demographics and clinical history were collected. Pre- and postoperative diagnoses from every operative report were noted as well as intra-articular intervention made during the time of arthroscopy.

RESULTS

The study included 49 men (58.3%) and 35 women (41.7%), with a mean age of 39.0 (range, 12-69; SD = 15.0) years. Sixty-three patients (75%) had new diagnoses detected by the addition of ankle arthroscopy. The most common new pathology seen arthroscopically were osteochondral lesions (n = 36, 41.9%) and posterior malleolus fractures (n = 28, 32.6%). Thirty-four patients had a total of 40 additional arthroscopic procedures in conjunction with their fracture management. Complications were noted in 13 patients, with hardware removal (n = 8) being the most common (62%).

CONCLUSION

Ankle arthroscopy can act as a significant diagnostic and prognostic tool and can help address intra-articular injuries without adding considerable cost or serious adverse events.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Osteochondral Lesions of the Distal Tibial Plafond: A Systematic Review of Lesion Locations and Treatment Outcomes

BACKGROUND

Osteochondral lesions of the tibial plafond (OLTPs) remain less common than osteochondral lesions of the talus (OLTs), but recognition of the condition has increased.

PURPOSE

To systematically evaluate the literature on lesion locations and treatment outcomes of OLTPs, whether in isolation or in combination with OLTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search was performed using the PubMed, Embase, and CINAHL databases for studies on lesion locations or with imaging or treatment outcomes of OLTPs. Case reports and reports based on expert opinion were excluded. Lesion locations as well as outcome measure results were aggregated. The Methodological Index for Non-randomized Studies score was used to assess methodological quality when applicable.

RESULTS

Included in this review were 10 articles, all published in 2000 or later. Most studies were evidence level 4, and the mean Methodological Index for Non-randomized Studies score was 8.6 (range, 8-10). Overall, 174 confirmed OLTP cases were identified, and the mean patient age was 38.8 years. Of the 157 lesions with confirmed locations, the most common was central-medial (32/157; 20.4%). Of 6 studies on treatment outcomes, all but 1 evaluated bone marrow stimulation techniques. Microfracture of small lesions (<150 mm2) was the most common treatment utilized. Imaging and functional outcomes appeared favorable after treatment. The data did not support differences in outcomes between isolated OLTPs and OLTPs with coexisting OLTs.

CONCLUSION

Osteochondral lesions of the distal tibia most commonly occurred at the central-medial tibial plafond. Microfracture of small lesions was the most common treatment utilized, and clinical and magnetic resonance imaging results were favorable, although data were heterogeneous. Areas for future research include the following: the effect of patient factors and additional pathologies on outcomes; larger or deeper lesion treatment; more direct comparisons of outcomes between kissing or coexisting lesions and isolated lesions; and head-to-head comparison of treatments, such as microfracture, bone marrow-derived cell transplantation, and osteochondral autografts/allografts.

Propensity Score-Matched Analysis of Arthroscopically Assisted Ankle Facture Treatment Versus Conventional Treatment

BACKGROUND

The aim of this study was to assess the prospective, longitudinal outcome after arthroscopically assisted open reduction and internal fixation (AORIF) and to compare the results with open reduction and internal fixation (ORIF) in complex ankle fractures.

METHODS

Acute, closed, bimalleolar equivalent, bimalleolar, or trimalleolar ankle fractures were included. The AORIF cohort was enrolled prospectively. The ORIF group was identified from a retrospective database. The same inclusion and exclusion criteria were applied. The only difference was the additional arthroscopy in the AORIF cohort. The patient-reported outcome measurement (PROM) following AORIF was assessed at 1 and 4 years of follow-up using the Olerud and Molander Ankle Score (OMAS) and Tegner activity scale (TAS). The AORIF cohort was propensity score matched (nearest-neighbor matching) to the ORIF database. The OMAS and Foot and Ankle Ability Measure (FAAM) were compared between the resulting groups. Nonparametric statistics were applied; values are presented as median (interquartile range). Twenty-six AORIF patients had a prospective 4-year follow-up.

RESULTS

No significant differences (1 year vs 4 years) were identified for the OMAS (90 [10] vs 90 [11]) and TAS (4 [2] vs 5 [2]). The severity of the cartilage lesions (International Cartilage Repair Society [ICRS] grade <4 vs ICRS of 4) had no significant influence on the PROMs. Twenty-five patients per cohort (AORIF vs ORIF) were matched. The OMAS (90 [13] vs 75 [40]; P = .008) and FAAM Activities of Daily Living (ADL; 96 [11] vs 88 [30]; P = .034) revealed significantly better outcomes for AORIF. More patients in the AORIF cohort returned to sport (96% vs 77%; P = .035), with a higher FAAM Sports score (88 [37] vs 56 [47]; P = .008).

CONCLUSION

AORIF for complex ankle fractures led to consistently good to excellent results. The propensity score-matched analysis revealed a significantly better outcome 4 years after surgery for AORIF compared with ORIF.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Advantages of preoperative planning using computed tomography scan for treatment of malleolar ankle fractures

Malleolar ankle fractures have been classified using plain radiographs, and there is no consensus regarding the role of computed tomography (CT) scans in preoperative planning. We analyzed critical aspects, such as limits of standard radiographs, types of injury, classification methods and cost/benefit evaluations. CT scans allow a 3D analysis of the fracture to be obtained and consequently assess the indication for surgical procedure, surgical access and the type of fixation devices required. This exam is useful for detecting lesions that may go unnoticed on radiographs and will help surgeons to clarify the pathoanatomy of ankle fractures. According to Arbeitsgemeinschaft fur Osteosynthesefragen/ Orthopaedic Trauma Association (AO/OTA) classification, CT scan is recommended in medial malleolar fractures with vertical rim, type 44B fractures with posterior malleolar involvement and all type 44C fractures (according to AO/OTA). Also Tillaux-Chaput fractures (43-B1 according to AO/OTA), malleolar fractures in the presence of distal tibial fractures (43 according to AO/OTA) and distal tibia fractures in adolescents should be studied with CT scans.

Osteochondral defects of the talus: radiological appearance and surgical candidate profiling - A retrospective analysis

BACKGROUND

Osteochondral defects of the talus (OCD) are a well-established pathology within the ankle. They are most commonly associated with ankle trauma and whilst many are asymptomatic, they can have a significant negative impact on the patient, most notably with regards pain and mobility. Treatment of these lesions remains variable across the diverse cohort of these patients.

AIMS

Evaluating the incidence of talus OCDs. Evaluating anatomic and morphologic data of the lesions against previous studies. Establishing if there was there any associated ligamentous injury. Determining the cohort of patients who were considered/underwent surgical intervention.

METHODS

A retrospective review was performed on patients presenting to a single Scottish Hospital with Talar OCDs between 2012-2016. Data collected included radiological appearance of the lesions (location and size), clinical history, associated ligament injury, treatment given and subsequent outcome. Categorical variables were presented as count and percentage while non-parametric variables were presented as median and interquartile range.

RESULTS

90 new cases that matched our inclusion criteria were identified. Using the Raikin classification, the majority of injuries are in the posteromedial (26%), centrolateral (21%), and centromedial (18%) segments of the talus. Of note, no lesions were identified in the posterocentral segment. 46% of patients had an associated ligamentous injury, either in the form of a sprain or tear. Most commonly the injury involved both ATFL and CFL (82%). 70% of patients that underwent surgery had radiological evidence of ligamentous injury. No statistically significant difference was identified between the management option and the involved segment according to Orr/Raikin classifications.

CONCLUSION

Talus osteochondral defects are a pathology which is more common than originally thought and their treatment remain a controversial topic. Little is known about the physical history of the condition as most cases are asymptomatic, thus poorly documented by definition. There is a clear opportunity and need for further research into developing evidence-based guidelines for their management. This study tried to correlate the management of OCDs with epidemiological and radiological data.

Role of Arthroscopy in Various Ankle Disorders

INTRODUCTION

Ankle arthroscopy has come a long way since it was thought, it is not feasible because of tight joint and anatomical characteristics of ankle joint. The same anatomical features like capsular attachment and safe accessory portals are used to access the whole joint even with a rigid arthroscope. Ankle distraction method was routinely used to access the anterior ankle. However, nowadays, anterior arthroscopy is done in dorsiflexion as this increases the anterior ankle joint volume, and thereby easy access to various anatomical structures. On the other hand, intermittent traction is used to access the posterior ankle. Initially used as a diagnostic tool, ankle arthroscopy is now used extensively as a therapeutic and reconstruction tool. New evidence is published for all inside ligament reconstructions, effective management of impingement syndromes, and osteochondral lesions. The indications are being extended to fracture management and arthrodesis.

METHODOLOGY

This narrative review was performed following a literature search in the Pubmed database and Medline using the following keywords: ankle arthroscopy, portals, ankle OCD, functional outcome. Related articles were then reviewed.

CONCLUSION

Complications rate is reduced with a better understanding of the relative anatomy of surrounding neurovascular structures and tendons with regard to the position of ankle joint. This review on ankle arthroscopy focuses on anatomy, indications, and complications. Ankle arthroscopy is a safe and elegant tool as any other joint arthroscopy.

Identifying Intra-Articular Pathology With Arthroscopy Prior to Open Ankle Fracture Fixation

Purpose

To assess the prevalence of intra-articular findings with ankle arthroscopy in patients undergoing operative fixation for ankle fractures.

Methods

This is a retrospective review of ankle fractures that were treated with arthroscopy and open reduction and internal fixation by a single surgeon. Between August 2016 and July 2018, operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. An analysis was performed with regard to fracture type, presence and location of osteochondral lesions, loose-bodies, syndesmotic injury, and deltoid injury.

Results

Fifty-seven ankle fractures were identified that met inclusion criteria. In total, 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by presence of intra-articular loose bodies and osteochondral defects.

Conclusions

In our study, use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects. The most common pathology was syndesmotic injury. The addition of an arthroscopic assessment in patients with operatively treated ankle fractures may help improve treatment provided to patients during ankle fracture surgery.

Level of Evidence

Level 4 Therapeutic Case Series.

HemiCAP® implantation after failed previous surgery for osteochondral lesions of the talus

BACKGROUND

The aim of this study is to enhance data about the effectiveness of HemiCAP® implantation after failed previous surgery for osteochondral defects (OCDs).

METHODS

12 consecutive patients were retrospectively included in this study. The American Orthopedic Foot and Ankle Society Score (AOFAS), the Visual Analogue Scale (VAS) score for pain, the sub-scales Pain and Disability of the Foot Function Index (FFI-P and FFI-D) Score, and the patients' satisfaction were evaluated.

RESULTS

AOFAS increased from poor to fair (p < 0.001), VAS score decreased from moderate to mild pain (p = 0.001), the final FFI-P and FFI-D were 37.50 ± 18.54 and 33.44 ± 16.24, respectively (p < 0.001). Five patients were not satisfied, three were moderately satisfied and four were highly satisfied. One implant repositioning, one ankle fusion (implant failing) and an additional surgery (double arthrodesis) were performed during the follow-up. Neither intra- nor postoperative complications were registered.

CONCLUSION

Despite the clinical improvement, pain was still present at the final follow-up. Metal resurfacing might not be considered a definitely valid alternative for treatment of OCDs after failed previous surgery.

LEVEL OF EVIDENCE

Level III, retrospective study.

Incidence of concomitant chondral/osteochondral lesions in acute ankle fractures and their effect on clinical outcome: a systematic review and meta-analysis

INTRODUCTION

Despite successful osteosynthesis, some patients report residual symptoms after ankle fractures. One of the reasons behind the postoperative complaints might be traumatic concomitant chondral lesions (CL) and/or osteochondral lesions (OCL) within the ankle joint. The study aims to systematically review the incidence of CL and/or OCL in ankle fractures and to assess their effect on the clinical outcome.

MATERIALS AND METHODS

This work was conducted according to PRISMA checklists. A systematic literature search was performed using following keywords: "Ankle Fractures" OR "Trimalleolar Fracture" OR "Bimalleolar Fracture" OR "Maisonneuve fracture" OR "Malleolus Fracture" AND "Cartilage" OR "Cartilage Diseases" OR "Cartilage, Articular" OR "chondral" up to March 2020. The identified articles were analysed to determine the incidence of CL and/or OCL. Included studies in the meta-analysis assessed possible cartilage damage through arthroscopy or MRI immediately after traumatic ankle fractures and described the postoperative clinical outcome.

RESULTS

The search identified a total of 111 publications; 19 described the incidence of CL and/or OCL after ankle fractures; six met the criteria to be included in the meta-analysis: five (n = 293) diagnosed CL and/or OCL through arthroscopy during ORIF and one study (n = 153) used preoperative MRI. The clinical outcome was evaluated in four studies (n = 177) using AOFAS score and in two (n = 269) using FAOS score. The mean incidence of arthroscopically detected CL and/or OCL was 65 ± 21% [95% CI 53.9 to 76.72]. The cumulative meta-analysis sample size comprised a total of 400 Patients (170 with and 230 without CL and/or OCL) available for a mean follow-up of 23.9 ± 11.5 months [95% CI 11.79 to 36.07]. The average age was 44.3 ± 5.5 years [95% CI 38.57 to 50.13]. The meta-analysis revealed a mean AOFAS score of 91.2 ± 4.8 [95% CI 83.53 to 98.93] with versus 94.4 ± 4.7 [95% CI 86.81 to 102.07] without CL and/or OCL (p = 0.15) and a mean FAOS score of 73.2 ± 11.31 [95% CI - 28.44 to 174.85] with versus 79.0 ± 18.4 [95% CI - 86.77 to 244.87] without CL and/or OCL (p = 0.18).

CONCLUSIONS

CL and/or OCL appear very frequently after ankle fractures. A tendency towards a favourable short- to mid-term clinical outcome was noticed in ankle fractures without CL and/or OCL, however without reaching statistical significance.

LEVEL OF EVIDENCE

Level I.

ACR Appropriateness Criteria® Acute Trauma to the Ankle

Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Role of Deltoid Repair and Arthroscopy in Ankle Fractures

Despite the fact that ankle fractures are common injuries, not all patients obtain satisfactory results. Historically, the deltoid ligament injury and intra-articular pathology have not often been treated at the time of fracture stabilization. Recent literature has suggested that repair of the deltoid ligament may lead to better stability of the ankle mortise. Additionally, the use of arthroscopy in conjunction with fracture fixation may allow for better identification and treatment of intra-articular lesions and improve detection and reduction of subtle instability.

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; r_s = -0.522 and -0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.

Long-term Prognosis After Successful Nonoperative Treatment of Osteochondral Lesions of the Talus: An Observational 14-Year Follow-up Study

Background:

Little is known about the long-term prognosis of osteochondral lesions of the talus (OLTs) after nonoperative treatment.

Purpose:

To evaluate the clinical and radiological long-term results of initially successfully treated OLTs after a minimum follow-up of 10 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 1998 and 2006, 48 patients (50 ankles) with OLTs were successfully treated nonoperatively. These patients were enrolled in a retrospective long-term follow-up, for which 24 patients could not be reached or were available only by telephone. A further 2 OLTs (6%) that had been treated surgically were excluded from the analysis and documented as failures of nonoperative treatment. The final study group of 22 patients (mean age at injury, 42 years; range, 10-69 years) with 24 OLTs (mean size, 1.4 cm²; range, 0.2-3.8 cm²) underwent clinical and radiological evaluation after a mean follow-up of 14 years (range, 11-20 years). Ankle pain was evaluated with a visual analog scale (VAS), ankle function with the American Orthopaedic Foot and Ankle Society (AOFAS) score, and sports activity with the Tegner score. Progression of ankle osteoarthritis was analyzed based on plain ankle radiographs at the initial presentation and the final follow-up according to the Van Dijk classification.

Results:

At final follow-up, the 24 cases (ie, ankles) showed a median VAS score of 0 (IQR, 0.0-2.25) and a median AOFAS score of 94.0 (IQR, 85.0-100). Pain had improved in 18 cases (75%), was unchanged in 3 cases (13%), and had increased in 3 cases (13%). The median Tegner score was 4.0 (IQR, 3.0-5.0). Persistent ankle pain had led to a decrease in sports activity in 38% of cases. At the final follow-up, 11 cases (73%) showed no progression of ankle osteoarthritis and 4 cases (27%) showed progression by 1 grade.

Conclusion:

Osteochondral lesions of the talus that successfully undergo an initial nonoperative treatment period have minimal symptoms in the long term, a low failure rate, and no relevant ankle osteoarthritis progression. However, a decrease in sports activity due to sports-related ankle pain was observed in more than one-third of patients.