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Category: Ankle; Hindfoot; Sports Introduction/Purpose: Autologous matrix-induced chondrogenesis (AMIC) has shown to result in favorable clinical outcome in patients with osteochondral lesions of the talus (OLT). Yet, the influence of ankle instability on cartilage repair of the ankle has still to be determined. This study sought to compare the clinical and radiographic outcome in patients with and without concomitant lateral ligament stabilization (LLS) undergoing AMIC for the treatment of OLT. Methods: This study evaluated AMIC that were implanted in patients for the treatment of symptomatic OLT with and without concomitant ankle instability. Postoperative MRI, Tegner, AOFAS and Cumberland Ankle Instability Tool (CAIT) were obtained at a minimum follow-up of 2 years. A musculoskeletal radiologist scored all grafts according to the MOCART 1 and 2.0 scores. Patients were stratified into two groups based on whether they underwent concomitant LLS for ankle instability. Patients without LLS served as controls. Patients were matched 1:1 for BMI, lesion size, follow-up and age. Results: Twenty-six patients that underwent AMIC with a mean follow-up of 4.2 +- 1.5 years were enrolled in this study (13 with and 13 without concomitant ankle instability). Patients' mean age was 33.4 +- 12.7 years with a BMI averaging 26.2 +- 3.7. Patients with concomitant LLS showed worse clinical outcome measured by AOFAS (85.1 +- 14.4 vs. 96.3 +- 5.8, p=0.034) and Tegner (3.8 +- 1.1 vs. 4.4 +- 2.3, p=0.012). No difference was seen between both groups regarding MOCART 1 and 2.0 scores (p=0.714 and p=0.371, respectively). Additionally, postoperative CAIT and AOFAS significantly correlated in patients that underwent concomitant LLS (r=0.766, p=0.002) with a CAIT score of > 24 (stable ankle joint) resulting in AOFAS scores comparable to scores in patients with isolated AMIC (90.1 +- 11.6 vs. 95.3 +- 6.6; p=0.442). Conclusion: The results of this study suggest a negative influence of ankle instability on the clinical outcome of cartilage repair with AMIC for the treatment of OLT. If postoperative ankle stability is achieved in patients with LLS, however, comparable outcome as seen after isolated AMIC can be expected.

Category: Hindfoot Introduction/Purpose: Different factors are well known influencing the development of adult acquired flatfoot (AAF) deformity. So far less attention was paid to the lateral ligament complex. The idea that the anterior talofibular ligament (ATFL) probably influences AAF could be obvious concerning its anatomical course. Goal of this study is to assess the influence of ATFL on AAF and on operative AAF correction by lateral calcaneal. Methods: We reviewed all patients that undergone lateral calcaneal lengthening in AAF from 01/01/2008 to 07/31/2018 in our clinic. Patients were grouped in patients with intact ATFL and in those with injured ligament. Two independent readers performed assessment of common radiographic flatfoot parameters in preoperative and postoperative radiographs. Results: Statistical significant difference between two groups could be observed for preoperative talonavicular uncoverage angle (p=0.018) and talocalcaneal angle (p=0.032), with more severe AAF in patients with injured ATFL. The other common radiographic parameters showed no significant difference, although a tendency to a more severe AAF could be observed within the group with damaged ATFL. No difference could be observed in surgical outcome or consistency after lateral calcaneal lengthening between two groups. Conclusion: ATFL seems to take impact in AAF concerning talonavicular uncoverage angle and talocalcaneal angle. In patients undergoing lateral calcaneal lengthening the integrity of the ligament seems not to influence the degree of correction or the consistency of the postoperative result.

Category: Bunion Introduction/Purpose: An optimal osteotomy angle can avoid shortening of the first metatarsal bone after hallux valgus surgery and therefore reduce the risk of transfer-metatarsalgia. Up to date the osteotomy is performed free-hand without guidance and is therefore prone to unwanted variability in accuracy. The purpose of the present ex-vivo study was to investigate whether overlaying a hologram (augmented reality, AR) would improve accuracy of the distal osteotomy during hallux valgus surgery. Methods: A polyamide foot skeleton was constructed based a CT scan of a cadaveric foot and covered with medical silicon soft tissue. Three different polyamide first metatarsals were inserted to simulate a light, moderate and severe hallux valgus deformity. Distal Osteotomies of the first metatarsals were performed by two surgeons with different levels of surgical experience each with (AR, n=15x2) or without (controls, n=15x2) overlay of a hologram depicting an angle of osteotomy perpendicular to the second metatarsal in the transverse plane. Subsequently, the deviation to the plumb line of the second metatarsal in the transverse plane of all 60 osteotomies angles were optically measured and statistically analyzed. Results: Overall, the AR-guided osteotomies were more accurate (4.9 ± 4.2°) compared to the freehand cuts (6.7± 6.1°) by tendency (p=0.2). However, while the inexperienced surgeon performed more accurate osteotomies with AR with a mean angle of 6.4± 3.5° compared to freehand 10.5 ± 5.5° (p=0.02), no significant difference was noticed for the experienced surgeon with an osteotomy angle of around 3° in both cases. Conclusion: This pilot-study suggests that augmented reality guided osteotomies can potentially improve accuracy during hallux valgus surgery, particularly for less experienced surgeons. However, clinical studies are needed to investigate the clinical benefit of augmented reality in hallux valgus surgery.

Category: Midfoot/Forefoot Introduction/Purpose: Recent studies have shown that Hallux valgus deformity can lead to transfermetatarsalgia due to an impairment and relative shortening of the first ray. During ReveL osteotomy the relative shortening of the MT I is not addressed. Furthermore, a posterior deviation of the osteotomy angle results in additional iatrogenic shortening of the MT I and might favor postoperative transfermetatarsalgia. Methods: A 3-dimensional model of a foot was obtained from CT scans of a cadaveric foot. The MT I of the 3-dimensional model was then pivoted medially to simulate a severe hallux valgus deformity of an intermetatarsal angle (IMA) of 18° and an intermediate hallux valgus deformity of an IMA of 13°. A ReveL operation was simulated to correct the IMA to 8° for the severe and the intermediate Hallux valgus. Therefore the osteotomy angle in the coronal plane (f=0) was chosen perpendicular to the axis of the second metatarsalia. Afterwards the length of MT I was measured. This procedure was repeated for an posterior altered osteotomy angle (f = 5°,10°, 15° and 20°). Results: The change in MT I length resulting from an osteotomy perpendicular to the axis of MT II was 0.6 mm for a severe hallux valgus (IMA correction from 18° to IMA 8°) and 0.3 mm for a moderate hallux valgus (IMA 13° to IMA 8°). A posterior deviation of the osteotomy angle led to additional shortening (max. 2.9 mm) with a total shortening of up to 3.5 mm (Figure 3). To avoid any shortening of MT I an osteotomy slightly pointing anterior (negative f) of 3.5° (IMA change of 10°) and 3° (IMA change of 5°) was found. Conclusion: ReveL procedure led only to a maximum shortening of 3.5 mm for a posterior deviation of 20°. Considering recently described MT I length cut off values of 2-3 mm for avoiding transfermetatarsalgia the osteotomy should be performed within an anterior directed cut angle of 4° and a posterior directed cut angle of 10° for the correction of a severe hallux valgus. However, further studies are needed to investigate the clinical impact of our findings.

Category: Ankle Arthritis Introduction/Purpose: Hemophilia is a rare hematological disease associated with spontaneous joint hemorrhaging causing hemophilic arthropathy. Symptoms comprise joint pain and deformity, paired with loss of function. In the presence of advanced joint deterioration, therapeutic options are confined to either arthroplasty or arthrodesis. For the ankle, the latter is still referred to as the procedure of choice. However - in light of its capacity to reduce pain while preserving ankle motion - total ankle replacement (TAR) has recently gained acceptance as an alternative. The aim of this study was to investigate the mid- to long-term results of TAR in hemophilic ankle arthropathy. Methods: Seventeen TARs were implanted between 1998 and 2012 (mean age: 43 years). Preoperative demographic and disease specific data, complications and revision surgeries were recorded. With a mean follow-up of 9.3 years (range, 2.2-17.8) implant survival was estimated using Kaplan-Meier analysis. Follow-up assessment of 12 TARs was performed after 9.6 years (5 lost to follow-up). Satisfaction and pain scales, the AOFAS hindfoot-score, and the SF-36 were obtained to assess clinical outcome. Radiographic evaluation of pre- and follow-up radiographs was conducted. Results: Three cases (17.6%) had undergone TAR removal secondary to loosening at an average interval of 7.5 years. The estimated implant survival was 94% at 5, 85% at 10, and 70% at 15 years (95% CI, 11.9-17.7). The mean estimated implant survival was 14.77 years (95% CI, 11.9-17.7). The mean level of satisfaction was 76%, and of pain 2/10 (VAS). ROM had increased significantly (p=0.037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot-score averaged 81/100 points. Conclusion: TAR is a viable treatment option for advanced hemophilic ankle arthropathy. Based on the herein presented follow- up, implant survival compares to that of non-hemophilic populations. Clinical mid- to long-term results are favorable. However, the majority of follow-up radiographs revealed component loosening and/or periprosthetic lucency. Considering the study population’s young age and specific risk factors, need for revision surgery secondary to symptomatic component loosening may arise.

Background: Autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLT) results in favorable clinical outcomes, yet high reoperation rates. The aim of this study was to report and analyze typical complications and their risk factors after AMIC for OLT. Methods: A total of 127 consecutive patients with 130 AMIC procedures for OLT were retrospectively assessed. All AMIC procedures were performed in an open fashion with 106 (81.5%) cases requiring a malleolar osteotomy (OT) to access the OLT. Seventy-one patients (54.6%) underwent subsequent surgery. These cases were evaluated at a mean follow-up of 3.1 years (±2.5) for complications reviewing postoperative imaging and intraoperative findings during revision surgery. Six patients (8.5%) were lost to follow-up. Regression model analysis was conducted to identify factors that were associated with AMIC-related complications. Results: Among the 65 (50%) patients who required revision surgery, 18 patients (28%) demonstrated AMIC-related complications with deep fissuring (83%) and thinning (17%) of the AMIC graft. Conversely, 47 patients (72%) underwent subsequent surgery due to AMIC-unrelated reasons including isolated removal of symptomatic hardware (n = 17) and surgery addressing concomitant pathologies with (n = 25) and without hardware removal (n = 5). Previous prior cartilage repair surgery was significantly associated with AMIC graft-associated complications in patients undergoing revision surgery (P =.0023). Among age, body mass index, defect size, smoking, and bone grafting, smoking was the only factor showing statistical significance with an odds ratio of 3.7 (95% CI 1.24, 10.9; P =.019) to undergo revision surgery due to graft-related complications, when adjusted for previous cartilage repair surgery. Conclusion: The majority of revision surgeries after AMIC for OLT are unrelated to the performed AMIC graft but frequently address symptomatic hardware and concomitant pathologies. Both smoking and previous cartilage repair surgery seem to significantly increase the risk of undergoing revision surgery due to AMIC-related complications. Level of evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Different fixation techniques are established for first metatarsophalangeal joint (MTPJ) arthrodesis, including compression screws, plates, Kirschner wires, metal- and bioabsorbable screws as well as staples. The purpose of this study was to investigate and present first clinical and radiologic results using a novel human, allogeneic cortical bone screw for arthrodesis of the first MTPJ. Methods: Arthrodesis of the first MTPJ was performed in 31 patients with hallux rigidus. Percentage union and time to union were the first outcomes; visual analog scale for pain, hallux valgus angle (HVA), intermetatarsal angle, and American Orthopaedic Foot & Ankle Society (AOFAS) hallux score were secondary outcomes. Results: Median time to union was 89 days, and union was observed in all patients. There were 4 complications (2 osteolysis margin, 1 cystic brightening, and 1 severe swelling at the first follow-up) all of that resolved at last follow-up. Pain significantly decreased from visual analog scale 8.0 to 0.2 points (P <.0001). The HVA decreased from 30.4 to 10.2 degrees in the patient group with deformities. The total AOFAS score increased significantly from 48 to 87 (P <.0001). Conclusion: Primary and revision arthrodesis of hallux rigidus with the human, allogeneic cortical bone screw reveals satisfying results similar to clinical and radiologic outcomes of other surgical techniques. Within 1 year, the human, allogeneic cortical bone screw is fully remodeled to host bone. Level of Evidence: Level IV, retrospective case series without control group. [ABSTRACT FROM AUTHOR]

Background: Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting. Methods: A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Metaanalysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome. Results: Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033). Conclusion: Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle. [ABSTRACT FROM AUTHOR]