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Background: External rotation stress (ERS) identifies ankle instability after fibular reduction of rotational ankle injuries. Combined hindfoot and ankle motions and an inconsistent starting position could mask differing degrees of instability resulting from syndesmotic and/or deltoid ligament disruption. The goal of this work was to use full 3D talar kinematics to evaluate the effects of hindfoot orientation and foot starting position during ERS on the ability to detect instability caused by ligament disruptions.Methods: Six cadaveric ankles with metallic fiducial markers were CT scanned in neutral and 3 stress positions: varus hindfoot internal rotation stress (IRS-var), valgus hindfoot ERS (ERS-val), and varus hindfoot ERS (ERS-var). Scans were obtained in stress positions after transecting the deep deltoid ligament (tDDL) and then the syndesmotic ligaments (tDDL+Syn). Talar rotations and translations were computed in the axial, coronal, and sagittal planes in each stress position. Changes in a fixed center of rotation (CoR) relative to the intact sequence were calculated.Results: Axial plane rotation beginning from IRS-var increased significantly for each level of ligamentous instability (P< .05 for all conditions) (10.9 degrees, intact; 14.1 degrees, tDDL; 22.7 degrees, tDDL+Syn during ERS-val; and 16.4 degrees, intact; 23.1 degrees, tDDL; 29.9 degrees, tDDL+Syn during ERS-var). With ERS-val, the talar CoR moved medially (3.6-5.4 mm) and posteriorly (0.5-5.2 mm); ERS-var moved anterior/laterally or posterior/medially depending on the specific ligamentous instability. With tDDL+Syn the ankle became grossly unstable and there were no clear trends in sagittal/coronal rotation or translation.Conclusion: An ERS test from internal to external rotation consistently differentiates between normal, tDDL, and tDDL+Syn. Talar CoR moved outside the mortise with ligamentous instability.Clinical Relevance: Significant residual deep deltoid instability is likely underrecognized with current practice. The most discriminatory test for detecting such instability in our laboratory was an ERS test performed by internally rotating the foot to a hard, bony endpoint, positioning the hindfoot in varus, and then performing the entire external rotation maneuver while maintaining the varus hindfoot position.

Background: Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of “osteochondral autograft” for osteochondral lesions of the talus.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.Results: A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Conservative Management and Biological Treatment Strategies” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 12 statements on Conservative Management and Biological Treatment Strategies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Ten statements reached strong consensus (greater than 75% agreement), and 2 achieved consensus.Conclusions: This international consensus derived from leaders in the field will assist clinicians with conservative management and biological treatment strategies for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Osteochondral Allograft” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.Results: A total of 15 statements on osteochondral allograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 14 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with osteochondral allograft as a treatment strategy for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Rehabilitation and Return to Sports developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 9 statements on rehabilitation and return to sports reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 9 statements reached strong consensus, with at least 86% agreement.Conclusions: The rehabilitation process for an ankle cartilage injury requires a multidisciplinary and comprehensive approach. This international consensus derived from leaders in the field will assist clinicians with rehabilitation and return to sports after treatment of a cartilage injury of the ankle.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Scaffold-Based Therapies” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.Level of Evidence: Level V, expert opinion.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Subchondral Pathology” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 9 statements on subchondral pathology reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. No statements achieved unanimous support, but all statements reached strong consensus (greater than 75% agreement). All statements reached at least 81% agreement.Conclusions: This international consensus statements regarding subchondral pathology of the talus derived from leaders in the field will assist clinicians in the assessment and management of this difficult pathology.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article was to report on the consensus statements on “Revision and Salvage Management” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 8 statements on revision and salvage management reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with revision and salvage management in the cartilage repair of the ankle.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Post-treatment Follow-up, Imaging and Outcome Scores developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 12 statements on Post-treatment Follow-up, Imaging, and Outcome Scores reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 12 statements reached strong consensus (greater than 75% agreement).Conclusions: This international consensus derived from leaders in the field will assist clinicians with post-treatment follow-up, imaging, and outcome scores after management of a cartilage injury of the ankle in the general population. Moreover, healing, rehabilitation, and final outcomes can be optimized for the individual patient.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Diagnosis: History, Physical Examination, Imaging, and Arthroscopy” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%.Results: A total of 12 statements on the diagnosis of cartilage injuries of the ankle reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support and 10 reached strong consensus (greater than 75% agreement). All statements reached at least 86% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians in the diagnosis of cartilage injuries of the ankle.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Debridement, Curettage and Bone Marrow Stimulation” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results: A total of 14 statements on debridement, curettage, and bone marrow stimulation reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 12 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 72% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with debridement, curettage and bone marrow stimulation as a treatment strategy for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Fixation Techniques” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.Results: A total of 15 statements on fixation techniques reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 15 statements achieved strong consensus, with at least 82% agreement.Conclusions: This international consensus derived from leaders in the field will assist clinicians with using fixation techniques in the treatment of osteochondral lesions of the talus.

Background:For triple arthrodesis, a single medial incision has been proposed to avoid lateral wound complications and has demonstrated satisfactory fusion rates. This study aimed to compare the disruption to the arterial supply of the talus between the single-medial-incision approach and the 2-incision approach.Methods:The 2 approaches for triple arthrodesis were compared by analyzing the disruption of arterial vasculature in 14 cadaveric specimens in randomized fashion. The arterial disruption was determined using CT angiography before and after surgery combined with analysis from dissection. The area of joint preparation from each technique was also analyzed and compared.Results:The single-medial-incision approach caused a high incidence of damage to the deltoid artery (6 of 7 specimens, 86%) and the artery of the tarsal canal (7 of 7 specimens, 100%). The 2-incision approach resulted in damage to the artery of the tarsal sinus in all specimens (7 of 7 specimens, 100%), but the medial vasculature was spared given the limited dissection required to access the talonavicular joint. Through the single-medial-incision approach the percentage of debridement of the calcaneocuboid joint (36%) was significantly lower than the debridement using the 2-incision approach (85%, P < .01). There was no significant difference in joint preparation of the talonavicular and subtalar joints between the 2 approaches with the number of specimens available.Conclusion:From this cadaveric study, we found that both approaches could result in substantial disruption of the main blood supply to the talus. The single-medial-incision approach consistently disrupted the majority of blood supply to the talar body, while the 2-incision approach caused various degrees of vascular disruption to the talar head and neck. Using the single-medial-incision approach, the calcaneocuboid joint did not show adequate removal of articular cartilage due to difficulty accessing the joint surfaces.Clinical Relevance:Vascular sparing to the talus should be considered when selecting an appropriate operative approach for triple arthrodesis. Although the clinical significance of this cadaveric study is limited, the 2-incision approach appeared to cause less vascular disruption to the talar body while allowing more complete joint preparation.