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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 mm 2 , large >150 mm 2 ) 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 ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Author JDB is helping to develop an arthroscopic microfracture device with Marrow Access Technologies. None of the patients in this study were treated with said device and it is not yet on the market.

Background: Ankle sprains are the most common musculoskeletal injury in the United States. Chronic lateral ankle instability can ultimately require operative intervention to decrease pain and restore stability to the ankle joint. There are no anatomic studies investigating the vascular supply to the lateral ankle ligamentous complex., Purpose: To define the vascular anatomy of the lateral ligament complex of the ankle., Study Design: Descriptive laboratory study., Methods: Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded., Results: The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%)., Conclusion: There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries., Clinical Relevance: Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability.

Background: Diagnosis of an interdigital neuroma (IDN) is clinically based on patient symptoms. During operative excision, it is common to send the excised specimen for routine histopathologic examination. The purpose of this study was to evaluate the accuracy of the clinical and intraoperative diagnosis of IDN and correlate these with the histopathologic results of IDN., Methods: Case logs of 3 fellowship-trained foot and ankle surgeons were reviewed to identify all neuroma excisions completed between 1997 and 2014. Charts were reviewed to identify the preoperative clinical diagnosis and intraoperative diagnosis as well as concern for pathology besides a neuroma. All results were compared to final histopathology to identify instances of discordance between diagnoses. A total of 123 patients with 133 neuromas were identified., Results: Of the total 133 neuromas, 5 cases included a clinical or intraoperative concern for a diagnosis other than neuroma. In these 5 instances surgeons accurately identified cysts and rheumatoid nodules. 132 of 133 histopathology reports indicated the presence of nerve tissue in their report. There were no reports of malignancy or abnormal nerve tissue. There were no changes to the postoperative protocol based on histopathology., Conclusion: The clinical, intraoperative, and histopathologic diagnosis of neuroma was in concordance 100% of the time. With a high level of clinical and intraoperative acumen in identifying a neuroma, we believe it is reasonable not to submit the specimen for histopathologic evaluation. In addition, limiting the amount of routine histopathologic evaluation could have saved approximately $480 per case., Level of Evidence: Level IV, case series., (© The Author(s) 2015.)

Background: Tibialis posterior tendon dysfunction is a common disorder leading to pain, deformity, and disability, although its pathogenesis is unclear. A vascular etiology has been proposed, but there is controversy regarding the existence of a hypovascular region that may render the tendon vulnerable. The purpose of this study was to provide a description of the arterial anatomy supplying the tibialis posterior tendon., Methods: Sixty adult cadaveric lower extremities were obtained from a university-affiliated body donation program. Thirty specimens obtained within 72 hours of death were used for microscopic analysis. Thirty specimens were previously frozen and used for macroscopic analysis. The tibialis anterior, tibialis posterior, and peroneal arteries were injected with India Ink and Ward's Blue Latex. The specimens used for macroscopic analysis were debrided with sodium hypochlorite to expose the extratendinous anatomy. For the microscopic analysis, the tendon was cleared using a modified Spälteholz technique to expose the intratendinous vascular anatomy., Results: Macroscopically, an average of 2.5 ± 0.7 vessels entered the tendon proximal to the navicular insertion. In all, 28/30 (93.3%) specimens had a vessel entering 4.1 ± 0.6 cm proximal to the medial malleolus and 24/30 (80.0%) specimens had a vessel entering 1.7 ± 0.9 cm distal to the medial malleolus. Microscopically, an average of 1.9 ± 0.3 vessels entered each tendon proximal to the navicular insertion. In total, 27/30 (90%) specimens had a vessel entering the tendon 4.8 ± 0.8 cm proximal to the medial malleolus and 30/30 (100%) specimens had a vessel entering the tendon 1.9 ± 0.8 cm distal to the medial malleolus. In all specimens, a hypovascular region was observed, starting 2.2 ± 0.8 cm proximal to the medial malleolus and ending 0.6 ± 0.6 cm proximal to the medial malleolus with an average length of 1.5 ± 1.0 cm. The insertion of the tendon was well vascularized both on microscopic and macroscopic specimens., Conclusion: The tibialis posterior tendon was supplied by 2 vessels entering the tendon approximately 4.5 cm proximal and 2.0 cm distal to the medial malleolus. A retromalleolar hypovascular region was observed., Clinical Relevance: Improved understanding of the vascularity of the tibialis posterior tendon may be helpful in clinical practice and potentially provides a basis for further evaluation of the causative factors of tibialis posterior tendinopathy., (© The Author(s) 2014.)

Context: Sideline management of sports-related joint dislocations often places the treating medical professional in a challenging position. These injuries frequently require prompt evaluation, diagnosis, reduction, and postreduction management before they can be evaluated at a medical facility. Our objective is to review the mechanism, evaluation, reduction, and postreduction management of sports-related dislocations to the shoulder, elbow, finger, knee, patella, and ankle joints., Evidence Acquisition: A literature review was performed using the PubMed database to evaluate previous and current publications focused on joint dislocations. This review focused on articles published between 1980 and 2013., Study Design: Clinical review., Level of Evidence: Level 4., Results: The clinician should weigh the benefits and risks of on-field reduction based on their knowledge of the injury and the presence of associated injuries., Conclusion: When properly evaluated and diagnosed, most sports-related dislocations can be reduced and initially managed at the game.

Background: Osteotomies of the medial cuneiform are commonly used to correct forefoot deformity. Bone healing occurs despite periosteal stripping of the dorsal and medial surfaces of this widely articulated bone followed by osteotomy in the midsection of the bone. The objective of this study was to characterize the blood supply of the medial cuneiform., Methods: Thirty matched pairs of adult cadaver legs, 60 legs total, were amputated below the knee, and arterial casts were created with India ink and latex. Soft tissues were debrided, allowing visualization of the extraosseous blood vessels. In 53 specimens the vascular supply to the medial cuneiform was photographed and recorded. Forty-nine specimens were then cleared using a modified Spälteholz technique. The intraosseous vascularity of the medial cuneiform was successfully characterized and reviewed in 48 of these specimens., Results: The extraosseous blood supply was similar to previous reports with a middle pedicle branch originating from the dorsalis pedis artery. The medial plantar and superficial medial plantar artery supplied the plantar aspect of the bone. Intraosseous analysis showed a dense capillary network throughout the cuneiform, with typically one central medial major and several minor nutrient arteries noted. Areas of hypovascularity were infrequent and when noted occurred at inconsistent locations., Conclusion: These findings support the clinical suspicion that the medial cuneiform is well vascularized from multiple sources. The plantar blood supply is likely sufficient to allow bone healing after dorsal periosteal exposure and possible injury to the middle pedicle branch of the distal medial tarsal artery., Clinical Relevance: A medial cuneiform opening wedge osteotomy can be used to correct forefoot deformity. This study investigates the blood supply to that bone to better characterize the healing potential of the medial cuneiform.

Background: A lateral closing wedge osteotomy is used for correction of varus hindfoot deformities. Since its original description, different techniques and geometries of the calcaneal bone wedge resection have been described. Even though the techniques seem similar, very different final bone architectures result from each technique, the effects of which are not known. This paper explores several of these techniques and the implications in deformity correction as well as the secondary effects of calcaneal shortening., Methods: Mathematical and geometric analysis is performed in 2-dimensions for several hypothetical calcaneal osteotomies as described by the original authors. The resulting changes are calculated and compared., Results: The shape of the bone resection for the lateral closing wedge osteotomy does not result in significantly different final calcaneal architectures. Both techniques studied result in the same amount of calcaneal shortening and deformity correction. However, when lateral calcaneal wedge resection is combined with lateral translation of the tuberosity for additional deformity correction, more calcaneal shortening is seen with posteriorly directed osteotomies than those that are transverse., Conclusion: The lateral closing wedge osteotomy of the calcaneus results in correction of varus hindfoot deformity at the expense of some calcaneal shortening. Lateral translation of the tuberosity may result in additional calcaneal. The clinical effects of calcaneal shortening or medial soft tissue or nerve tethering from these different techniques are unknown and deserve further investigation., Level of Evidence: Level V, expert opinion.

Background: As clinical suspicion increases and radiographic evaluation improves, navicular stress fractures are becoming a more recognized injury. To date, there is a small volume of literature examining these stress fractures, particularly as it pertains to outcomes of surgical management., Purpose: To evaluate the clinical and computed tomography (CT) outcomes of surgically treated navicular stress fractures., Study Design: Case series; Level of evidence, 4., Methods: Ten navicular stress fractures in 10 patients were available for follow-up at an average of 42.4 months postoperatively (range, 16.8-79.9). These patients underwent a clinical examination and a CT scan of their operatively treated foot. The American Orthopaedic Foot & Ankle Society (AOFAS) and SF-36 scores were completed for each fracture at the time of examination. The CT scans were blindly evaluated for bony union., Results: According to the CT scan evaluation, 8 of 10 navicula (80%) had gone on to union. Clinical outcome scores on all patients were an average AOFAS hindfoot score of 88.5 and an average SF-36 score of 88.3. The feet with united fractures had an average AOFAS score of 92.1 (range, 83-100) and an average SF-36 score of 91.9 (range, 79-98). The 2 patients with nonunions had AOFAS scores of 74 and 74 and SF-36 scores of 70 and 78, respectively. Both nonunions were complete, displaced fractures on preoperative imaging., Conclusion: In our series of operatively treated navicular stress fractures, 80% went on to union, as verified by CT scan. Patients with united fractures had a clinically significant improvement in outcome, with higher AOFAS and SF-36 scores as compared with the 2 patients with nonunions. Patients with complete, displaced navicular stress fractures may be more likely to develop nonunions.

Context: Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint., Evidence Acquisition: This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010., Results: Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair., Conclusion: With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.