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Category: Ankle; Arthroscopy Introduction/Purpose: A hypertrophic distal fascicle of the anterior tibiofibular ligament (ATiFLdf) is commonly encountered in patients with anterior ankle impingement. Repetitive snapping of the hypertrophic ATiFLdf has the potential to create osteochondral lesions (OCLs) at the lateral talar dome. However, the clinical manifestations of these OCLs in the setting of a hypertrophic ATiFLdf has not been described to date. The purpose of this retrospective review was to determine the prevalence of OCLs of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic ATiFLdf. In addition, we sought to evaluate the anatomy of the ATiFL to fully elucidate its role in creating chondral wear of the talus. Methods: Retrospective chart review identified 40 patients who underwent arthroscopy of the anterior ankle joint for the management of anterior ankle impingement. Pre-operative magnetic resonance imaging (MRI) scans were obtained and correlated with intra-operative arthroscopic findings. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, return to work data and return to sport data. Results: Thirty-two patients with a mean follow-up time of 29.3±10.4 months were included. The ATiFLdf was hypertrophic in 29 patients (90.6%), the mean thickness of which was 2.5±0.4 mm. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic ATiFLdf visualized during arthroscopy. The international cartilage repair society gradings of the lesions included: 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from pre-operative to post-operative (p< 0.001). No cases of syndesmotic instability were observed following resection of ATiFLdf. The mean post-operative Likert score was 4.1±0.4. There were 5 failures (15.6%) at a mean time of 9.0±4.7 months. Conclusion: This retrospective case series demonstrated that a hypertrophic ATiFLdf was closely associated with the development of an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, pre-operative MRI proved to demonstrate poor sensitivity for the detection of these OCLs. Suspicion should be raised for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf. Figure 1. (a) Hypertrophic ATiFLdf with associated OCL of the lateral talar dome; (b) Biter resecting hypertrophic ATiFLdf; (c) Resected hypertrophic ATiFLdf; (d) and (e) Hypertrophic ATiFLdf identified on coronal and axial MRI scans

Category: Sports; Other Introduction/Purpose: The purpose of this study was to assess outcomes following acute Achilles tendon ruptures (AATR) sustained by athletes participating in the Major League Soccer (MLS). Methods: Athletes participating in the MLS who sustained an AATR were identified using a publicly available database, match reports and injury reports. The years of inclusion was from 2008-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play (RTP), time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, assists, goals, passes, pass %, crosses, shots, shots on target and shot %. Results: Twenty-six athletes sustained an AATR in the MLS (0.008564 per 10,000 athlete-exposures). The mean age was 25.8±8.4 years and the mean BMI was 22.5±6.6kg/m 2 . There were 15 (57.7%) AATRs sustained by defensive players, 5 (19.2%) AATRs sustained by midfield players, 3 (11.6%) AATR sustained by forwards and 3 (11.6%) AATR sustained by goalkeepers. All athletes (100%) underwent surgical intervention. The mean number of games played prior to injury was 164.7±154.9. The RTP rate to the MLS was 73.1% at mean time of 11.1±5.5 months. The mean number of games missed due to injury was with 30.1±11.7 games. There was a statistically significant decrease in the mean number of games played, goals scored and shots taken following RTP. Conclusion: This current study found that AATRs were an uncommon injury in the MLS with an incidence of 0.008564 per 10,000 athlete-exposures. Sustaining an AATR was associated with a 73.1% return to play rate to the MLS at a mean time of 11.1 ± 5.5 months. There was a statistically significant deterioration in key performance metrics such as mean games played, goals scored and shots taken. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Sports; Other Introduction/Purpose: The purpose of this systematic review was to evaluate rates of return to play and levels of performance following acute Achilles tendon ruptures (AATR) in the National Football League (NFL). Additionally, we sought to determine the prevalence rates of AATR and identify any risk factors for the development of AATR. Methods: During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following treatment of acute Achilles tendon ruptures (AATR) in the NFL. Twelve studies were included. Results: In total, 676 players (698 Achilles) sustained an AATR in the NFL. The playing positions that sustained the highest rates of AATRs was linebackers (19.0%), wide receivers (11.9%) and running backs (9.0%). 139 AATRs (50.4%) occurred in the preseason, 135 AATRs (48.9%) occurred during the regular season and 2 AATRs (0.7%) occurred during a post-season game. Playing surface was not associated with an increased risk of AATR. The return to play rate was 66.2% at a weighted mean time of 10.9±1.3 months. The mean number of games played per season following AATR was 12.9 games and the weighted mean career length following AATR was 2.2 ± 0.8 seasons. Overall, player performance deteriorated significantly following AATR, as demonstrated by lower power rankings and position specific metrics. Conclusion: This systematic review found was that the proportion of athletes participating in the NFL who returned to play following AATR was 66.2%. Both the mean number of games played per season and the mean number of seasons played decreased significantly following AATR. Overall, player performance deteriorated following AATR, regardless of player position. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Ankle; Sports Introduction/Purpose: The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up. Methods: Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures. Results: Thirty-nine patients with a mean lesion size was 122.3±64.1 mm 2 and mean follow-up time of 138.9±16.9months were included. The mean FAOS scores improved from a preoperative score of 51.9±16.0 to 75.3±21.9 (p < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R2=0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9±5.2ms) compared to the superficial layer of the adjacent native cartilage (35.8±3.8ms) (p < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI. Conclusion: This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs.

Background: This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade. Methods: The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers. Results: During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%. Conclusion: Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Purpose: The purpose of the study was to evaluate, as a pilot trial, safety and tolerability of CAM-101 10% and 30% topical ophthalmic fibrinogen-depleted human platelet lysate (FD hPL) solution in patients with dry eye disease (DED) secondary to graft-versus-host disease (GvHD) after 6 weeks of treatment. Design: A phase I/II, pilot, prospective, multicenter, randomized, double-masked clinical trial. Participants: Patients with DED secondary to GvHD. Methods: Sixty-four adult patients were stratified by “symptom severity” (Ocular Surface Disease Index [OSDI], ocular discomfort Visual Analog Scale (VAS), ocular symptom frequency, and use of artificial tears) and then randomized 1:1:1 to CAM-101 (FD hPL) at 10% or 30% concentration or an electrolyte (Plasma-Lyte A) vehicle control, 1 drop in both eyes, 4 times daily, for 42 days. After 42 days, control patients were offered 42 days of open-label treatment with 30% FD hPL. Main Outcome Measures: Primary outcome safety measures were ocular and systemic adverse events and the number of patients in each group with clinically significant change from normal to abnormal in any ocular findings. Secondary outcomes were changes from baseline to day 42 in ocular discomfort, OSDI, fluorescein corneal staining, and lissamine green conjunctival staining relative to the vehicle control. The ocular symptom frequency was assessed on a 100-point VAS. Results: FD hPL 10% and 30% were safe and well tolerated. Relative to the vehicle control, significant decreases from baseline to day 42 were seen in the FD hPL 30% group with regard to ocular discomfort (mean decrease = −18.04; P = 0.018), frequency of burning/stinging (−20.23; P = 0.022), eye discomfort (−32.97; P < 0.001), eye dryness (−21.61; P = 0.020), pain (−15.12; P = 0.044), photophobia (−24.33; P = 0.0125), and grittiness (−20.08; P = 0.0185). Decreases were also seen for itching and foreign body sensation, though not statistically significant. Improvements were seen in tear breakup time (mean increase = 1.30 seconds; P = 0.082) and the investigator’s global evaluation 4-point scale (mean decrease = −0.86; P = 0.026). Corneal fluorescein staining was not improved. The OSDI had a mean decrease of −8.88 compared to the vehicle, although not statistically significant. Conclusions: Fibrinogen-depleted human platelet lysate appears to be well tolerated, with no significant toxicity at concentrations of 10% and 30%. These initial data suggest some efficacy, especially for subjective outcome measures relative to baseline assessments and treatment with the vehicle, but larger studies are needed to confirm these effects.