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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 “terminology for osteochondral lesions of the ankle” developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four 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 characterised as follows: consensus, 51%–74%; strong consensus, 75%–99%; unanimous, 100%. Results: A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT. Conclusions: This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.

As the scope of podiatric surgery expands, the relative roles and outcomes of orthopedic surgeons and podiatrists need to be defined. With growing demand for foot and ankle services, the roles of podiatrists and orthopedic surgeons are increasingly overlapping. Few studies have examined the overlapping scope of practice of each of the groups or compared the relative costs and outcomes associated with each.

To determine the effects of unilateral and bilateral ankle stabilization surgery with or without additional concurrent procedures for other pathologies on return to activity in patients who were allowed unrestricted weight bearing postoperatively. Ninety-three athletes underwent 120 ankle stabilization surgeries including 27 that underwent bilateral simultaneous surgery using the all-inside arthroscopy-modified lasso-loop technique and were divided into two groups: arthroscopic ligament repair alone without concurrent procedures (group A) and with simultaneous procedures for other pathologies (group B). Group A was further subdivided into unilateral (group A1) and simultaneous bilateral ankle surgery (group A2), and group B into ankle stabilization surgery with simultaneous procedures not requiring weight bearing postoperatively (Group B1) and with concurrent procedures allowing weight bearing (Group B2). Return to activity postoperatively was assessed by recording the time to walk without any support, jog, and return to full athletic activities. Clinical outcomes were assessed preoperatively and 12 months postoperatively using a subjective clinical score. The average time between surgery and unsupported walk, jog, and return to full athletic activities was 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3 days in group A, 17.2 ± 19.6, 34.5 ± 20.8, and 60.9 ± 22.8 days in group B, 1.7 ± 2.9, 16.1 ± 2.4, and 41.6 ± 18.2 days in group A1, 1.3 ± 0.6, 18.9 ± 5.5, and 44.6 ± 22.5 days in group A2, 25.3 ± 20.2, 43.3 ± 21.1, and 70.7 ± 23.1 days in group B1, and 4.8 ± 11.7, 20.7 ± 11.7, and 45.0 ± 13.7 days in group B2, respectively. These results indicate that the patients in group B2 showed a statistically significant faster time to return to activity than did those restricted from weight bearing. Differences in ankle stabilization alone between patients in groups A1 and A2 as well as groups B2 and A were not statistically significant. Clinical outcomes were similar for patients in groups B2 and A1 versus group A2. Time to return to activity and clinical outcomes after ankle stabilization surgery using the modified lasso-loop technique were negatively affected if simultaneous bilateral surgery or simultaneous concurrent procedures were added or if weight bearing was unrestricted. However, a delay in return to athletic activity was observed when ankle stabilization surgery was performed using the modified lasso-loop technique with concurrent procedures that require non-weight bearing postoperatively. Level III.

Background: Pain following autograft harvest has been studied; however, published literature has typically focused on the iliac crest with follow-up limited to only a few years. It remains unknown if pain continues or improves over time. The purpose of this study was to evaluate long-term pain associated with autograft harvest to supplement hindfoot or ankle arthrodesis. Methods: Subjects in the control arm of a previously conducted trial comparing autograft with a synthetic bone graft for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Harvest site, fusion site, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS). Of the 130 invited subjects, 60 (46.1%) returned for assessment, 58 of whom completed pain assessments. Results: At a mean follow-up of 9.0 years (range, 7.8-10.5), more than a third (36.6%) of subjects had some level of harvest site pain. Using VAS greater than 20 mm as a threshold of clinical significance, pain remained clinically significant in 5.2% of subjects. There was a significant correlation between harvest site pain and both weight-bearing and fusion site pain. There was not a significant correlation between harvest site pain and volume of graft harvested. Conclusion: Autograft harvest can result in chronic, clinically significant pain that can last up to 10 years. In the era of shared decision making, this information will help surgeons and patients quantify the risks of chronic pain after arthrodesis procedures that include a secondary operative incision for graft harvest. Level of Evidence: Level II, prospective comparative study.

Background The lack of consensus on the relevance of the varus talar tilt test (VTTT) might be due to the divergence between the insufficiency vector of lateral ankle instability and the direction of this clinical test. Our hypothesis is that the VTTT is more accurate to diagnose lateral ankle ligaments rupture when it's applied with a pre-positioning of the foot in internal rotation (IR). Methods We compared, in 12 cadaver ankles, the varus opening during a classic VTTT with the same test starting in an IR pivot, using a new arthrometer. Results The classic VTTT caused a 13° tilt after ATFL section and 23,8° after ATFL and CFL section. The application of a VTTT with an IR prepositioning caused a 21,2° tilt after ATFL section (p = 0,002) and 29,5° after ATFL and CFL section (p = 0,006). Conclusion The VTTT is better to identify lateral ankle ligaments' insufficiency when it's applied with a pre-positioning of the foot in internal rotation. The resulting vector is similar to the supination trauma.

Background: Single photon emission computed tomography combined with computed tomography (SPECT/CT) could potentially aid in diagnosing periarticular arthritis/activity and progression, facilitate effective treatment options, and evaluate the effect surgery has on the clinical outcome of patients with ankle arthritis. The goal of our study was to assess SPECT/CT activity in the ankle and periarticular joints before and after ankle fusion surgery and determine whether it was associated with clinical pain and function scores. Methods: Thirty-four patients recruited into this study underwent either arthroscopic or open ankle fusion. X-ray (XR) and SPECT/CT imaging was obtained as well as completion of patient Ankle Osteoarthritis Scale (AOS) and 36-item Short Form Survey (SF-36) questionnaires preoperatively and at 6 months postoperatively. Ankle, subtalar, and talonavicular joint arthritis grading on XR and CT, along with SPECT/CT activity, was evaluated by 2 nuclear medicine radiologists. Data were assessed for normality and analyzed with the appropriate comparative test. P value was set at Results: SPECT/CT activity showed no significant difference in the ankle joint at 6 months postoperatively while periarticular joint activity significantly increased ( P < .05). Six months postoperatively, patients had significant improvements in their AOS and SF-36 scores ( P < .05). SPECT/CT grading of all joints analyzed, however, was not associated with AOS or SF-36 scores preoperatively or at 6 months postoperatively. Conclusion: In this study, intensity of activity as evaluated by SPECT/CT in periarticular hindfoot joints in patients who had ankle arthrodesis was not associated with clinical/functional scores at 6 months postoperatively. Level of Evidence: Level IV, diagnostic study.

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 “Pediatric Ankle Cartilage Lesions” developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four 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 characterised as follows: consensus: 51–74%; strong consensus: 75–99%; unanimous: 100%. Results: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis.Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type.The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p0.05). Pain was reduced significantly in both sexes postoperatively (p0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar.Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: 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 present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 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. Results: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). Conclusion: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. Level of Evidence: Level V, mechanism-based reasoning.

The purpose of this study was to determine the feasibility and safety of a novel decellularized dermal matrix (DDM) for the treatment of chronic diabetic foot ulcers (DFUs).An interventional, single-arm, prospective study of DDM for DFU treatment was conducted in 2 Canadian centres from July 1, 2016 to May 30, 2017. Individuals ≥18 years of age, with an active DFU of ≥2 weeks and ulcer area ≥1 cmA total of 11 patients were enrolled, with 9 patients (82%) having achieved 100% closure between 2 and 8 weeks. The mean and median times to wound closure for these patients were 3.3 and 2.5 weeks, respectively. The mean and median reductions in wound area at 4 weeks posttreatment were 87% and 100%, respectively. The proportion of patients having achieved complete healing at 12 weeks was 82%. All patients received only 1 DDM application to achieve these results. There were no adverse events related to use of the product. No cases of recurrence during a 1-year follow up after completion of the study were reported for patients who achieved wound closure.These findings provide evidence that this DDM may be safe and effective for the treatment of chronic, hard-to-heal neuropathic DFUs. Specifically, DDM demonstrated the potential to accelerate healing of DFUs when compared with reported times of 8 to 12 weeks required to achieve closure using the current standard of care.

End-stage ankle arthritis is a disabling condition that has a similar effect on morbidity, pain, and loss of function to hip arthritis. We compared clinical outcomes of total ankle replacement (TAR) involving the HINTEGRA prosthesis (Integra LifeSciences), arthroscopic ankle arthrodesis (AAA), and open ankle arthrodesis (OAA) in patients with isolated, non-deformed end-stage ankle arthritis.Patients ≥18 years old who underwent TAR, AAA, or OAA from 2002 to 2012 with a minimum follow-up of 2 years were retrospectively identified from the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database. All patients had symptomatic COFAS Type-1 end-stage ankle arthritis without intra-articular or extra-articular deformity or surrounding joint arthritis. Clinical outcomes included the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36). Revision was defined as removal of 1 or both metal ankle prosthesis components for TAR and as reoperation for malposition, malunion, or nonunion for AAA and OAA.Analysis included 238 ankles (88 TAR, 50 AAA, and 100 OAA) in 229 patients with a mean follow-up of 43.3 ± 18.5 months. The TAR group had more female patients (55%; p = 0.0318) and a higher mean age (p = 0.0005). Preoperative AOS pain, disability, and total scores were similar for all groups. SF-36 physical and mental component summary scores were similar across groups, both preoperatively and postoperatively. Improvement in AOS total score was significantly larger for TAR (34.4 ± 22.6) and AAA (38.3 ± 23.6) compared with OAA (25.8 ± 25.5; p = 0.005). Improvement in AOS disability score was also significantly larger for TAR (36.7 ± 24.3) and AAA (40.5 ± 26.4) compared with OAA (26.0 ± 26.2; p = 0.0013). However, the greater improvements did not meet the minimal clinically important difference. The TAR group underwent more reoperations than AAA and OAA groups (p0.0001). Revision rates were similar for all 3 groups (p = 0.262).AAA and OAA resulted in comparable clinical outcomes to TAR in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis. The rate of component revision in patients who underwent TAR was similar to the rate of revision for patients who underwent AAA or OAA; however, TAR patients underwent a greater number of additional procedures. Overall, AAA and TAR involving the HINTEGRA prosthesis were not significantly different surgical options in terms of short-term outcomes; patients should be counseled regarding higher reoperation rates for TAR.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Importance Patients with chronic ankle instability (CAI) who have failed non-operative treatments are most commonly treated with open ankle repair or reconstruction of the anterior talofibular ligament and/or calcaneofibular ligament. Over 50 operative techniques have been described for the treatment of CAI. However, there is no current systematic evaluation of currently used open operative techniques for the treatment of CAI. Aim/Objective The primary objective of this study is to provide evidence-based treatment recommendations for CAI in adults based on a comprehensive systematic review of the literature. Evidence review The literature review of PubMed, EMBASE, Cochrane and Web of Science databases was completed on 22 February 2017. Search terms included two concepts: lateral ligament of the ankle (patients) and open reconstructive or repair procedures (intervention). All published clinical studies with English translation were included. Biomechanical, cadaveric, review articles, minimally invasive procedures and arthroscopic procedures were excluded. Open operative procedures from included articles were classified as anatomical or non-anatomical and repair or reconstructive. Articles were then assigned a level of evidence (I-V) to denote quality of the research methods. Articles were reviewed collectively to provide a grade of recommendation (A-C or I) in support for or against the operative intervention in treatment of CAI. Findings Seventy one of 1635 identified articles were included for review. There is fair evidence (Grade B) in support of anatomical repair, anatomical reconstruction and non-anatomical reconstruction procedures. There was insufficient evidence available to grade internal brace and non-anatomical repair procedures. Conclusions and relevance Although only fair-quality evidence exists in support of open operative treatment of CAI, this systematic review helps reassure clinicians of their current practices. The literature reaffirms support for open anatomical repair and anatomical reconstruction technique for CAI. Level of evidence Level II, systematic review.

Summary Hallux Rigidus causes pain, loss of toe motion and dysfunction. When nonoperative treatment fails the most common successful operative options has been metatarsophalangeal arthrodesis. Recently a motion sparing surgical treatment option with Cartiva hemiarthroplasty for treatment of Hallux Rigidus has been proven to be as safe and effective as arthrodesis in a level I randomized control trial. Further, subsequent studies have shown that safety and efficacy of Cartiva hemiarthroplasty has been sustained to mid term follow-up out to five years. In this paper the surgical technique for Cartiva hemiarthroplasty is described and evidence to support its use is reviewed. Last, in this review we review additional literature on other benefits of Cartiva hemiarthroplasty and provide some tips to improve outcomes.

Synthetic cartilage implant surgery is an excellent option for the patient with great toe arthritis and good alignment of the toe who wishes to retain first metatarsophalangeal motion and obtain 90% improved pain relief and function. Patients with osteoporosis, osteopenia, or bone defects from surgery or disease may not maintain the implant position due to poor bone quality, resulting in less than desired outcomes. Despite this being a straightforward surgery, patients need to be aware that the pain relief may not begin until 3+ months after surgery because this procedure does require bone resection and implant placement.

Background: A prospective, randomized, noninferiority clinical trial of synthetic cartilage implant hemiarthroplasty for hallux rigidus demonstrated functional outcomes and safety equivalent to first metatarsophalangeal (MTP) joint arthrodesis at 24 months. We prospectively assessed safety and efficacy outcomes for synthetic cartilage implant hemiarthroplasty at a minimum of 5 years. Methods: Of 135 eligible patients from the original trial, 112 (83.0%) were enrolled (mean age, 58.2 ± 8.8 years; 87 females). Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), and FAAM Sports subscales were completed preoperatively and 2 and 5 years postoperatively. Great toe active dorsiflexion, weightbearing radiographs, secondary procedures, and safety parameters were also evaluated. Results: At 24 months, 14/152 (9.2%) patients had undergone implant removal and conversion to arthrodesis. In years 2 to 5, 9/119 (7.6%) patients underwent implant removal and conversion to arthrodesis. At mean 5.8 ± 0.7 (range, 4.4-8.0) years’ follow-up, pain VAS, FAAM ADL, and FAAM Sports scores improved by 57.9 ± 18.6 points, 33.0 ± 17.6 points, and 47.9 ± 27.1 points, respectively, from baseline. Clinically significant changes in VAS pain, FAAM ADL, and FAAM Sports were reported by 103/106 (97.2%), 95/105 (90.5%), and 97/104 (93.3%) patients, respectively. Patient-reported outcomes at 24 months were maintained at 5.8 years in patients who were not revised. Active MTP joint peak dorsiflexion was maintained. Ninety-nine of 106 (93.4%) patients would have the procedure again. Conclusion: Clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty observed at 2 years were maintained at 5.8 years. The implant remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus. Level of Evidence: Level IV, case series.

Chronic ankle instability following ankle sprains causes pain and functional problems such as recurrent giving way. Within the 3 ligaments of the lateral ligament complex, 80% of patients tear the anterior talofibular ligament (ATFL), whereas the other 20% of patients tear the ATFL and calcaneofibular ligament (CFL). Rarely, the posterior talofibular ligament is involved. An incidence of 10% to 30% of patients will fail conservative treatment and result in chronic ankle instability that may require surgical treatment. To date, numerous open surgical procedures for anatomic repair or reconstruction of ATFL and/or CFL provide good clinical results.

As the scope of podiatric surgery expands, the relative roles and outcomes of orthopedic surgeons and podiatrists need to be defined. With growing demand for foot and ankle services, the roles of podiatrists and orthopedic surgeons are increasingly overlapping. Few studies have examined the overlapping scope of practice of each of the groups or compared the relative costs and outcomes associated with each.

Background Inversion ankle sprains, or lateral ankle sprains, often result in symptomatic lateral ankle instability, and some patients need lateral ankle ligament reconstruction to reduce pain, improve function, and prevent subsequent injuries. Although anatomically reconstructed ligaments should behave in a biomechanically normal manner, previous studies have not measured the strain patterns of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) after anatomical reconstruction. This study aimed to measure the strain patterns of normal and reconstructed ATFL and CFLs using the miniaturization ligament performance probe (MLPP) system. Methods The MLPP was sutured into the ligamentous bands of the ATFLs and CTLs of three freshly frozen cadaveric lower-extremity specimens. Each ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N m force was applied to the ankle and subtalar joint complex. Results The normal and reconstructed ATFLs exhibited maximal strain (100) during supination in three-dimensional motion. Although the normal ATFLs were not strained during pronation, the reconstructed ATFLs demonstrated relative strain values of 16–36. During the axial motion, the normal ATFLs started to gradually tense at 0° plantar flexion, with the strain increasing as the plantar flexion angle increased, to a maximal value (100) at 30° plantar flexion; the reconstructed ATFLs showed similar strain patterns. Further, the normal CFLs exhibited maximal strain (100) during plantar flexion-abduction and relative strain values of 30–52 during dorsiflexion in three-dimensional motion. The reconstructed CFLs exhibited the most strain during dorsiflexion-adduction and demonstrated relative strain values of 29–62 during plantar flexion-abduction. During the axial motion, the normal CFLs started to gradually tense at 20° plantar flexion and 5° dorsiflexion. Conclusion Our results showed that the strain patterns of reconstructed ATFLs and CFLs are not similar to those of normal ATFLs and CFLs.

The evolution towards more minimally invasive ankle lateral ligament surgeries to stabilize the ankle joint has led to an increase in publications. In this study, the minimally invasive surgical techniques for treatment of chronic ankle instability were classified into four major categories: arthroscopic repair, non-arthroscopic minimally invasive repair, arthroscopic reconstruction, and non-arthroscopic minimally invasive reconstruction. Most papers published after 2000 are level of evidence IV or V. On the basis of this current literature, most of the minimally invasive approaches to treat CAI deserve a Grade C recommendation (poor quality evidence Level III, IV, and V studies recommending for the use of this intervention).

Percutaneous AntiRoLL (P-AntiRoLL) is performed if there is no ligament fiber on stress ultrasonography, and there are no intra-articular comorbid lesions including osteochondral lesions and/or anterior ankle impingement on MRI or CT scan before surgery.

A recent review of the literature has demonstrated an increase in the development of new minimally invasive and arthroscopic surgical techniques for the treatment of chronic ankle instability (Matsui et al., Knee Surg Sports Traumatol Arthrosc 24:1040–1048, 2016). However, in order to understand the efficacy and need for adoption of these newer surgical techniques one must first have a comprehensive understanding of the current published literature available to support preexisting surgical procedures. In this chapter, we provide a comprehensive review of the current published literature available to support the open treatment of Chronic Ankle instability.

Arthroscopic AntiRoLL (A-AntiRoLL) is performed if there is no ligament fiber, and if intra-articular comorbid lesions including osteochondral lesions and/or anterior ankle impingement were clarified preoperatively. There are four steps for AntiRoLL: step 1 as make the portals; step 2 as make a Y-shaped graft; step 3 as make the bone tunnels at each attachment to fibula, talus, and calcaneus; step 4 as introduce a Y-shaped graft into the bone tunnels and fix with the interference screw. After surgery, the full weight-bearing walking is allowed according to pain from a day after surgery, jogging and proprioceptive training at 4 weeks postoperatively, and returning to sports without external fixation after 6–8 weeks postoperative.

Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: A recent survey of 100 international foot and ankle orthopaedic surgeons revealed that patient age greater than 60 years is not considered to be a significant risk factor for nonunion following foot and ankle arthrodesis. This finding was surprising as published basic science research shows that autologous bone graft used during fusion surgery may be less effective when harvested from older patients due to both diminished osteogenic potential and migration capacity of mesenchymal stem cells. The purpose of this study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. Methods: A Level 1 clinical trial was performed comparing fusion success in 397 hindfoot or ankle arthrodesis subjects (597 joints) supplemented with either autograft or an osteoinductive recombinant human protein derived growth factor (rhPDGF- BB/β-TCP) bone graft substitute. Fusion status was determined using computed tomography, with fusion defined as evidence of at least 50% osseous bridging. In this secondary analysis of that dataset, the odds of fusion success were compared for joints in autograft subjects older or younger than the following age thresholds: 55, 60, 65, 70 and 75 years. This analysis was then repeated for joints in rhPDGF-BB/β-TCP subjects. Finally, odds of fusion success were also compared for the autograft and rhPDGF-BB/β- TCP groups for subjects older than each threshold age. Results: Joints in autograft subjects younger than 60 and 65 years exhibited over two times the odds of fusion as those in older subjects (60 years: OR 2.24, p=0.003; 65 years: OR 2.74, pConclusion: This study indicates that age is an identifiable and potentially concerning risk for nonunion following hindfoot or ankle arthrodesis. These findings are in contrast to the wider perception of the surgeon community, as documented in the published survey. Notably, patients over the age of 60 years who are supplemented with autograft have statistically lower odds of fusion compared to those younger, a difference not seen with the use of recombinant technology. This analysis suggests that use of rhPDGF-BB/β-TCP as an alternative bone healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Synthetic cartilage implants for first metatarsophalangeal osteoarthritis have been used for nearly a decade with Level 1 clinical evidence showing 84.9% of implants remain in place at a mean follow-up of 5.8 years. In contradiction to these positive results, however, some recent publications have shown higher revision rates and attempted to correlate the need for revision with the postoperative joint space interval. Most of these studies performed assessments based off of routine anterior-posterior (AP) radiographs using hand drawn measurements without image calibration or scaling. The purpose of this independent radiographic review was to further explore any relationship between joint space integrity and the need for revision surgery. Methods: An independent radiographic review by two board-certified, fellowship-trained, practicing musculoskeletal radiologists with no competing financial interests was conducted for 15 subjects from a previously concluded Level 1 clinical trial looking at outcomes of a synthetic cartilage implant. Ten (10) subjects with positive outcomes and 5 who required revision were selected at random for evaluation. Weight-bearing AP and lateral radiographs at baseline, 2 weeks, 6, 12, 24, and 60 months were reviewed. Using previously validated Quantitative Motion Analysis software, joint space was measured in the medial, central, and lateral locations on AP radiographs and dorsal, central, and plantar locations on lateral radiographs (Coughlin et al. 2003). Measurements were normalized to the proximal phalanx width in the relevant view (AP or lateral) to adjust for lack of image scaling or calibration. Normalized joint spaces at each interval and changes from the 2-week visit, the earliest with the implant in place, were evaluated. Results: In this pilot study, no relationship between mean normalized joint space and implant removal was found at any time point over the 60-month follow-up. Scatterplots were used to determine if movement in different directions impacted mean values. There was significant overlap for the two groups in joint space at each subject’s final visit with the implant in place and the change from the 2-week visit to the final visit (Figure 1). The majority of subjects in both groups experienced changes in joint space of less than 10% across all measurements. The maximum change from the 2-week visit in the revision group was less than 15%, compared to over 25% for subjects in the retention group. Conclusion: Neither joint space at final follow-up nor joint space change from initial postoperative assessment were associated with revision. The maximum observed decrease in the revision group was less than 15%, or 0.5 mm in a joint space of 3 mm. Both the clinical relevance of this minimal decrease and whether or not it can be reliably assessed remain unclear. Future studies could examine patient factors other than joint space to determine success or failure of this implant. These preliminary results suggest joint space integrity evaluated from plain film is a weak indicator of clinical efficacy with this synthetic cartilage implant.

To determine the effects of unilateral and bilateral ankle stabilization surgery with or without additional concurrent procedures for other pathologies on return to activity in patients who were allowed unrestricted weight bearing postoperatively.Ninety-three athletes underwent 120 ankle stabilization surgeries including 27 that underwent bilateral simultaneous surgery using the all-inside arthroscopy-modified lasso-loop technique and were divided into two groups: arthroscopic ligament repair alone without concurrent procedures (group A) and with simultaneous procedures for other pathologies (group B). Group A was further subdivided into unilateral (group A1) and simultaneous bilateral ankle surgery (group A2), and group B into ankle stabilization surgery with simultaneous procedures not requiring weight bearing postoperatively (Group B1) and with concurrent procedures allowing weight bearing (Group B2). Return to activity postoperatively was assessed by recording the time to walk without any support, jog, and return to full athletic activities. Clinical outcomes were assessed preoperatively and 12 months postoperatively using a subjective clinical score.The average time between surgery and unsupported walk, jog, and return to full athletic activities was 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3 days in group A, 17.2 ± 19.6, 34.5 ± 20.8, and 60.9 ± 22.8 days in group B, 1.7 ± 2.9, 16.1 ± 2.4, and 41.6 ± 18.2 days in group A1, 1.3 ± 0.6, 18.9 ± 5.5, and 44.6 ± 22.5 days in group A2, 25.3 ± 20.2, 43.3 ± 21.1, and 70.7 ± 23.1 days in group B1, and 4.8 ± 11.7, 20.7 ± 11.7, and 45.0 ± 13.7 days in group B2, respectively. These results indicate that the patients in group B2 showed a statistically significant faster time to return to activity than did those restricted from weight bearing. Differences in ankle stabilization alone between patients in groups A1 and A2 as well as groups B2 and A were not statistically significant. Clinical outcomes were similar for patients in groups B2 and A1 versus group A2.Time to return to activity and clinical outcomes after ankle stabilization surgery using the modified lasso-loop technique were negatively affected if simultaneous bilateral surgery or simultaneous concurrent procedures were added or if weight bearing was unrestricted. However, a delay in return to athletic activity was observed when ankle stabilization surgery was performed using the modified lasso-loop technique with concurrent procedures that require non-weight bearing postoperatively.Level III.

Background Freiberg’s disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions. Methods Fifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I–V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A–C, I). Results Two studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV–V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg’s disease. Conclusion Poor evidence exists to support the surgical interventions for Freiberg’s disease, higher quality trials are needed to support the increasing application of these surgical techniques. Level of Evidence Level IV, Systematic review.

Ankle arthrodesis (AA) and replacement (TAA) are widely accepted options in managing end-stage ankle arthritis (ESAA). We hypothesize that clinical outcomes would be similar for both interventions.We conducted a multicenter randomized controlled trial that collected data on patient demographics, complication rates, Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. We evaluated pre and postoperative scores within and between cohorts.The thirty-nine ankles enrolled had a mean follow-up of 5.1 ± 2.8 years. Total AOS scores improved significantly in both groups; 59.4 ± 15.9 to 38 ± 20 (p-value = 0.002) for TAA and 64.6 ± 19.7 to 31.8 ± 16.5 (p-value0.001) for AA at last follow-up. Complication rate was higher in the AA cohort with four major complications (20%).We observed a statistically significant benefit with TAA and AA. As a pilot trial, this study is meant to inform on design and feasibility of future RCTs.II.

Background Measuring the strain patterns of ligaments at various joint positions informs our understanding of their function. However, few studies have examined the biomechanical properties of ankle ligaments; further, the tensile properties of each ligament, during motion, have not been described. This limitation exists because current biomechanical sensors are too big to insert within the ankle. The present study aimed to validate a novel miniaturized ligament performance probe (MLPP) system for measuring the strain patterns of the anterior talofibular ligament (ATFL) during ankle motion. Methods Six fresh-frozen, through-the-knee, lower extremity, cadaveric specimens were used to conduct this study. An MLPP system, comprising a commercially available strain gauge (force probe), amplifier unit, display unit, and logger, was sutured into the midsubstance of the ATFL fibers. To measure tensile forces, a round, metal disk (a “clock”, 150 mm in diameter) was affixed to the plantar aspect of each foot. With a 1.2-Nm load applied to the ankle and subtalar joint complex, the ankle was manually moved from 15° dorsiflexion to 30° plantar flexion. The clock was rotated in 30° increments to measure the ATFL strain detected at each endpoint by the miniature force probe. Individual strain data were aligned with the neutral (0) position value; the maximum value was 100. Results Throughout the motion required to shift from 15° dorsiflexion to 30° plantar flexion, the ATFL tensed near 20° (plantar flexion), and the strain increased as the plantar flexion angle increased. The ATFL was maximally tensioned at the 2 and 3 o’clock (inversion) positions (96.0 ± 5.8 and 96.3 ± 5.7) and declined sharply towards the 7 o’clock position (12.4 ± 16.8). Within the elastic range of the ATFL (the range within which it can return to its original shape and length), the tensile force was proportional to the strain, in all specimens. Conclusion The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns.

Background There are few reports in terms of detailed biomechanics of the deltoid ligament, and no reports have measured the biomechanics of each ligamentous band, due to the difficulty in inserting sensors into the narrow ligaments. This study aims to measure the strain pattern of the deltoid ligament bands using a miniaturization ligament performance probe (MLPP) system. Methods The MLPP was sutured into the ligamentous bands of the deltoid ligament in 6 fresh-frozen lower extremity cadaveric specimens. The strain was measured using a round metal disk (clock) fixed on the plantar aspect of the foot. The ankle was manually moved from 15° of dorsiflexion to 30° plantar flexion, and a 1.2-N-m force was applied to the ankle and subtalar joint complex. The clock was then rotated every 30° to measure the strain of each ligamentous band at each endpoint. Results The tibionavicular ligament (TNL) begins to tense at 10° plantar flexion and the tension becomes stronger as the angle increases; the TNL works most effectively in plantar flex-abduction. The tibiospring ligament (TSL) begins to tense gradually at 15° plantar flexion and the tension becomes stronger as the angle increases. The TSL works most effectively in the abduction. The tibiocalcaneal ligament (TCL) begins to tense gradually at 0° dorsiflexion, and the tension becomes stronger as the angle increases. The TCL works most effectively in pronation (dorsiflexion-abduction). The superficial posterior tibiotalar ligament (SPTTL) begins to tense gradually at 0° dorsiflexion, and the tension becomes stronger as the angle increases, with the SPTTL working most effectively in dorsiflexion. Conclusion Our results provide a better understanding of the biomechanical function of the superficial deltoid ligament and could help in improving repair and reconstruction procedures.

First metatarsophalangeal joint (MTPJ1) hemiarthroplasty using a novel synthetic cartilage implant was as effective and safe as MTPJ1 arthrodesis in a randomized clinical trial. We retrospectively evaluated operative time and recovery period for implant hemiarthroplasty (n=152) and MTPJ1 arthrodesis (n=50).Perioperative data were assessed for operative and anaesthesia times. Recovery and return to function were prospectively assessed with the Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) subscales and SF-36 Physical Functioning (PF) subscore.Mean operative time for hemiarthroplasty was 35±12.3min and 58±21.5min for arthrodesis (p0.001). Anaesthesia duration was 28min shorter with hemiarthroplasty (p0.001). At weeks 2 and 6 postoperative, hemiarthroplasty patients demonstrated clinically and statistically significantly higher FAAM Sport, FAAM ADL, and SF-36 PF subscores versus arthrodesis patients.MTPJ1 hemiarthroplasty with a synthetic cartilage implant took less operative time and resulted in faster recovery than arthrodesis.III, Retrospective case control study.