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Background: Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT., Methods: Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups., Results: Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs -3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina ( P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02)., Conclusion: The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

Background: Microfracture (MF) has been used historically to treat osteochondral lesions of the talus (OLTs), with favorable outcomes reported in approximately 80% to 85% of cases. However, MF repairs have been shown to degrade over time at long-term follow-up, suggesting that further study into optimal OLT treatment is warranted. The use of adjuvant extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) has not been extensively evaluated in the literature. We present a comparison of patient-reported and radiographic outcomes following ECM-BMAC repair vs traditional MF., Methods: Patients who underwent MF (n = 67) or ECM-BMAC (n = 62) treatment for an OLT were identified and their charts were retrospectively reviewed. Postoperative magnetic resonance imaging (MRI) was evaluated and patient-reported outcome scores, either Foot and Ankle Outcome Scores (FAOS) or Patient-Reported Measurement Information System (PROMIS) scores, were collected. MRIs were scored by a radiologist, fellowship trained in musculoskeletal radiology, using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) system. Radiographic and clinical outcomes were compared between groups., Results: On average, patients treated with ECM-BMAC demonstrated a higher total MOCART score compared to the MF group (73 ± SD 11.5 vs 54.0 ± 24.1; P = .0015). ECM-BMAC patients also had significantly better scores for the Infill, Integration, and Signal MOCART subcategories. Last, patients treated with ECM-BMAC had a lower rate of revision compared to those treated with MF (4.8% vs 20.9%; P = .007). FAOS scores were compared between groups, with no significant differences observed., Conclusion: When comparing outcomes between patients treated for an OLT with ECM-BMAC vs traditional MF, we observed superior MRI results for ECM-BMAC patients. The rate of revision surgery was higher for MF patients, although patient-reported outcomes were similar between groups. The use of ECM-BMAC as an adjuvant therapy in the treatment of OLTs may result in improved reparative tissue when compared to MF., Level of Evidence: Level III, comparative series.

Background: Historically, microfracture has been used to treat small talar osteochondral lesions with good results, whereas osteochondral autologous transplantation (OAT) has proven effective for the treatment of larger lesions. It is not clear which method is more effective for medium-sized lesions around the critical size of 150 mm 2 , above which microfracture outcomes tend to be poor. The purpose of this study was to determine the potential advantages of OAT augmented with a combination of extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC) compared to debridement with ECM-BMAC (DEB) in the treatment of medium-sized osteochondral lesions of the talus (OLTs)., Methods: Clinical and radiographic data were collected retrospectively for patients treated by a single fellowship-trained foot and ankle surgeon. Magnetic resonance images (MRIs) were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system and were evaluated for the presence of cysts and edema. Fifty-two patients met inclusion criteria, with 25 who received an OAT procedure. Age, body mass index, lesion size, lesion location, and follow-up time were similar between groups. Average MRI follow-up times were 16.7 months for the OAT group and 20.3 months for the DEB group ( P = .38)., Results: Patients treated with OAT had significantly higher average total MOCART scores (69 vs 55, P = .04) and significantly lower rates of cyst (14% vs 55%, P < .01), edema (59% vs 90%, P = .04), revision surgery (0% vs 19%, P = .05), and therapeutic injection for pain (4% vs 30%, P = .02) compared to patients treated with DEB. No significant differences were detected in patient-reported outcome scores between groups., Conclusion: The native hyaline cartilage introduced by OAT appears to result in higher-quality repair tissue when compared to DEB, as evidenced by OAT patients' higher MOCART scores and lower rates of cyst and edema. There was no difference in clinical outcome scores, though OAT patients did not require revision surgery or therapeutic injection for pain as frequently as DEB patients., Level of Evidence: Level III, retrospective comparative study.

Background: Hallux rigidus is a common arthritic condition that has been addressed surgically with a range of techniques, from an isolated cheilectomy to first metatarsophalangeal (MTP) joint fusion. Recently, hemiarthroplasty with polyvinyl alcohol (PVA) hydrogel implant has been used as an alternative treatment to relieve pain while preserving motion of the first MTP joint. We retrospectively reviewed patient-reported outcome scores and clinical outcomes for patients treated for hallux rigidus with PVA hydrogel implant at an academic, multisurgeon center., Methods: A total of 103 patients who underwent first MTP hemiarthroplasty with PVA hydrogel implant between January 2017 and October 2018 were retrospectively reviewed (average, 26.2 months). Eight surgeons were represented. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) scores for the Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression domains were collected prospectively and compared with PROMIS scores collected at a minimum of 1 year postoperatively (average, 13.9 months). Seventy-three patients had both preoperative and postoperative scores. Ten of these patients had undergone a prior procedure of the first MTP, and 52 underwent concurrent Moberg osteotomy at the time of PVA hydrogel implantation., Results: For patients with baseline and postoperative PROMIS scores, significant pre- to postoperative improvement was detected for the Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains ( P < .05). Patients who had undergone a prior procedure of the first MTP had significantly higher postoperative Pain Intensity scores compared with those who did not undergo a prior procedure. Patients undergoing concurrent Moberg osteotomy had significantly lower postoperative Pain Interference and Pain Intensity scores compared with those who did not undergo a Moberg. Two patients underwent revision procedures in the first 2 years postoperatively, one with revision hemiarthroplasty and one with conversion to arthrodesis., Conclusion: On average across our entire cohort, physical function and pain scores improved significantly pre- to postoperatively; however, postoperative pain scores were significantly higher for patients who had undergone a prior procedure of the first MTP and significantly lower for patients who underwent concurrent Moberg osteotomy. The implant displayed excellent survivorship in the first 2 years postoperatively, with only 2 revision procedures., Level of Evidence: Level III, comparative series.

Background: The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads., Methods: Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size., Results: CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used., Conclusions: Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Tibialis anterior tendon ruptures are rare and can cause significant dysfunction. Often, conservative measures are prescribed because of the morbidity of a tendon transfer as an operative solution. We present a novel reconstruction technique using hamstring autograft, which may obviate the need for local tendon transfer and long-term bracing., Methods: Patients who underwent tibialis anterior reconstruction with hamstring autograft between 2011 and 2015 were screened for inclusion. Eight were included. Functional outcomes were assessed pre-and-postoperatively using the Foot and Ankle Outcome Score (FAOS), Visual Analog Pain Scale (VAS), and Short-Form-12 (SF-12) general health questionnaire. Isokinetic testing using a dynamometer (Biodex System 4 Pro) was performed at 60 and 120 degrees/s, respectively, for inversion/eversion and plantarflexion/dorsiflexion on both ankles at a minimum of 6 months postoperatively to determine peak torque, average power, and total work. Range of motion (ROM) testing was also performed, using a goniometer, at a minimum of 6 months postoperatively. Average follow-up was 17.3 (6.0-40.0) months for strength testing and ROM testing, and 18.5 (12.0-26.0) months for functional outcome scores., Results: Average postoperative functional scores improved for all tests. ROM was similar between the uninvolved and involved ankles for inversion/eversion and plantarflexion/dorsiflexion. Patients showed deficits in dorsiflexion strength in all measures tested and improvements in inversion strength. All patients were able to ambulate without a brace., Conclusion: Use of a hamstring autograft for tibialis anterior reconstruction resulted in good clinical outcomes. This procedure successfully restored ankle ROM postoperatively and tendon strength in inversion and dorsiflexion, with most patients showing little deficit when comparing their involved and uninvolved sides., Level of Evidence: Level IV, Case series.