A Firm Foundation

It can be hard to appreciate the benefit of some of life’s experiences when you’re mired in the midst of them. Have you ever accepted a responsibility that seemed pointless or even painful? You set your jaw, put your head down, and plow forward, just trying to get through the situation and move on to something more pleasant or pertinent to your personal goals. It may be years before you fully appreciate how valuable the undertaking really was. I had such an episode following my surgical internship in 1976. I was thrilled to be offered the possibility of spending the year in a research and clinical fellowship with John Marshall, an important thinker and innovator in orthopaedic sports medicine. The catch? In return for hospital funding of the fellowship, Dr Marshall had agreed to loan the fellow’s services to the foot and ankle clinic 1 full day each week. There was a chronic manpower shortage on this rotation, which was generally unpopular with the residents. Every Friday, I dutifully reported for work at the foot and ankle clinic, knowing that such was the price of getting to spend the other working days doing something I really enjoyed. For 8 or 10 hours, I lent a sympathetic ear to the complaints of the clientele, typically elderly women with hideous bunions, gnarled toes that deviated toward all points of the compass, and paper-thin layers of plantar fat that had long-since abandoned their mission of cushioning the burgeoning body weight of their owners. While I could sympathize with the patients’ distress, I did not see how caring for them would prove useful in my future sports medicine career. When I became a team physician, however, I recognized the value of that year in the foot and ankle clinic. I had learned to look at the foot and ankle as a functioning organ, a complex structure to be evaluated both statically and dynamically. I realized that lamb’s wool, adhesive foam, metatarsal pads, and artfully posted orthotics could be just as helpful to a competitive athlete as they were to an octogenarian. I appreciated the wisdom of the chief of service, who never missed an opportunity to point out that the foot is the indispensable foundation of the human body. Although foot and ankle problems are common in most sports, they are often overshadowed in the orthopaedic sports medicine literature by the attention paid to other body parts. Serendipity, with a gentle nudge from your editor-in-chief, has produced a confluence of articles in this issue of The American Journal of Sports Medicine focused on one specific ankle disorder that can seriously affect an athlete’s performance: osteochondral lesions of the talus (OLT). This subject has been the object of considerable attention in the pages of AJSM in the last few years. Hannon and colleagues set the stage for the topic with a systematic review of the literature on microfracture for OLT. Rather than synthesizing the evidence for the efficacy of this treatment, the authors focus on the consistency of reporting of important demographic, clinical, and outcome parameters among published studies. They may have originally intended to perform a meta-analysis of the existing literature, but were stymied by the inconsistency of reporting that they encountered. As they note, knowledge of these variables is vital for comparing treatment results among studies as well as identifying factors that may affect prognosis. A search of 2 electronic databases from 1966 to 2011 yielded 24 articles that met the authors’ inclusion criteria, which required a follow-up of 6 months in studies that unambiguously identified OLT as the diagnosis and microfracture as the treatment. Among those papers, basic information such as study design, age and sex of patients, lesion location, surgical approach, and rehabilitation techniques were almost always disclosed. Encouragingly, the vast majority reported outcomes using patient-oriented pain, function, and activity scales. Unfortunately, the 24 studies utilized a total of 23 different scoring systems, making it difficult to synthesize their results. Details that might be useful in determining prognosis such as lesion size, associated injuries, body mass index (BMI), and athletic participation were only revealed in a minority of the studies. The ability of the procedure to restore a normal articular surface was evaluated by postoperative magnetic resonance imaging (MRI) in a mere 25% of the papers. Despite this general weakness in the literature, a number of studies, particularly recent ones, have sought to identify variables that might help predict the prognosis in OLT. Lesion size has often been recognized as an important parameter, with 150 mm cited by several authors as a useful cut-off for determining prognosis and choosing among treatment options. In this issue of AJSM, Yoshimura and colleagues have chosen to concentrate exclusively on the prognostic factors in 50 cases of OLT that were smaller than this. All were treated with bone marrow stimulation, achieved either by drilling or microfracture. The overall results at an average of 36 months after surgery showed an improvement in the mean American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale from 74 (range, 18-90) to 90 (range, 67-100). Lesion depth, location, and patient age were all associated with outcome, although the differences were fairly small in magnitude. Keeping in mind that only smaller lesions were included, they found no association between lesion size and outcome. Editorial