Purpose of Review Trauma is the principle cause of osteoarthritis in the ankle, which is associated with significant morbidity. This review highlights the current literature for the purpose of bringing the reader up-to-date on the management of posttraumatic ankle arthritis, describing treatment efficacy, indications, contraindications, and complications. Recent Findings Recent studies on osteoarthritis have demonstrated variability among anatomic locations regarding the mechanisms and rates of development for posttraumatic osteoarthritis, which are attributed to newly discovered biological differences intrinsic to each joint. Regarding surgical management of posttraumatic ankle arthritis, osteochondral allograft transplantation of the talus, and supramalleolar osteotomies have demonstrated promising results. Additionally, the outpatient setting was found to be appropriate for managing pain following total ankle arthroplasty, associated with low complication rates and no readmission. Summary Management for posttraumatic ankle arthritis is generally progressive. Initial treatment entails nonpharmacologic options with surgery reserved for posttraumatic ankle arthritis refractory to conservative treatment. Patient demographics and lifestyles should be carefully considered when formulating a management strategy, as outcomes are dependent upon the satisfaction of each set of respective criteria. Ultimately, the management of posttraumatic ankle arthritis should be individualized to satisfy the needs and desires, which are specific to each patient.

Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy seen in children. In addition to skeletal muscle, DMD also has a significant impact on bone. The pathogenesis of bone abnormalities in DMD is still unknown. Recently, we have identified a novel bone‐regulating cytokine, fibroblast growth factor‐21 (FGF‐21), which is dramatically upregulated in skeletal muscles from DMD animal models. We hypothesize that muscle‐derived FGF‐21 negatively affects bone homeostasis in DMD. Dystrophin/utrophin double‐knockout (dKO) mice were used in this study. We found that the levels of circulating FGF‐21 were significantly higher in dKO mice than in age‐matched WT controls. Further tests on FGF‐21 expressing tissues revealed that both FGF‐21 mRNA and protein expression were dramatically upregulated in dystrophic skeletal muscles, whereas FGF‐21 mRNA expression was downregulated in liver and white adipose tissue (WAT) compared to WT controls. Neutralization of circulating FGF‐21 by i.p. injection of anti‐FGF‐21 antibody significantly alleviated progressive bone loss in weight‐bearing (vertebra, femur, and tibia) and non–weight bearing bones (parietal bones) in dKO mice. We also found that FGF‐21 directly promoted RANKL‐induced osteoclastogenesis from bone marrow macrophages (BMMs), as well as promoted adipogenesis while concomitantly inhibiting osteogenesis of bone marrow mesenchymal stem cells (BMMSCs). Furthermore, fibroblast growth factor receptors (FGFRs) and co‐receptor β‐klotho (KLB) were expressed in bone cells (BMM‐derived osteoclasts and BMMSCs) and bone tissues. KLB knockdown by small interfering RNAs (siRNAs) significantly inhibited the effects of FGF21 on osteoclast formation of BMMs and on adipogenic differentiation of BMMSCs, indicating that FGF‐21 may directly affect dystrophic bone via the FGFRs‐β‐klotho complex. In conclusion, this study shows that dystrophic skeletal muscles express and secrete significant levels of FGF‐21, which negatively regulates bone homeostasis and represents an important pathological factor for the development of bone abnormalities in DMD. The current study highlights the importance of muscle/bone cross‐talk via muscle‐derived factors (myokines) in the pathogenesis of bone abnormalities in DMD. © 2019 American Society for Bone and Mineral Research.

The most recent studies have shown benefits for biologic use in patients predisposed to poor bone and soft tissue healing. Biologics have shown benefit in treating soft tissue injuries such as Achilles ruptures as well as the complications of trauma such as non-unions and osteoarthritis. Biologics have shown some benefit in improving functional and pain scores, as well as reducing time to heal in foot and ankle traumatic injuries, with particular success shown with patients that have risk factors for poor healing. As the use of biologics continues to increase, there is a need for high-level studies to confirm early findings of lower level reports.

Objectives:Jones’ fractures, 5th metatarsal metaphyseal-diaphyseal junction fractures, are a debilitating injury for the elite athlete, particularly in cutting/pivoting sports. These injuries are usually managed surgically due to the high rate of nonunion and re-fracture. Despite primary screw fixation, delayed union and nonunion are not uncommon. Bone marrow aspirate concentrate (BMAC), an autologous source of hematopoietic and mesenchymal stem cells, has been used to augment healing due to the poor healing potential in the watershed region. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes.Methods:This study was a prospectively collected and maintained review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were evaluated preoperatively and postoperatively to assess differences in patient reported outcomes including VAS, PROMIS, FAAM, SF-12 scores, return to play, and complications. Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant.Results:A total of 41 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 25.59 years (range 19-42). There were 26 (63%) males and 15 females included in the study. Type of athlete ranged across the following sport activities: football, basketball, soccer, volleyball. Of note, patients had significantly improved with lower visual analog score for pain (mean Δ3.56, p= 0.001), higher FAAM scores (mean Δ 43.6, p< 0.001), and PASS scores (increased from 11% to 85%, p< 0.001) at 6 months. Additionally, patients showed improvement in SF12, PROMIS10, and FAAM scores at 12 months, although this was not statistically significant due to insufficient follow up at this time. The average numbers of days lost to competition was 131 days. All patients that have returned to elite competitive sport activity report minimal to no pain.Conclusion:Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. The use of patient reported outcomes continues to be a focus of quality measures and should guide clinical decision making for surgical intervention, return to play, and to assess impact of treatment. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.

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