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Last update: February 8, 2016

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February 2016

The cycle for science tour Amsterdam - Barcelona 2016 is a fact! Cycling for science, in the defense of life. We will ride from Amsterdam to Barcelona and you are all invited to join!
The goal of this project is to raise funds to support research in the field of orthopedic sport medicine with focus on prevention of disease. The tour consists of eight stages, which brings the participants from the 2014 ESSKA hosting city, Amsterdam, to the 17th biannual ESSKA congress in Barcelona. During the tour in each city there will be a symposium with renowned speakers, charity dinners and auctions. Are you in?
For more information:



Arthroscopy Techniques 2016: pp e1-e9 

Arthroscopic Repair of Ankle Instability With All-Soft Knotless Anchors

Hélder Pereira, Gwen Vuurberg, Nuno Gomes,Joaquim Miguel Oliveira, Pedro L. Ripoll, Rui Luís Reis, C.Eng., João Espregueira-Mendes and C. Niek van Dijk.

In recent years, arthroscopic and arthroscopically assisted techniques have been increasingly used to reconstruct the lateral ligaments of the ankle. Besides permitting the treatment of several comorbidities, arthroscopic techniques are envisioned to lower the amount of surgical aggression and to improve the assessment of anatomic structures. We describe our surgical technique for arthroscopic, two-portal ankle ligament repair using an all-soft knotless anchor, which is made exclusively of suture material. This technique avoids the need for classic knot-tying methods. Thus it diminishes the chance of knot migration caused by pendulum movements. Moreover, it avoids some complications that have been related to the use of metallic anchors and some currently available biomaterials. It also prevents prominent knots, which have been described as a possible cause of secondary complaints.

January 2016


 Knee Surg Sports Traumatol Arthrosc. 2016 Jan 23.

Rehabilitation after surgical treatment of peroneal tendon tears and ruptures.

van Dijk PA, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GM.

PURPOSE: The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures.
METHODS: A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies.
RESULTS: In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options.
CONCLUSION: Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation.


Knee Surg Sports Traumatol Arthrosc. 2016 Jan 12.

Midterm results of posterior arthroscopic ankle fusion.

de Leeuw PA, Hendrickx RP, van Dijk CN, Stufkens SS, Kerkhoffs GM.

PURPOSE: The presented study was performed to evaluate the midterm clinical and radiological results and complication rates of the first 40 patients with an ankle fusion through a posterior arthroscopic approach.
METHODS: Forty consecutive patients with end-stage post-traumatic ankle osteoarthritis were treated with posterior arthroscopic ankle fusion. All patients were assessed clinically as well as radiologically with a minimum follow-up of 2 years. The Foot and Ankle Ability Measure (FAAM) and Foot Function Index (FFI) were used to assess clinical improvement.
RESULTS: Clinical fusion was achieved in 40 patients within 3 months (100 %), and radiological fusion was achieved in 40 patients at 12 months. Two screw mal-placements occurred. Both complications were solved following revision surgery. A significant improvement was noted for both the FAAM [median 38 (range 17-56) to 63 (range 9-84)] and FFI scores [median 66 (range 31-89) to 32 (range 11-98)] for all 40 patients.
CONCLUSION: The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up.

 Knee Surg Sports Traumatol Arthrosc. 2016 Jan 7.

Evidence-based indications for hindfoot endoscopy.

Spennacchio P, Cucchi D, Randelli PS, van Dijk NC.

PURPOSE: The 2-portal hindfoot endoscopic technique with the patient in prone position, first introduced by van Dijk et al. (Arthroscopy 16:871-876, 2000), is currently the most used by foot and ankle surgeons to address endoscopically pathologies located in the hindfoot. This article aims to review the literature to provide a comprehensive description of the level of evidence available to support the use of the 2-portal hindfoot endoscopy technique for the current generally accepted indications.
METHODS: A comprehensive review was performed by use of the PubMed database to isolate literature that described therapeutic studies investigating the results of different hindfoot endoscopy treatment techniques. All articles were reviewed and assigned a classification (I-V) of level of evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for hindfoot endoscopy. A subscale was used to further describe the evidence base for indications receiving a grade of recommendation indicating poor-quality evidence.
RESULTS: On the basis on the available evidence, posterior ankle impingement syndrome, subtalar arthritis and retrocalcaneal bursitis have the strongest recommendation in favour of treatment (grade Cf).
CONCLUSION: Although a low level of evidence of the included studies, the review showed that adequate literature to support the use of the 2-portal endoscopic techniques for most currently accepted indications exists. Future "higher quality" evidence could strengthen current recommendations and further help surgeons in evidence-based practice.


ESSKA- AFAS 2-day course
From 28 till 29 January 2016, the ESSKA-AFAS 2-day course will be held and consists of a theoretical and a hands-on part. Many open and arthroscopic techniques can be trained under supervision of a large international faculty. This course provides you with a broad basis for foot and ankle surgery and a unique change to explore new techniques. During the course professor C. Niek van Dijk will lead several case discussions and on day 2 of the course he will give a summary of the ESSKA-AFAS Budapest Consensus Meeting about Chronic Syndesmotic Instability.
For more details, click here .

III International Congress Sport Traumatology "The Battle"
From 29 till 30 January 2016, the III International Congress Sport Traumatology "The Battle", will be held in Rome, Italy. On Saturday January 30rd, Prof. C.N. van Dijk will battle Piero Volpi during the ankle session. The title is: "Ankle Sprain, instability, pain, chondral damage in Athlete: Rationale of a treatment".
For more details, click here .

 World J Orthop. 2015 Dec 18;6(11):944-53.

Diagnosing, planning and evaluating osteochondral ankle defects with imaging modalities.

Christiaan JA van Bergen, Rogier M Gerards, Kim TM Opdam, Gino MMJ Kerkhoffs


This current concepts review outlines the role of different imaging modalities in the diagnosis, preoperative planning, and follow-up of osteochondral ankle defects. An osteochondral ankle defect involves the articular cartilage and subchondral bone (usually of the talus) and is mostly caused by an ankle supination trauma. Conventional radiographs are useful as an initial imaging tool in the diagnostic process, but have only moderate sensitivity for the detection of osteochondral defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are more accurate imaging modalities. Recently, ultrasonography and single photon emission CT have been described for the evaluation of osteochondral talar defects. CT is the most valuable modality for assessing the exact location and size of bony lesions. Cartilage and subchondral bone damage can be visualized using MRI, but the defect size tends to be overestimated due to bone edema. CT with the ankle in full plantar flexion has been shown a reliable tool for preoperative planning of the surgical approach. Postoperative imaging is useful for objective assessment of repair tissue or degenerative changes of the ankle joint. Plain radiography, CT and MRI have been used in outcome studies, and different scoring systems are available.

December 2015


Knee Surg Sports Traumatol Arthrosc. 2015 Dec 28.

Computed tomography analysis of osteochondral defects of the talus after arthroscopic debridement and microfracture.

Reilingh ML, van Bergen CJ, Blankevoort L, Gerards RM, van Eekeren IC, Kerkhoffs GM, van Dijk CN.


PURPOSE: The primary surgical treatment of osteochondral defects (OCD) of the talus is arthroscopic debridement and microfracture. Healing of the subchondral bone is important because it affects cartilage repair and thus plays a role in pathogenesis of osteoarthritis. The purpose of this study was to evaluate the dimensional changes and bony healing of talar OCDs after arthroscopic debridement and microfracture.
METHODS: Fifty-eight patients with a talar OCD were treated with arthroscopic debridement and microfracture. Computed tomography (CT) scans were obtained at baseline, 2 weeks postoperatively, and 1 year postoperatively. Three-dimensional changes and bony healing were analysed on CT scans. Additionally, clinical outcome was measured with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and numeric rating scales (NRS) for pain.
RESULTS: Average OCD size increased significantly (p < 0.001) in all directions from 8.6 (SD 3.6) × 6.3 (SD 2.6) × 4.8 (SD 2.3) mm (anterior-posterior × medial-lateral × depth) preoperatively to 11.3 (SD 3.4) × 7.9 (SD 2.8) × 5.8 (SD 2.3) mm 2 weeks postoperatively. At 1-year follow-up, average defect size was 8.3 (SD 4.2) × 5.7 (SD 3.0) × 3.6 (SD 2.4) mm. Only average defect depth decreased significantly (p < 0.001) from preoperative to 1 year postoperative. Fourteen of the 58 OCDs were well healed. No significant differences in the AOFAS and NRS-pain were found between the well and poorly healed OCDs.
CONCLUSION: Arthroscopic debridement and microfracture of a talar OCD leads to an increased defect size on the direct postoperative CT scan but restores at 1-year follow-up. Only fourteen of the 58 OCDs were filled up completely, but no differences were found between the clinical outcomes and defect healing at 1-year follow-up.


Knee Surg Sports Traumatol Arthrosc. 2015 Dec 24.

Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V.


PURPOSE: The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management.
METHODS: A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid.
RESULTS: The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries.
CONCLUSIONS: The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width.


Knee Surg Sports Traumatol Arthrosc. 2015 Dec 24.

Evaluation of the Dutch version of the Foot and Ankle Outcome Score (FAOS): responsiveness and Minimally Important Change.

Sierevelt IN, van Eekeren IC, Haverkamp D, Reilingh ML, Terwee CB, Kerkhoffs GM.


PURPOSE: The aim of this study was to evaluate the responsiveness of the Foot and Ankle Outcome Score (FAOS) and provide data on the Minimally Important Change (MIC) in patients 1 year after hindfoot and ankle surgery.
METHODS: Prospective pre-operative and 1 year post-operative FAOS scores were collected from 145 patients. A patient's global assessment and a longitudinal derived Function Change Score were used as external anchors. To assess responsiveness, effect sizes (ES) and Standardized Response Means (SRM) were calculated and hypotheses on their magnitudes were formulated. Additional ROC curve analysis was performed, and the Area Under the Curve (AUC) was calculated as a measure of responsiveness. MIC values were estimated using two different methods: (1) the mean change method and (2) the optimal cut-off point of the ROC curve.
RESULTS: Responsiveness was supported by confirmation of 84 % of the hypothesized ES and SRM and almost all AUCs exceeding 0.70. MIC values ranged from 7 (symptoms) to 38 (sport) points. They varied between calculation methods and were negatively associated with baseline values. A considerable amount of MIC values did not exceed the smallest detectable change limit, indicating that the FAOS is more suitable at group level than for longitudinally following individual patients.
CONCLUSIONS: The FAOS demonstrated good responsiveness in patients 1 year after hindfoot and ankle surgery. Due to their wide variation, MIC estimates derived in this study should be interpreted with caution. However, these estimates can be of value to facilitate sample size calculation in future studies.

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