Zwiers R, Wiegerinck JI, Murawski CD, Smyth NA, Kennedy JG, van Dijk CN

Surgical Treatment for Posterior Ankle Impingement

Arthroscopy. 2013 Mar 28. pii: S0749-8063(13)00065-0

PURPOSE: This study aims to provide an overview of both the open and endoscopic procedures used to treat posterior ankle impingement, as well as an analysis, evaluation, and comparison of their outcomes.
METHODS: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases and the Cochrane Database of Clinical and Randomized Controlled Trials was performed. Quality of included studies was assessed by use of the Downs and Black scale.
RESULTS: After we reviewed 783 studies, 16 trials met the inclusion criteria. Of these trials, 6 reported on open surgical techniques and 10 evaluated endoscopic techniques. The complication rate (15.9% v 7.2%) and time to return to full activity (16.0 weeks v 11.3 weeks) differed between the 2 groups, both favoring endoscopic surgery.
CONCLUSIONS: Although the level of evidence of the included studies is relatively low, it can be concluded that the endoscopic technique is superior to the open procedure.
LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

van Bergen CJ, Kox LS, Maas M, Sierevelt IN, Kerkhoffs GM, van Dijk CN

Arthroscopic Treatment of Osteochondral Defects of the Talus: Outcomes at Eight to Twenty Years of Follow-up

J Bone Joint Surg Am. 2013 Mar 20;95(6):519-25.

BACKGROUND: The primary aim of this study was to assess the long-term clinical and radiographic outcomes of arthroscopic debridement and bone marrow stimulation for talar osteochondral defects. The secondary aim was to identify prognostic factors that affect the long-term results.
METHODS: Fifty (88%) of fifty-seven eligible patients with a primary osteochondral defect treated with arthroscopic debridement and bone marrow stimulation were evaluated after a mean follow-up of twelve years (range, eight to twenty years). Clinical assessment included the Ogilvie-Harris score, Berndt and Harty outcome question, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Short Form-36 (SF-36) as well as resumption of work and sports. Weight-bearing radiographs were compared with preoperative radiographs with use of an ankle osteoarthritis classification system. The size, location, and classification of the defect, patient age and body mass index, traumatic etiology, and duration of symptoms were recorded and analyzed with use of univariate logistic regression.
RESULTS: The Ogilvie-Harris score was excellent in 20% of patients, good in 58%, fair in 22%, and poor in 0%. According to the Berndt and Harty outcome question, 74% of patients rated the ankle as good, 20% as fair, and 6% as poor. The median AOFAS score was 88 (range, 64 to 100). Of the eight subscales of the SF-36, six were comparable with population norms and two were superior in the study group. Ninety-four percent of patients had resumed work and 88% had resumed sports. The radiographs indicated an osteoarthritis grade of 0 in 33% of the patients, I in 63%, II in 4%, and III in 0%. Compared with the preoperative osteoarthritis classification, 67% of radiographs showed no progression and 33% showed progression by one grade. None of the prognostic factors was significantly associated with the Ogilvie-Harris score or progression of osteoarthritis.
CONCLUSIONS:  This study suggests that initial success of arthroscopic debridement and bone marrow stimulation for osteochondral defects of the talus are maintained over time. No factors that were predictive of the outcome could be identified.
LEVEL OF EVIDENCE: Therapeutic Level IV

Yntema CL, Wiegerinck JI, Kerkhoffs GM, Dijk CN van, Struijs PAA

Treatment of Severs Disease; a review of the literature

Sport en Geneeskunde 2013;46(1):12-19.

Purpose: To give a clear overview of and assess the quality of the available literature on the effectiveness of various treatments for Sever's disease (apophysitis calcanei).
Methods: MEDLINE, EMBASE (Classic), CINAHL and Google Scholar were systematically searched. Search terms: Therapeutic studies reporting on patient satisfaction, pain or relief of symptoms of children with Sever's disease were eligible. Potentially eligible trials were independently selected by two review authors; for quality assessment the GRADE classification was used.
Results: 14 trials (425 patients; one RCT) out of 339 reviewed abstracts were included. The
included studies were graded as "low" or "very low" in the GRADE classification with substantial risks of bias in all studies. A variety of conservative treatment methods are used: rest; heel raise; stretching and strengthening of the calf muscles. Most studies combine mix treatment strategies. Two insoles were compared in the RCT; a heel wedge vs. custom-made heel cup, both insoles showed a relief of pain. 77% of the subjects preferred the cup.
Conclusions: The level of evidence for any treatment modality is very low. Many treatment modalities for Sever's disease are used; the majority has a relative quick relieve of symptoms. Based on the current the level of evidence, it is impossible to recommend a specific treatment. As all current treatments show a relief of pain, future studies should focus on high quality evaluations of these treatments.

J Bone Joint Surg Am. 2013 Mar 20;95(6):519-25.

Arthroscopic Treatment of Osteochondral Defects of the Talus: Outcomes at Eight to Twenty Years of Follow-up

van Bergen CJ, Kox LS, Maas M, Sierevelt IN, Kerkhoffs GM, van Dijk CN

BACKGROUND:
The primary aim of this study was to assess the long-term clinical and radiographic outcomes of arthroscopic debridement and bone marrow stimulation for talar osteochondral defects. The secondary aim was to identify prognostic factors that affect the long-term results.

METHODS:
Fifty (88%) of fifty-seven eligible patients with a primary osteochondral defect treated with arthroscopic debridement and bone marrow stimulation were evaluated after a mean follow-up of twelve years (range, eight to twenty years). Clinical assessment included the Ogilvie-Harris score, Berndt and Harty outcome question, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Short Form-36 (SF-36) as well as resumption of work and sports. Weight-bearing radiographs were compared with preoperative radiographs with use of an ankle osteoarthritis classification system. The size, location, and classification of the defect, patient age and body mass index, traumatic etiology, and duration of symptoms were recorded and analyzed with use of univariate logistic regression.

RESULTS:
The Ogilvie-Harris score was excellent in 20% of patients, good in 58%, fair in 22%, and poor in 0%. According to the Berndt and Harty outcome question, 74% of patients rated the ankle as good, 20% as fair, and 6% as poor. The median AOFAS score was 88 (range, 64 to 100). Of the eight subscales of the SF-36, six were comparable with population norms and two were superior in the study group. Ninety-four percent of patients had resumed work and 88% had resumed sports. The radiographs indicated an osteoarthritis grade of 0 in 33% of the patients, I in 63%, II in 4%, and III in 0%. Compared with the preoperative osteoarthritis classification, 67% of radiographs showed no progression and 33% showed progression by one grade. None of the prognostic factors was significantly associated with the Ogilvie-Harris score or progression of osteoarthritis.

CONCLUSIONS:
This study suggests that initial success of arthroscopic debridement and bone marrow stimulation for osteochondral defects of the talus are maintained over time. No factors that were predictive of the outcome could be identified.

Br J Sports Med. 2013 Mar 6.

Fifth metatarsal fractures among male professional footballers: a potential career-ending disease

Ekstrand J, van Dijk CN.

BACKGROUND:
There is little information about Metatarsal Five (MT-5) fractures for specific sports.
OBJECTIVE:
To study the occurrence, the imaging characteristics, the lay-off times and healing problems of MT-5 fractures among male footballers.
METHODS:
Sixty-four European elite teams were monitored from 2001 to 2012. x-Rays were collected and classified by the Torg criteria.
RESULTS:
Of 13 754 injuries, 0.5% (67) proved to be MT-5 fractures. Their incidence was 0.04 injuries/1000 h of exposure. A team of 25 players might thus expect an MT-5 fracture every fifth season. Of these fractures, 67% (38) were primary and 33% were refractures. One of the 38 primary fractures was an avulsion of the tuberosity; all the others (97%) located towards the base. In total, 32% of the players with MT-5 fracture were younger than 21 years, 40% of the fractures occurred during the preseason and 45% of the players had prodromal symptoms. In total, 54% of the initial x-rays were classified as Torg type II (stress fractures), and 46% were classified as Torg type I (acute type). After surgical treatment the fractures healed faster, compared with conservative treatment (75% vs 33%, p<0.05). There was no significant difference in lay-off days between players that had been operated, and those that had not (80 vs 74 days, p=0.67).
CONCLUSIONS:
The majority of MT-5 fractures are stress fractures, and mainly occur among young players. There are frequent healing problems, which might be explained by the stress nature of the injury. After surgery there are less healing problems, compared with those in conservative treatment.

Reilingh ML, Blankevoort L, van Eekeren IC, van Dijk CN

Knee Surg Sports Traumatol Arthrosc. 2013 Jan 18

Morphological analysis of subchondral talar cysts on microCT

PURPOSE:
Osteochondral talar defects often present in conjunction with subchondral bone cysts. The exact aetiology of these cysts is unknown. Recently was shown in a computational bone model that pressurized fluid and osteocyte death could lead to cyst growth, through mechanoregulated bone adaptation. However, a difference in cyst morphology was present between the mechanisms. The purpose of this study was to evaluate and compare the cyst morphology of human cadaveric tali by using microCT with the morphological simulation results previously reported.
MATERIALS AND METHODS:
Sixty-six fresh-frozen human cadaveric tali were screened in a regular CT for subchondral bone cysts, radiologically defined as unexpected rounded radiolucent area. Subsequently, the tali with a cyst were scanned in a microCT. The shape of the cysts, the presence of an opening through the subchondral bone plate, and the bone volume fraction around and next to the cyst were analysed.
RESULTS:
In total, six tali were found to have a single cyst. Four cysts had an irregular shape, and two cysts were rounded. A clear opening from the cyst through the subchondral bone plate was found (diameter 0.5-1.7 mm) in four cysts. The bone volume fraction was higher (p = 0.025) around the cyst then next to the cyst.
CONCLUSIONS:
The morphological findings that we found are only compatible with the previously reported simulation results of cyst growth in response to pressurized fluid, or pressurized fluid in combination with osteocyte death. It is therefore most likely that pressurized fluid plays a role in the pathoaetiology of cyst growth. A better understanding of cyst growth may improve treatment and prevent further cyst formation.

Longo UG, Loppini M, Romeo G, van Dijk CN, Maffulli N, Denaro V.

Knee Surg Sports Traumatol Arthrosc. 2013 Jan 19.

Bone bruises associated with acute ankle ligament injury: do they need treatment?

PURPOSE: The aim of this systematic review is to analyse the current knowledge, incidence, relevance, and need for treatment of bone bruises associated with acute ankle ligament injury.
METHODS: A search was made of PubMed, OVID/Medline, Cochrane databases using the keyword "bone bruises" in combination with "ankle", "sprain", "management", "surgery", and "conservative treatment".
RESULTS: No randomized controlled trials or prospective cohort studies were found. Only case series were retrieved. A critical appraisal for validity and usefulness of the studies revealed that the best level of evidence on this topic is represented by retrospective comparative studies. Nine studies evaluating the management of bone bruises associated with acute ankle ligament injuries were found.
CONCLUSION: The clinical prognosis of bone bruises is generally good, with a normalization of MRI appearance usually within 6-12 months after trauma. Currently, there is no evidence that these lesions need specific treatment. Thus, the management of the concomitant ligament lesions is sufficient. Further research is necessary to successfully address the management of bone bruises, and more evidence is required to decide if these lesions need to be treated at all.

© Copyright Real Madrid Club de Fútbol, 2011

Combined posterior and anterior ankle arthroscopy

Treatment of combined anterior and posterior ankle pathology usually consists of either combined anterior and posterior arthrotomies or anterior ankle arthroscopy with an additional posterolateral portal. The first technique bears the risk of complications associated with the extensive exposure, the latter technique provides limited access to the posterior ankle joint. A case is described of combined anterior and posterior arthroscopy, with the patient lying prone and then turned supine, addressing both anterior and posterior ankle pathologies in one tempo. This minimally invasive combined approach allows quick recovery and early return to work and sports activities.

The World Orthopaedic Alliance (WOA) was inaugurated on November 16, 2012 in Beijijng, China. The initiative was taken by the Chinese Orthopaedic Association and their president Prof Yan Wang and Prof KM Chan from Hong Kong. The WOA is an international non profit organization dedicated to the advancement of high quality musculoskeletal care in developing countries. Countries identified as developing countries are China, India, Russia, Poland, Turkey, Brazil and Mexico. The WOA advocates a global strategy to unite the resources and musculoskeletal expertise around the world to meet the challenge of an aging population through cooperation, advocacy, research, education and patient care. 190 key orthopaedic opinion leathers representing national and all relevant international orthopaedic organisations attended the Beijing 2012 Summit. ESSKA was represented by their past president Niek van Dijk. Important topics were harmonisation in regulations, introduction of the Arthroplasty Watch (prof Lars Lindgren) and a forum on the orthopaedic surgeon perspective on policy changes and opportunities in emerging markets with contributions from Brazil, India en Turkey. The increasing and rising costs of implants world wide is a growing issue. The world wide community is under pressure to develop cost effective care. Other important topics were web-learning and skills training. It was concluded that CME internet based education will be a key element in world wide orthopaedic training in the next 10 years. Key elements to be solved are quality insurance and the language barrier. Concerning skills training it was concluded that this needs an individualized approach. Hands on training should focus on local solutions. External experts should train local surgeons to become local trainers according to the ` train the trainer` principle. This training should be accompanied by refresher courses for the new trainers and by interactive web-based reference material which meets the requirement of continuous orthopaedic education for both trainers and new trainees. Teaching should not just focus on how we do it but why we do it!

It is clear that there is still a lot of work to do!