Last update: October 9, 2015

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October 2015

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: www.cycleforscience.com.



Eur J Sport Sci. 2015 Sep 30:1-8.

Prevalence and determinants of symptoms of common mental disorders in retired professional Rugby Union players

Gouttebarge V, Kerkhoffs G, Lambert M.

The primary aim of this study was to determine the prevalence of symptoms of common mental disorders (CMD) (distress, anxiety/depression, sleeping disturbance, adverse nutrition behaviour, adverse alcohol behaviour and smoking) among retired professional Rugby Union players. The secondary aim was to explore the associations between stressors (life events, Rugby Union career dissatisfaction) and the health conditions under study. Therefore, cross-sectional analyses were conducted on baseline questionnaires from an ongoing prospective cohort study of retired professional Rugby Union players. An electronic questionnaire was established using validated questionnaires to assess symptoms of CMD and stressors. The electronic questionnaire was subsequently distributed to retired players by the national Rugby Union players' associations in France, Ireland and South Africa. Among 295 retired professional Rugby Union players (mean age of 38 years), prevalence rates were 25% for distress, 28% for anxiety/depression, 29% for sleeping disturbance, 24% for adverse nutrition behaviour, 15% for smoking and 62% for adverse alcohol behaviour. A higher number of life events were associated with distress (OR = 1.2; 95% CI 1.1-1.4), anxiety/depression (OR = 1.6; 95% CI 1.2-2.1), sleeping disturbance (OR = 1.6; 95% CI 1.2-2.1) and adverse nutrition behaviour (OR = 1.8; 95% CI 1.3-2.5). A higher level of dissatisfaction of the player's Rugby Union career was associated with distress (OR = 0.9; 95% CI 0.8-1.0), sleeping disturbance (OR = 0.9; 95% CI 0.9-1.0), smoking (OR = 0.9; 95% CI 0.9-1.0) and adverse nutrition behaviour (OR = 0.9; 95% CI 0.8-0.9). In conclusion, our study suggests that prevalence of symptoms of CMD is high among retired professional Rugby Union players, being associated with both a higher number of life events and a higher level of Rugby Union career dissatisfaction.


Foot Ankle Int. 2015 Sep 29. pii: 1071100715603999.

Diagnostic Accuracy of 2-Dimensional Computed Tomography for Articular Involvement and Fracture Pattern of Posterior Malleolar Fractures.

Meijer DT, de Muinck Keizer RO, Doornberg JN, Sierevelt IN, Stufkens SA, Kerkhoffs GM, van Dijk CN; Ankle Platform Study Collaborative-Science of Variation Group.

BACKGROUND: Up to 44% of ankle fractures have involvement of the posterior tibial margin. Fracture size and morphology are important factors to guide treatment of these fragments, but reliability of plain radiography in estimating size is low. The aim of the current study was to evaluate the accuracy of 2-dimensional computed tomography (2DCT) in the assessment of posterior malleolar fractures. Additionally, the diagnostic accuracy of 2DCT and its value in preoperative planning was evaluated.
METHODS: Thirty-one patients with 31 ankle fractures including a posterior malleolar fragment were selected. Preoperative CT scans were analyzed by 50 observers from 23 countries. Quantitative 3-dimensional CT (Q3DCT) reconstructions were used as a reference standard.
RESULTS: Articular involvement of the posterior fragment was overestimated on 2DCT by factors 1.6, 1.4, and 2.2 for Haraguchi types I, II, and III, respectively. Interobserver agreement on operative management ("to fix, or not to fix?") was substantial (κ = 0.69) for Haraguchi type I fractures, fair (κ = 0.23) for type II fractures, and poor (κ = 0.09) for type III fractures. 2DCT images led to a change in treatment of the posterior malleolus in 23% of all fractures. Surgeons would operatively treat type I fractures in 63%, type II fractures in 67%, and type III fractures in 22%.
CONCLUSION: Surgeons overestimated true articular involvement of posterior malleolar fractures on 2DCT scans. 2DCT showed some additional value in estimating the involved articular surface when compared to plain radiographs; however, this seemed not yet sufficient to accurately read the fractures. Analysis of the CT images showed a significant influence on choice of treatment in 23% with a shift toward operative treatment in 12% of cases compared to evaluating plain lateral radiographs alone.


During a meeting in Kiev on September 26th, Prof C.Niek van Dijk was appointed as Honorary member of the Ukrainian Arthroscopy & SportsTrauma Association (UASTKA founded in 1998).
On the picture also dr. Igor Zazirny (on the left) and prof. A. Kastrup (on the right). It was for the first time of the existence of UASTKA that they appointed an honorary membership to their society.

During a meeting in Portugal on September 24th, Prof C.Niek van Dijk was appointed as Honorary member of the Portuguese Arthroscopy & Sports Trauma Society (SPAT founded in 1994). On the picture he receives the certificate from SPAT president Jose Filipe Salreta. Van Dijk is the third orthopaedic surgeon to receive this recognition.

September 2015


BMC Musculoskelet Disord. 2015 Aug 20;16(1):211. doi: 10.1186/s12891-015-0649-4.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

Weel H, Mallee WH, van Dijk CN, Blankevoort L, Goedegebuure S, Goslings JC, Kennedy JG, Kerkhoffs GM.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union.
METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent.
DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures.
TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).



PhD Thesis:" The conservative treatment of ankle osteoarthritis" By Angelique Witteveen.

Promotor: Prof. dr. C.N. van Dijk, co-promotores: Prof. dr. G.M.M.J. Kerkhoffs en dr.ir. L. Blankevoort.
September 9 2015, 2.00 p.m. Agnietenkapel, UvA, Oudezijds Voorburgwal 229-231, Amsterdam.


In 70% to 78% of patients with ankle osteoarthritis (OA), they present themselves with the sequelae of a traumatic event in the past. Ankle trauma occurs in many patients at a relatively young age. Consequently, the expected life span of many patients with ankle OA is relatively long.
Many treatment modalities are offered. Evidence for conservative treatment is limited. The conservative treatment of symptomatic ankle OA consists mainly of treating symptoms like pain and stiffness. No clear-cut treatment algorithm for ankle OA is used. The choice of treatment depends on the severity of the disease, the patients' age, medical and social history and the level of physical activity to be demanded of the joint.
This thesis addresses the efficacy and safety of hyaluronic acid injections for ankle OA, the dosage schedule of HA and the optimum injection technique for the osteoarthritic ankle. Additionally, the impact of ankle OA on daily life and the available evidence for conservative treatments of ankle OA are evaluated. Finally, the stage of ankle OA at which patients are referred to a tertiary center, what treatment they underwent, the cause of their ankle OA and the treatment that was prescribed are addressed.

August 2015

 Ned Tijdschr Geneeskd. 2015

Dutch-language patient-reported outcome measures for foot and ankle injuries; a systematic review

Weel H, Zwiers R, Sierevelt IN, Haverkamp D, van Dijk CN, Kerkhoffs GM.


OBJECTIVE: To investigate which valid and reliable patient-reported outcome measures (PROMs) are available for foot and ankle disorders in the Dutch population, and which of these is the most suitable for uniform use.
DESIGN: Systematic review.
METHOD: PubMed, Embase and Google Scholar were systematically searched for relevant articles; subsequently two researchers screened first the title and the abstract, and then the full article within a selection of these articles. Studies that described a validation process for foot- and ankle-PROMs in a Dutch population were included. Data on measurement characteristics and translation procedure were extracted, and methodological quality of the studies was assessed using the COSMIN checklist. ('COSMIN' stands for 'Consensus-based standards for the selection of health status measurement instruments'.)
RESULTS: Two general foot- and ankle-PROMs in the Dutch language were validated: the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measurement (FAAM); two foot-PROMs: the Manchester Foot Pain and Disability Index (MFPDI) and the 5-point Foot Function Index (FFI-5pt) were also validated. There were also two disorder-specific PROMs available in Dutch: the Victorian Institute of Sports Assessment-Achilles (VISA-A) for Achilles tendinopathies and the Foot Impact Scale for Rheumatoid Arthritis (FIS-RA) for rheumatoid arthritis patients.
CONCLUSION: The FAOS and the FFI-5pt showed the strongest evidence for having good measurement characteristics. Currently, we regard the FAOS as the most appropriate foot- and ankle-PROM for general foot and ankle problems. Further studies of higher methodological quality are, however, required to draw firmer conclusions.


Knee Surg Sports Traumatol Arthrosc. 2015 Aug


Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events.

van den Bekerom MP, Sjer A, Somford MP, Bulstra GH, Struijs PA, Kerkhoffs GM.


PURPOSE: In the recent clinical guideline for acute lateral ankle sprain, the current best evidence for diagnosis, treatment and prevention strategies was evaluated. Key findings for treatment included the use of ice and compression in the initial phase of treatment, in combination with rest and elevation. A short period of taking non-steroidal anti-inflammatory drugs (NSAIDs) may facilitate a rapid decrease in pain and swelling can also be helpful in the acute phase. The objective was to assess the effectiveness and safety of oral and topical NSAID in the treatment for acute ankle sprains.
METHODS: Randomised controlled trials comparing oral or topic NSAID treatment with placebo or each other were included. Primary outcome measures were pain at rest or at mobilisation and adverse events. Trials were assessed using the Cochrane risk of bias tool.
RESULTS: Twenty-eight studies were included, and 22 were available for meta-analysis. Superior results were reported for oral NSAIDs when compared with placebo, concerning pain on weight bearing on short term, pain at rest on the short term, and less swelling on short- and intermediate term. For topical NSAIDs, superior results compared with placebo were found for pain at rest (short term), persistent pain (intermediate term), pain on weight bearing (short- and intermediate term) and for swelling (short and intermediate term). No trials were included comparing oral with topic NSAIDs, so conclusions regarding this comparison are not realistic.
CONCLUSIONS: The current evidence is limited due to the low number of studies, lack of methodological quality of the included studies as well as the small sample size of the included studies. Nevertheless, the findings from this review support the use of NSAIDs for the initial treatment for acute ankle sprains.
LEVEL OF EVIDENCE: Meta-analysis of RCTs, Level I.


Injury. 2015 Jul 26.

Guesstimation of posterior malleolar fractures on lateral plain radiographs.

Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, Stufkens SA; Ankle Platform Study Collaborative - Science of Variation Group; Ankle Platform Study Collaborative - Science of Variation Group.

BACKGROUND: Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs.
METHODS: Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm2) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus?
RESULTS: The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25).
CONCLUSIONS: Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).

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