Knee Surg Sports Traumatol Arthrosc. 2016 Jul 14.
Opdam KT, Zwiers R, Wiegerinck JI, Kleipool AE, Haverlag R, Goslings JC, van Dijk CN.
PURPOSE: Patient-reported outcome measures (PROMs) have become a cornerstone for the evaluation of the effectiveness of treatment. The Achilles tendon Total Rupture Score (ATRS) is a PROM for outcome and assessment of an Achilles tendon rupture. The aim of this study was to translate the ATRS to Dutch and evaluate its reliability and validity in the Dutch population.
METHODS: A forward-backward translation procedure was performed according to the guidelines of cross-cultural adaptation process. The Dutch ATRS was evaluated for reliability and validity in patients treated for a total Achilles tendon rupture from 1 January 2012 to 31 December 2014 in one teaching hospital and one academic hospital. Reliability was assessed by the intraclass correlation coefficients (ICC), Cronbach's alpha and minimal detectable change (MDC). We assessed construct validity by calculation of Spearman's rho correlation coefficient with domains of the Foot and Ankle Outcome Score (FAOS), Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) and Numeric Rating Scale (NRS) for pain in rest and during running.
RESULTS: The Dutch ATRS had a good test-retest reliability (ICC = 0.852) and a high internal consistency (Cronbach's alpha = 0.96). MDC was 30.2 at individual level and 3.5 at group level. Construct validity was supported by 75 % of the hypothesized correlations. The Dutch ATRS had a strong correlation with NRS for pain during running (r = -0.746) and all the five subscales of the Dutch FAOS (r = 0.724-0.867). There was a moderate correlation with the VISA-A-NL (r = 0.691) and NRS for pain in rest (r = -0.580).
CONCLUSION: The Dutch ATRS shows an adequate reliability and validity and can be used in the Dutch population for measuring the outcome of treatment of a total Achilles tendon rupture and for research purposes.
LEVEL OF EVIDENCE: Diagnostic study, Level I.
The 16th Amsterdam Foot and Ankle Course and the 2nd Advanced Amsterdam Foot and Ankle Course are coming up soon. From 22nd -24th of June 2016, we will be happy to turn the Academic Medical Center Amsterdam into a course venue full of Cadaver Lab sessions, Lectures, Computer courses, Live surgery and much more. The faculty is ready and the preparations are in full swing. We are looking forward to have you in Amsterdam, the Netherlands.
This year the Teach the Teacher course is held from 26-28 May in ASTC, National University Hospital, Singapore. The course is an intensive three day event to include lectures, debates and Cadaver workshops made possible by smith&nephew. The objective of the program is to build a group of connected surgeons dedicated to ankle arthroscopy. These surgeons are the (future) leaders in this field in their countries. The faculty for the course consists of Prof. Niek van Dijk, prof Jean Brilhault, prof Xu Dong MIAO and prof. Zhong Ming SHI.
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.
Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):944-56. doi:10.1007/s00167-016-4059-4.
Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN.
Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.
Knee Surg Sports Traumatol Arthrosc. 2016 Mar 26.
Identification of the superficial peroneal nerve : Anatomical study with surgical implications.
de Leeuw PA, Golanó P, Blankevoort L, Sierevelt IN, van Dijk CN.
PURPOSE:To prevent iatrogenic damage to the superficial peroneal nerve during ankle arthroscopy, it needs to be identified. The purpose of the present study was to determine which clinical test identified the superficial peroneal nerve most frequently and which determinants negatively affected the identification.
METHODS:A total of 198 ankles (99 volunteers) were examined for identification of the superficial peroneal nerve. Race, gender, body mass index (BMI), shoe size and frequency of physical activity were collected.
RESULTS:The best method to identify the superficial peroneal nerve was the maximal combined ankle plantar flexion and inversion test. In this position, the nerve was identified in 57 % of the ankles by palpation. BMI was the only independently influential factor in the identification of the superficial peroneal nerve.
CONCLUSION:Since in nearly six out of the ten ankles the superficial peroneal nerve can be identified, it is advised to assess its anatomy prior to portal placement. A higher BMI negatively influences the identification of the superficial peroneal nerve.
Knee Surg Sports Traumatol Arthrosc. 2016 Mar 29.
Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay.
Dalmau-Pastor M, Yasui Y, Calder JD, Karlsson J, Kerkhoffs GM, Kennedy JG.
The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.
Our department received the accreditation as IOC Research Centerfor Prevention of Injury and Protection of Athlete Health. Only nine centers worldwide received this recognition. The IOC has chosen our Amsterdam Collaboration on Health & Safety in Sports (ACHSS), because we stand at the forefront of the sports medicine research. The ACHSS brings together the two teaching hospitals in Amsterdam, combining the two Dutch leading groups on research and practice on prevention and treatment in sports medicine. Within the ACHSS research focuses on the prevention and treatment of sports injuries in Olympic athletes in the broadest sense. We were honoured to receive the accreditation from professor Lars Engebretsen, head of the International Olympic Committee medical research.
Knee Surg Sports Traumatol Arthrosc. 2016 Mar 18.
Calder JD, Freeman R, Domeij-Arverud E, van Dijk CN, Ackermann PW
PURPOSE: To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.
METHODS: Following a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.
RESULTS: 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6 % (95 % CI 0.4-0.8 %) and 1 % (95 % CI 0.2-1.7 %), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5 % (95 % CI 6.8-18.2 %) and 10.5 % (95 % CI 5.0-15.9 %), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7 % (95 % CI 5.5-8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4-44.3 %).
CONCLUSION: Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.
Knee Surg Sports Traumatol Arthrosc. 2016 Mar 12.
Baltes TP, Zwiers R, Wiegerinck JI, van Dijk CN.
PURPOSE: The aim of this study was to systematically evaluate the available literature on surgical treatment for midportion Achilles tendinopathy and to provide an overview of the different surgical techniques.
METHODS: A systematic review of the literature available in MEDLINE, EMBASE and the Cochrane database of controlled trials was performed. The primary outcome measure in terms of patient satisfaction and the secondary outcome measures that consisted of complication rate, pain score, functional outcome score and success rate were evaluated. The Downs & Black checklist and the Coleman methodology scale were used to assess the methodological quality of included articles.
RESULTS: Of 1090 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 1285 procedures in 1177 patients. The surgical techniques were divided into five categories. Eleven studies evaluated open surgical debridement, seven studies described minimally invasive procedures, three studies evaluated endoscopic procedures, one study evaluated open gastrocnemius lengthening, and one study reported on open autologous tendon transfer. Results regarding patient satisfaction (69-100 %) and complication rate (0-85.7 %) varied widely.
CONCLUSIONS: This study demonstrates the large variation in surgical techniques available for treatment of midportion Achilles tendinopathy. None of the included studies compared surgical intervention with nonsurgical or placebo intervention. Minimally invasive and endoscopic procedures yield lower complication rates with similar patient satisfaction in comparison with open procedures. Minimally invasive and endoscopic procedures might therefore prove to be the future of surgical treatment of Achilles midportion tendinopathy.
Knee Surg Sports Traumatol Arthrosc. 2016 Feb 4.
van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V.
PURPOSE: Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries.
METHODS: review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015.
RESULTS: The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries.
CONCLUSIONS: the ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery.
Knee Surg Sports Traumatol Arthrosc. 2016 Feb 4.
van Eekeren IC, van Bergen CJ, Sierevelt IN, Reilingh ML, van Dijk CN.
PURPOSE: Osteochondral defects (OCD) often have a severe impact on the quality of life due to deep ankle pain during and after weight bearing, which prevents young patients from leading an active life. Arthroscopic debridement and bone marrow stimulation are currently the gold standard treatment. The purpose of this study was to evaluate the number of patients that resume and maintain sports to their pre-injury activity level after arthroscopic debridement and bone marrow stimulation.
METHODS: This retrospective study evaluated patients treated with arthroscopic debridement and bone marrow stimulation between 1989 and 2008. All patients who were participating in sports before injury were included. The Ankle Activity Scale (AAS) was used to determine activity levels during specific time points (before injury, before operation, after operation and at the time of final follow-up).
RESULTS: Ninety-three patients were included. Fifty-seven (76 %) patients continued participating in sports at final follow-up. The median AAS before injury of 8 (range 3-10) significantly decreased to 4 (range 2-10) at final follow-up.
CONCLUSION: It is shown that 76 % of the patients were able to return to sports at long-term follow-up after arthroscopic debridement and bone marrow stimulation of talar OCDs. The activity level decreased at long-term follow-up and never reached the level of that before injury. The data of our study can be of importance to inform future patients on expectations after debridement and bone marrow stimulation of a talar OCD.
Arthroscopy Techniques 2016: pp e1-e9
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.
Knee Surg Sports Traumatol Arthrosc. 2016 Jan 23.
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.
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.
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.
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.
Knee Surg Sports Traumatol Arthrosc. 2015 Dec 28.
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.
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.
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.
Am J Sports Med. 2015 Nov 20.
Kleipool RP, Natenstedt JJ, Streekstra GJ, Dobbe JG, Gerards RM, Blankevoort L, Tuijthof GJ.
BACKGROUND: A new type of ankle brace (EXO-L) has recently been introduced. It is designed to limit the motion of most sprains without limiting other motions and to overcome problems such as skin irritation associated with taping or poor fit in the sports shoe.
PURPOSE: To evaluate the claimed functionality of the new ankle brace in limiting only the motion of combined inversion and plantar flexion.
STUDY DESIGN: Controlled laboratory study.
METHODS: In 12 patients who received and used the new ankle brace, the mobility of the joints was measured with a highly accurate and objective in vivo 3-dimensional computed tomography (3D CT) stress test. Primary outcomes were the ranges of motion as expressed by helical axis rotations without and with the ankle brace between the following extreme positions: dorsiflexion to plantar flexion, and combined eversion and dorsiflexion to combined inversion and plantar flexion. Rotations were acquired for both talocrural and subtalar joints. A paired Student t test was performed to test the significance of the differences between the 2 conditions (P ≤ .05).
RESULTS: The use of the ankle brace significantly restricted the rotation of motion from combined eversion and dorsiflexion to combined inversion and plantar flexion in both the talocrural (P = .004) and subtalar joints (P < .001). No significant differences were found in both joints for the motion from dorsiflexion to plantar flexion.
CONCLUSION: The 3D CT stress test confirmed that under static and passive testing conditions, the new ankle brace limits the inversion-plantar flexion motion that is responsible for most ankle sprains without limiting plantar flexion or dorsiflexion.
CLINICAL RELEVANCE: This test demonstrated its use in the objective evaluation of braces.
Knee Surg Sports Traumatol Arthrosc. 2015 Oct 30
van Dijk PA, Gianakos AL, Kerkhoffs GM, Kennedy JG.
PURPOSE: The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures.
METHODS: A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included.
RESULTS: Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5 % at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022).
CONCLUSIONS: Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair.
J Tissue Eng Regen Med. 2015 Oct 29
Correia SI, Silva-Correia J, Pereira H, Canadas RF, da Silva Morais A, Frias AM, Sousa RA, van Dijk CN, Espregueira-Mendes J, Reis RL, Oliveira JM
Osteochondral defects of the ankle are common lesions affecting the talar cartilage and subchondral bone. Current treatments include cell-based therapies but are frequently associated with donor-site morbidity. Our objective is to characterize the posterior process of the talus (SP) and the os trigonum (OT) tissues and investigate their potential as a new source of viable cells for application in tissue engineering and regenerative medicine. SP and OT tissues obtained from six patients were characterized by micro-computed tomography and histological, histomorphometric and immunohistochemical analyses. Proliferation and viability of isolated cells were evaluated by MTS assay, DNA quantification and live/dead staining. The TUNEL assay was performed to evaluate cell death by apoptosis. Moreover, the production of extracellular matrix was evaluated by toluidine blue staining, whereas cells phenotype was investigated by flow cytometry. Characterization of ankle explants showed the presence of a cartilage tissue layer in both SP and OT tissues, which represented at least 20%, on average, of the explant. The presence of type II collagen was detected in the extracellular matrix. Isolated cells presented a round morphology typical of chondrocytes. In in vitro studies, cells were viable and proliferating for up to 21 days of culture. No signs of apoptosis were detected. Flow-cytometry analysis revealed that isolated cells maintained the expression of several chondrocytic markers during culture. The results indicated that the SP and OT tissues were a reliable source of viable chondrocytes, which could find promising applications in ACI/MACI strategies with minimal concerns regarding donor zone complications.
Eur J Sport Sci. 2015 Sep 30:1-8.
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.
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.
BMC Musculoskelet Disord. 2015 Aug 20;16(1):211. doi: 10.1186/s12891-015-0649-4.
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.
Ned Tijdschr Geneeskd. 2015
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
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.
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).
J Foot Ankle Surg. 2015 Jul 25
Bech NH, de Leeuw PA, Haverkamp D
Pain posteriorly in the ankle can be caused by bony impingement of the posterolateral process of the talus. This process impinges between the tibia and calcaneus during deep forced plantar flexion. If this occurs it is called posterior ankle impingement syndrome. We report the case of 2 athletic monozygotic twin brothers with bony impingement posteriorly in the left ankle. Treatment consisted of ankle arthroscopy in both patients during which the symptomatic process was easily removed. At 3 months after surgery, both patients were completely free of pain, and 1 of the brothers had already returned to sports. The posterior ankle impingement syndrome is not a rare syndrome, but it has not been described in siblings thus far. That these 2 patients are monozygotic twin brothers suggests that genetics could play a role in the development of skeletal deformities that can result in posterior ankle impingement syndrome.
BMJ Clin Evid. 2015 Jul
Struijs PA, Kerkhoffs GM.
Injury of the lateral ligament complex of the ankle joint occurs in about one in 10,000 people per day, accounting for a quarter of all sports injuries.
METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of acute ankle sprains? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).
RESULTS: At this update, searching of electronic databases retrieved 158 studies. After deduplication and removal of conference abstracts, 97 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 48 studies and the further review of 49 full publications. Of the 49 full articles evaluated, one systematic review and four RCTs were added. We performed a GRADE evaluation for four PICO combinations.
CONCLUSIONS: In this systematic overview, we categorised the efficacy for three interventions, based on information relating to the effectiveness and safety of oral NSAIDs versus placebo, oral versus topical NSAIDs, selective COX-2 inhibitors versus other NSAIDs, and topical NSAIDs versus placebo.
Foot Ankle Int. 2015 Jul 9.
van der Plaat LW, van Engelen SJ, Wajer QE, Hendrickx RP, Doets KH, Houdijk H, van Dijk CN.
After ankle arthrodesis (AA), compensatory increased range of motion in adjacent joints might lead to increased osteoarthritis. Evaluation of patient-reported outcomes after AA with validated questionnaires is rare. Likewise, reliable radiographic analysis of the position of the AA, expected to influence the range of motion of the hind- and midfoot, is lacking. Therefore, the current study was performed.
Seventeen patients with unilateral AA were included. Sagittal hind- and midfoot range of motion was measured radiographically. The position of the AA in the sagittal and coronal planes and osteoarthritis of adjacent joints were also evaluated radiographically. Measurements were compared to the contralateral side. Patient-reported outcomes via validated questionnaires were compared to a control group (n = 18).
Average follow-up was 3.5 years. Mean combined hind- and midfoot sagittal range of motion after AA equaled that of the contralateral side (20.8 vs 21.0 degrees; P = .93). The tibiotalar angle after AA equaled that of the contralateral side (107 vs 107 degrees; P = .86). The talus was translated posteriorly after AA (T-T ratio 0.45 vs 0.34; P < .001). Low intraclass correlation coefficients (ICC) precluded reliable evaluation of the coronal position of the hindfoot (ICC, 0.07 and -0.34) and osteoarthritis in adjacent joints (ICC range, 0-0.54). SF-36 physical health scores after AA are lower as compared with those of controls (50 vs 56; P = .01). Scores on the Foot and Ankle Outcome Score and Ankle Osteoarthritis Scale were also significantly lower. Patient satisfaction with AA was high (average visual analog scale score, 83).
No increased sagittal range of motion in the hind- and midfoot after AA was found at 3.5 years of follow-up as compared with the contralateral side. Tibiotalar angles were equal. The talus was translated posteriorly. The hindfoot alignment view was not suitable to analyze the position of the hindfoot. Low ICC of the Kellgren and Lawrence scale precluded evaluation of osteoarthritis of adjacent joints. Patients scored lower than controls on self-reported outcome questionnaires but were satisfied with the result of AA.
The 15th Amsterdam Foot & Ankle Course took place on the 17th and 18th of June 2015. There were 76 participants coming from all continents. The average score for the lectures, interactive computer courses, live surgery and of course the hands-on time in the cadaver lab sessions was 4,47(out of 5)!
Quotes of participants:
"Very balanced course, interesting interactive lectures, useful life surgery and instructive hands-on cadaver time. Even the social program is really good. Thanks for everything professor van Dijk!"
"Great course! Professor van Dijk is an excellent teacher and a good man. Keep on going!"
"Learning to do a good arthroscopy from the man himself. His tips and tricks makes me a better surgeon in only two days. I thoroughly enjoyed it!"
Next year course dates are 22th and 23th of June 2016.
The first Advanced Amsterdam Foot & Ankle Course took place on the 17th and 18th of June 2105. The 34 enthusiastic participants reward the course with an average score of 4,5!(out of 5).
Quotes of participants:
"A few years ago I went to the beginner course which was very wonderful and I learned a lot. During the advanced course we had more cadaver time to practice difficult procedures with very helpful course instructions from professor van Dijk!"
"It was really an honor to participate in the first advanced foot and ankle course. Great course and great faculty!"
"I did my first FHL-transfer!!! Wow what a course!"
Next year course dates are 23th and 24th of June 2016.
Knee Surg Sports Traumatol Arthrosc. 2015 Jun 5.
van den Bekerom MP, van Kimmenade R, Sierevelt IN, Eggink K, Kerkhoffs GM, van Dijk CN, Raven EE.
Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury (ALALI) in favour of immobilization treatment. There is no single most effective functional treatment (tape, semi-rigid brace or lace-up brace) based on currently available randomized trials.
This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grades II and III ALALIs. The Karlsson score and the FAOS were evaluated at 6-month follow-up.
One hundred and ninety-three patients (52 % males) were randomized, 66 patients were treated with tape, 58 patients with a semi-rigid brace and 62 patients with a lace-up brace. There were no significant differences in any baseline characteristics between the three groups. Mean age of the patients was 37.3 years (35.1-39.5; SD 15.3). Ninety-five males (49 %) were included. One hundred and sixty-one (59 + 50 + 52) patients completed the study through final follow-up; 32 % lost at follow-up. In two patients treated with tape support, the treatment was changed to a semi-rigid brace because of dermatomal blisters. Except for the difference in Foot and Ankle Outcome Score sport between the lace-up and the semi-rigid brace, there are no differences in any of the outcomes after 6-month follow-up.
The most important finding of current study was that there is no difference in outcome 6 months after treatment with tape, semi-rigid brace and a lace-up brace.
J Pediatr Orthop. 2015 May 6.
Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert HC, van Dijk CN, Struijs PA.
Calcaneal apophysitis is a frequent cause of heel pain in children and is known to have a significant negative effect on the quality of life in affected children. The most effective treatment is currently unknown. The purpose of this study is to evaluate 3 frequently used conventional treatment modalities for calcaneal apophysitis.
Three treatment modalities were evaluated and compared in a prospective randomized single-blind setting: a pragmatic wait and see protocol versus a heel raise inlay (ViscoHeel; Bauerfeind) versus an eccentric exercise regime under physiotherapeutic supervision. Treatment duration was 10 weeks.
age between 8 and 15 years old, at least 4 weeks of heel pain complaints due to calcaneal apophysitis based, with a minimal Faces Pain Scale-Revised of 3 points. Primary exclusion criteria included other causes of heel pain and previous similar treatment. Primary outcome was Faces Pain Scale-Revised at 3 months. Secondary outcomes included patient satisfaction and Oxford Ankle and Foot Questionnaire (OAFQ). Points of measure were at baseline, 6 weeks, and 3 months. Analysis was performed according to the intention-to-treat principles.
A total of 101 subjects were included. Three subjects were lost to follow-up. At 6 weeks, the heel raise subjects were more satisfied compared with both other groups (P<0.01); the heel raise group improved significantly compared with the wait and see group for OAFQ Children (P<0.01); the physical therapy group showed significant improvement compared with the wait and see group for OAFQ Parents (P<0.01). Each treatment modality showed significant improvement of all outcome measures during follow-up (P<0.005). No clinical relevant differences were found between the respective treatment modalities at final follow-up.
Treatment with wait and see, a heel raise inlay, or physical therapy each resulted in a clinical relevant and statistical significant reduction of heel pain due to calcaneal apophysitis. No significant difference in heel pain reduction was found between individual treatment regimes. Calcaneal apophysitis is effectively treated by the evaluated regimes. Physicians should deliberate with patients and parents regarding the preferred treatment.
Our department has recently received recognition of the International Olympic Committee (IOC) as IOC Research Center for Prevention of Injury and Protection of Athlete Health. Only nine centers worldwide have received this recognition. We received this recognition together with the VU
Over the next four years, all nine centers will be tasked with researching, developing and implementing effective preventive treatment methods for sports-related injuries and illnesses.
During the combined AEA-SEROD meeting in Madrid, Prof C.Niek van Dijk was appointed as Honorary member of the Spanish Arthroscopy Association (AEA)
It is for the first time in the existence of the AEA that they decided to appoint an honorary member . This makes him the first honorary member of their Society.
With a certificate he also received the gold pin which is reserved for the pastpresidents of the AEA.
On the picture also John Bergfeld (pastpresident of ISAKOS) who was appoited honorary member of SEROD.
Arthroscopy. 2015 Mar 19.
Zwiers R, Wiegerinck JI, Murawski CD, Fraser EJ, Kennedy JG, van Dijk CN.
To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement.
A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review.
Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement.
Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome.
J Orthop Trauma. 2015 Mar 14.
Mangnus L, Meijer D, Stufkens SA, Mellema JJ, Steller EP, Kerkhoffs GM, Doornberg JN.
To 1) characterize posterior malleolar fracture morphology using Cole fracture mapping; and 2) study reliability of Quantification of Three-Dimensional Computed Tomography (Q3DCT)-modelling for posterior malleolar fractures with respect to quantification of fragment size (mm) and true articular involvement (mm).
PATIENTS & METHODS:
CT-scans of a consecutive series of 45 patients with an ankle fracture involving the posterior malleolus were reconstructed to calculate 1) fracture maps, 2) fragment volume; 3) articular surface of the posterior malleolar fragment; 4) articular surface of intact tibia and 5) articular surface of the medial malleolus by three independent observers. 3D-animation of this technique is shown on www.traumaplatform.org.
Fracture mapping revealed 1) a continuous spectrum of postero-lateral oriented fracture lines and 2) fragments with postero-lateral to postero-medial oriented fracture lines extending into the medial malleolus. Reliability of measurements of the volume and articular surface of posterior malleolar fracture fragments was defined as almost perfect according to the categorical system of Landis (inter-class coefficient (ICC), range 0.978 - 1.000).
Mapping of posterior malleolar fractures revealed a continuous spectrum of Haraguchi III to I fractures, and identified Haraguchi type II as a separate pattern. Q3DCT-modelling is reliable to assess fracture characteristics of posterior malleolar fracture fragments. Morphology might be more important than posterior malleolar fracture size alone for clinical decision making.
Knee Surg Sports Traumatol Arthrosc. 2014 Dec 25.
Weel H, Zwiers R, Azim D, Sierevelt IN, Haverkamp D, van Dijk CN, Kerkhoffs GM.
The aim of the study was to develop a Dutch language version of the Foot and Ankle Ability Measure (FAAM) and evaluate its measurement properties according to the consensus-based standards for the selection of health measurement instruments (COSMIN) definitions.
A forward-backward translation procedure was performed and subsequently the Dutch version of the FAAM was evaluated for its reliability and validity in 369 patients with a variety of foot and ankle complaints. The reliability was assessed by calculating the intraclass correlation coefficients (ICC, test-retest reliability), Cronbach's alpha (internal consistency), the standard error of measurement and the minimal detectable change (MDC). Additionally, this was done for athletes. The construct validity was assessed by the use of Spearman's correlation coefficient between FAAM domains and similar and contradictory domains of the Foot and Ankle Outcome Score, Short Form 36 and the Numeric Rating Scale for pain.
The ICC of the subscales ranged from 0.62 to 0.86. Cronbach's alpha's minimum was 0.97. At individual level, the MDC ranged from 23.9 to 44.7 and at group level from 2.77 to 4.32. In the subgroup of athletes, the reliability was higher. The hypothesized correlations of the construct validity were supported by an 80 % confirmation rate.
The Dutch version of the FAAM met adequate measurement properties, although the reliability is not optimal. The FAAM-Sport subscale is more useful in athletes and the FAAM-Sport % seems not to contribute. In athletes with various foot and ankle symptoms, the FAAM can be used for functional assessment and follow-up at group level. For the general population, the FAAM is less appropriate.
Foot Ankle Surg. 2014 Dec;20(4):241-7. doi: 10.1016/j.fas.2014.05.008. Epub 2014 Jun 9.
Witteveen AG, Hofstad CJ, Breslau MJ, Blankevoort L, Kerkhoffs GM.
Outcome measures for ankle osteoarthritis (OA) are created by physicians with little input of the target patient group. The aim of this study was to determine the difference in opinion between patients and orthopedic surgeons concerning the importance of specific symptoms of ankle OA and its impact on daily life and function.
A modified Delphi method was applied, consisting of structured interviews with patient focus groups and experts, followed by a poll using 32 statements. The difference in opinion between patients and orthopedic surgeons was evaluated.
Forty patients and forty orthopedic surgeons responded to the 32 statements. Statistically significant differences in opinion on symptoms, function and the impact of ankle OA on daily life were found.
This study demonstrates a significant difference in opinion between patients and orthopedic surgeons concerning specific symptoms of ankle OA. These results advocate incorporating the needs and demands of the individual patient for new outcome measures.
The first Teach the Teacher ankle arthroscopy course in Hong Kong! The course will take place in the Prince of Wales hospital from 3 till 5 December 2014.
Knee Surg Sports Traumatol Arthrosc. 2014 Nov 1.
Zwiers R, Wiegerinck JI, van Dijk CN
In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.
Acta Orthop. 2014 Oct 28:1-7.
Cernohorsky P, Kok AC, Bruin DM, Brandt MJ, Faber DJ, Tuijthof GJ, Kerkhoffs GM, Strackee SD, van Leeuwen TG.
Background and purpose:
Optical coherence tomography (OCT) is a light-based imaging technique suitable for depiction of thin tissue layers such as articular cartilage. Quantification of results and direct comparison with a reference standard is needed to confirm the role of OCT in cartilage evaluation.
Materials and methods:
Goat talus articular cartilage repair was assessed quantitatively with OCT and compared with histopathology using semi-automated analysis software. Osteochondral defects were created centrally in goat tali with subsequent healing over 24 weeks. After sacrifice, the tali were analyzed using OCT and processed into histopathology slides. Cartilage thickness, repair tissue area, and surface roughness were measured. Also, light attenuation coefficient measurements were performed to assess differences in the properties of healthy tissue and repair tissue.
Intra-class correlation coefficients for resemblance between the 2 techniques were 0.95 (p < 0.001) for thickness, 0.73 (p = 0.002) for repair tissue area, and 0.63 (p = 0.015) for surface roughness. Light attenuation differed significantly between healthy cartilage (8.2 (SD 3.9) mm-1) and repair tissue (2.8 (SD 1.5) mm-1) (p < 0.001).
Compared to histopathology as the standard reference method, OCT is a reproducible technique in quantitative analysis of goat talus articular cartilage, especially when assessing cartilage thickness and to a lesser extent when measuring repair tissue area and surface roughness. Moreover, differences in local light attenuation suggest measurable variation in tissue structure, enhancing the clinical applicability of quantitative measurements from cartilage OCT images.
Prof. dr. C. Niek van Dijk will give three Instructional Course Lectures on Thursday the 16th of October:
- "Endoscopic treatment of the Achillies tendon" (8.00 - 8.30 a.m.)
- "Anterior and posterior ankle arthroscopy" (1.30 - 2.00 p.m.)
- "The rational for the diagnosis and treatment of talar OCD" (3.30-4.00 p.m.)
More information is available on the website.
PhD Thesis: "The Achilles Heel of Adults and Children" by Jan Joost Wiegerinck.
Promotor: Prof. dr. C.N. van Dijk, co-promotores: Prof. dr. G.M.M.J. Kerkhoffs and dr. P.A.A. Struijs. October 1 2014, 1.00 p.m. Aula UvA, Singel 411, Amsterdam.
This thesis focuses on the imaging and treatment of the Achilles heel of adults and children. The figurative and literal Achilles heel consists of a number of pathologies: ankle impingement, Achilles tendinopathy, retrocalcaneal bursitis and calcaneal apophysitis. The aim of the thesis is to clearly describe the structures and pathologies leading to complaints in the region of the Achilles tendon, furthermore conventional radiologic imaging techniques of this region are evaluated as well as the treatment of adults and children who are impaired by the aforementioned disorders.
Click here to read the thesis.
Knee Surg Sports Traumatol Arthrosc. 2014 Aug 8.
Stunt JJ, Kerkhoffs GM, Horeman T, van Dijk CN, Tuijthof GJ.
Virtual reality simulators used in the education of orthopaedic residents often lack realistic haptic feedback. To solve this, the (Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment) PASSPORT simulator was developed, which was subjected to fundamental changes: improved realism and user interface. The purpose was to demonstrate its face and construct validity.
Thirty-one participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task, which was timed. Face validity, educational value and user-friendliness were determined with two representative exercises and by asking participants to fill out the questionnaire. A value of 7 or greater was considered sufficient.
Construct validity was demonstrated between experts and novices. Median task time for the fifth trial was 55 s (range 17-139 s) for the novices, 33 s (range 17-59 s) for the intermediates, and 26 s (range 14-52 s) for the experts. Median task times of three trials were not significantly different between the novices and intermediates, and none of the trials between intermediates and experts. Face validity, educational value and user-friendliness were perceived as sufficient (median >7). The presence of realistic tactile feedback was considered the biggest asset of the simulator.
Proper preparation for arthroscopic operations will increase the quality of real-life surgery and patients' safety. The PASSPORT simulator can assist in achieving this, as it showed construct and face validity, and its physical nature offered adequate haptic feedback during training. This indicates that PASSPORT has potential to evolve as a valuable training modality.
J Foot Ankle Surg. 2014 Aug 13.
Comparison of Postinjection Protocols After Intratendinous Achilles Platelet-rich Plasma Injections: A Cadaveric Study. Wiegerinck JI, de Jonge S, de Jonge MC, Kerkhoffs GM, Verhaar J, van Dijk CN.
The purpose of the present investigation was to evaluate the distribution of intratendinous injected platelet-rich plasma (PRP) after 15 minutes of prone resting versus immediate manipulation simulating weightbearing.
Ten cadaveric lower limbs were injected under ultrasound guidance with PRP dyed with India blue ink. The dyed PRP was injected into the mid-portion of the Achilles tendon, after which 5 specimens were placed in the prone position for 15 minutes (simulating rest) and the remaining 5 specimens were manipulated through 100 cycles of ankle dorsiflexion and plantar flexion (simulating walking). Thereafter, the specimens were dissected, and the distribution of the India blue dye was ascertained.
In the simulated rest group, every specimen showed dyed PRP in the Achilles tendon and in the space between the paratenon and tendon. The median craniocaudal spread of the PRP was 140 (range 125 to 190) mm. In 4 of the simulated rest tendons (80%), the distribution of PRP extended across the entire transverse plane width of the tendon. In the simulated motion group, every specimen showed dyed PRP extending across the entire transverse plane width of the tendon and in the space between the paratenon and tendon. The median craniocaudal spread was 135 (range 115 to 117) mm. No statistically significant difference was found in the amount of craniocaudal spread between the simulated motion and rest groups.
In conclusion, it does not appear to matter whether the ankle has been moved through its range of motion or maintained stationary during the first 15 minutes after PRP injection into the mid-portion of the Achilles tendon. The precise meaning of this information in the clinical realm remains to be discerned.
Pau Golanó (1965-2014)
Scientist, Artist and Teacher
It was a Saturday in April 2004: it was St Jordi day. In discotheque Luz de Gas at 4AM we were celebrating our first successful 2-day dissection course for my residents. We talked about life. "I will not get old" he said. And he looked serious, "another 10 years". Then we laughed and took another beer.
Pau Golanó died on 23 July, 2014. A massive stroke. Out of the blue, on the top of his career. So many plans, so many horizons to cross. Pau Golanó became 49 years old.
Pau was professor of Pathology and Experimental Therapeutics at the University of Barcelona. His exceptional anatomical dissection skills and passion for education was quickly recognized by the orthopaedic surgeons surrounding him. And it did not take long before his skills were recognized worldwide and he became the leading expert on orthopaedic anatomy of the last decade. He devoted his career and life to the education of orthopaedic surgeons, making them better doctors by teaching anatomy in the finest details. The door of his Department in Barcelona was always open.
Over the years he has written many inspiring papers on orthopaedic surgical anatomy. A great number of them were the result of the collaboration between Pau and our department. Once every 2 years we organized in Barcelona a dissection course for all the residents of our Department. We practiced all the open surgical approaches. Pau Golanó was our teacher. But Pau was a teacher for all orthopaedic surgeons. Together with the love of his life Celine, he enjoyed travelling the world, meeting friends and sharing his knowledge.
He was a scientist who devotes his energy to orthopaedics. Pau Golanó allowed us to be better doctors for our patients. In 2012 he won the KSSTA best Paper Award for "Anatomy of the Ankle Ligaments: a Pictoral Essay" (Golanó, P. et al (2010). KSSTA Journal, 18(5), 557-569)
And in May 2014 at our ESSKA congress in Amsterdam he was honoured with the prestigious ESSKA AWARD for Most Dedicated Individual ESSKA Member. This AWARD gave him the International recognition which he deserved. This recognition was very important for him.
Pau Golanó was a nonconformist. His unique strength was his artistic vision. He was not quickly satisfied with his achievements and created an extreme high standard for himself. No concessions! This made him sometimes collide with his environment who could not always understand or follow him. But he was an artist with always a smile. With his charm he was liked by all. He worked best under pressure. Deadlines were never met. And the projects and deadlines were piling up. He was at the top of his career. Projects in Qatar, Pittsburgh, Amsterdam and the ESSKA Academy were lying ahead. Although he was a team worker he worked on his own. An anatomist among Orthopods. Alone among many friends.
And his work became better and better. Always in search for new techniques and better ways to expose our inner world. He collaborated with surgeons worldwide. The interaction was always fruitful and many ideas were born in his lab. His favourite joint was the ankle joint. The recent publication of near 100 pieces of his artwork was a culmination of his skills. (van Dijk CN, Golanó P, Ankle Arthroscopy. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014) Each picture an example of his unsurpassed eye for detail and his skills to disclose the beauty of the human body. One of his contributions to the worlds literature is the rediscovery of the forgotten Rouvière-Canela ligament. Together with our PhD Peter de Leeuw he started working on this publication in 2006. It is ready to be submitted. Peter will defend his thesis later this year. Pau would have been there.
But his legacy will go on. The "Golanó`s" will now & then pop-up in future presentations all over the world. And you will recognize a Golanó when you see one.
An anatomist among orthopods. He was one of us!
We will miss him
Niek van Dijk
Arthroscopy 2014 Jul 9
Wiegerinck JI, Vroemen JC, van Dongen TH, Sierevelt IN, Maas M, Dijk CN
The purpose of the current study was to clinically evaluate the diagnostic value of the new posterior impingement (PIM) view in the detection of an os trigonum, compared with the standard lateral view, using computed tomography (CT) as a reference standard.
Three observers, 2 experienced (orthopaedic surgeon and radiologist) and one inexperienced (resident), independently scored 142 radiographic images for the presence of an os trigonum. The diagnostic performance was assessed using the computed tomographic scan as the reference standard. Accuracy, sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated.
The PIM view had significantly superior accuracy compared with the lateral view for each observer: orthopaedic surgeon, PIM view = 90 versus lateral view = 75 (P = .013); radiologist, PIM view = 80 versus lateral view = 64 (P = .019); resident, PIM view = 90 versus lateral view = 79 (P = .039). The mean sensitivity and specificity of the lateral view for all observers was 50% and 81%, respectively. For the PIM view, this was 78% and 89%, respectively. The PPV was 50% for the lateral view and 70% for the PIM view. The NPV was 84% for the lateral view and 93% for the PIM view.
The PIM view has significantly superior diagnostic accuracy compared with the conventional lateral view in the detection of an os trigonum. In cases of symptomatic posterior ankle impingement, we advise that a PIM view be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied reference gold standard.
The 14th Amsterdam Foot and Ankle Course is coming up soon. On the 19th and 20th of June, we will be happy to turn the Academic Medical Center Amsterdam into a course venue full of Cadaver Lab sessions, Lectures, Computer courses, Live surgery and much more. The faculty is ready and the preparations are in full swing.
We are looking forward to have you on June 19 and 20, Amsterdam, the Netherlands.
From June 4-7, the XII International Congress of the Asociación Argentina de Artroscopía (AAA) will take place in Buenos Aires, Argentina. The honorary president of Argentina 2014 is Dr. Miguel Ayerza and the president is Dr. Daniel Slullitel. The congress is in cooperation with the AAOSSM and the ESSKA.
Prof. C.N. van Dijk will be the Presidential Guest Speaker with a lecture on "Current and Future Dilemmas in Orthopaedics".
In addition, he will give the following lectures:
- "Ankle Instability"
- "What about tendoscopy in Achilles lesions?"
- "What to do when we fail in the treatment of an O.C. Lesion?"
For complete program Click Here
Knee Surg Sports Traumatol Arthrosc. 2014 May 20
Kerkhoffs GM, Reilingh ML, Gerards RM, de Leeuw PA
The purpose of this study was to describe the short-term clinical outcome of a new arthroscopic fixation technique for primary osteochondral talar defects: lift, drill, fill and fix (LDFF).
Seven patients underwent an arthroscopic LDFF surgery for osteochondral talar defects, the mean follow-up was 12 months (SD 0.6). Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS) and the numeric rating scales (NRS) of pain at rest and during walking. Remodelling and bone ingrowth after LDFF were analysed on weight-bearing radiographs during follow-up.
In all patients, LDFF led to an improvement of the AOFAS and NRS of pain. The AOFAS significantly improved from 63 to 99 (p < 0.001). The NRS of pain at rest significantly improved from 2.9 to 0.1 (p = 0.004), and pain with walking significantly improved from 7.6 to 0.1 (p < 0.001). On the final radiographs, five of seven patients showed remodelling and bone ingrowth after LDFF.
The LDFF of an osteochondral talar defect appears to be a promising arthroscopic treatment option for primary talar osteochondral defects. Although the clinical and radiological results of 1-year follow-up are encouraging, more patients and longer follow-up are needed to draw any firm conclusions and determine whether the results stand the test of time.
From 22nd to the 25th of May 2014 the 87th Annual Meeting of the Japanese Orthopaedic Association (JOA) will be held at the Kobe Convention Center in Kobe, Japan. The conference will cover areas like Education for the young surgeons in the orthopedic industry, locomotive syndrome, regenerative medicine and tissue engineering in orthopedic, feasibility of cell therapy for cartilage injury, developing arthroscopic surgery for sports medicine, revision and primary total joint replacement, conventional and future strategies for limb joint surgery, spinal surgery, current state and future prospects of malignant bone tumors, current state and future prospects of fracture treatment, current state and future prospects of ACL reconstruction and other topics.
Prof. C.N. van Dijk will give a lecture on Ankle arthroscopy: State of the art and future perspective
For the complete program click here
Knee Surg Sports Traumatol Arthrosc. 2014 May 8
Hendrickx RP, de Leeuw PA, Golano P, van Dijk CN, Kerkhoffs GM.
To study the safety and efficiency of posterior arthroscopic ankle arthrodesis.
Ten fresh-frozen human lower leg specimens without evidence of previous surgery to the foot and ankle were selected. Arthroscopic debridement of the tibiotalar joint was performed in all specimens using a standardized protocol. Anatomical dissections were regarded the gold standard for safety analysis. To evaluate the efficacy of the posterior ankle arthroscopic arthrodesis, the debrided articular tibiotalar parts were resected and subsequently analysed using Image-analysis software, Image J (Wayne Rasband, National Institutes of Health, Bethesda, MD).
In none of the specimens, iatrogenic damage was detected during the anatomical dissection following the posterior ankle arthroscopic procedure. A total talar joint surface area of 95 % and total tibial joint surface area of 96 % was addressed during the arthroscopic debridement.
The posterior ankle arthroscopic arthrodesis can be regarded safe and is also highly effective in the debridement of cartilage, resulting in optimal biology for fusion to occur. Therefore, this new arthroscopic technique potentially will diminish existing non-union rates for the fusion of the ankle joint.
WEDNESDAY, MAY 14
Live surgical demonstration (AFAS) (10:30 - 11:30)
Hindfoot endoscopy, Os trigonum, retrograde drilling OCD, endoscopic groove deepening, subtalar arthrodesis
Prof. C.N. van Dijk
Free paper presentations: Foot, ankle & tendon (14.00-15.00)
14.10-14.15 - Treatment of apofysitis calcanei: A therapeutic randomized clinical trial
Symposium: Acute and chronic syndesmotic injury: a solution for everything (16:00 - 17:00)
16:00 - 16:12 - Diagnosis of syndesmotic injury: Delayed physical examination vs. US vs. MR
Prof. G.M.M.J Kerkhoffs
16:36 - 16:48 - Operative options for treatment of chronic syndesmotic injury.
Prof. C.N. van Dijk
Debate: Achilles tendon rupture (17.00-17.30)
17.00 - 17.30 - Follow the guidelines or just treat the patient?
Prof. C.N. van Dijk, D. Meuffels
ROOM: E 104-107
AOSSM Symposium: Acute injuries in athletes: A case based debate on treatment and return to play (17:15 - 18:00)
17:45 - 18:00 - Case III: Foot and ankle - Acute grade II-III syndesmosis injury.
Prof. C.N. van Dijk, Prof. N. Amendola
ROOM: G 106-107
Symposium: Ligament healing: State of the art (14:15 - 15:30)
14:59 - 15:10 - Clinical application: Healing of the lateral / medial ankle ligaments and the syndesmosis - State of the art
Prof. C.N. van Dijk
THURSDAY, MAY 15
ROOM: G 104-105
ICL 04: Achilles tendon rupture treatment: still a weak spot? (7:30 - 08:55)
07:30 - 07:42 - Presentation of Achilles tendon study group consensus book
08:06 - 08:18 - Key elements of successful open surgery for primary Achilles tendon rupture
Prof. C.N. van Dijk
ROOM: G 102-103
Symposium: Primary talar OCD: What is new? (14:00 - 15:30)
14:00 - 14:15 - Diagnostic work-up: MR vs. CT vs. US
14:45 - 15:00 - LDFF procedure best practice, (not) only in children?
Prof. G.M.M.J Kerkhoffs
15:00 - 15:15 - Developments in debridement and drilling: healing water?
Star Paper Session (10:30 - 12:00)
10:30 - 10:40 - Metal resurfacing inlay implant for osteochondral defects of the talus after failed previous surgery: a prospective study.
C. van Bergen
FRIDAY, MAY 16
ROOM G 106-107
ICL 11: Subchondral bone and reason for surgery (07:30 - 08:55)
08:38 - 08:55 - How to treat subchondral bone pathologies in the ankle joint
FORTE resident programme: Ankle (14:30 - 15:30)
14:30 - 14:50 - Debridement and drilling vs chondrocyte transplant.
Prof. C.N. van Dijk, F. Vannini
14:50 - 15:10 - Open vs scopic achilles tendon release
M. van Sterkenburg, U. Longo
15:10 - 15:30 - Open vs scopic ankle arthrodesis
Prof. G.M.M.J Kerkhoffs , T. Ogut
SATURDAY, MAY 17
ROOM: G 106-107
Symposium: Injury in female soccer player (12:00 - 13:00)
12:00 - 12:10 - Ankle injury
Prof. G.M.M.J Kerkhoffs
During the ESSKA Congress, every day there will be a Live Surgical Demonstration provided by one of the ESSKA sections. On Wednesday Prof. C.N. van Dijk will demonstrate, on behalf of ESSKA-AFAS, some Hindfoot endoscopy procedures, like Os trigonum removal, retrograde drilling for osteochondral defects, endoscopic groove deepening for recurrent peroneal tendon luxations and subtalar artrhodesis. Moderator of this session will be Prof. G.M.M.J Kerkhoffs.
Wednesday, May 14
10.30 - 11.30 - Room: FORUM
During the ESSKA congress Ankleplatform will be present with our own Amsterdam Foot & Ankle Booth! Here you can find information about the Platform, the Website, the Amsterdam Foot & Ankle Course, and, of course, the just released book: Ankle Arthroscopy by prof. C.N. van Dijk!
Hope to see you next week!
On Friday, May 16, there will be the ESSKA Gala Dinner. Join the ESSKA community for a fantastic evening! Enjoy the spectacular venue, the entertainment programme with music and dance and an evening among friends.
This will be one of the highlights of the Congres with performance of the Dutch National Ballet, Eric Vloeimans and an Award ceremony in the Maritime Museum Amsterdam.
For Registration Click Here (E 100,= per ticket)
For photos and the latest news, follow @Ankleplatform on Twitter or join Ankleplatform on Facebook!
Arch Orthop Trauma Surg. 2014 Apr 19
van Bergen CJ, Sierevelt IN, Hoogervorst P, Waizy H, van Dijk CN, Becher C.
Outcome assessment is critical in evaluating the efficacy of orthopaedic procedures. The Foot and Ankle Outcome Score (FAOS) is a 42-item questionnaire divided into five subscales, which has been validated in several languages. Germany has no validated outcome score for general foot and ankle pathology. The aim of this study was to develop a German version of the FAOS and to investigate its psychometric properties.
MATERIALS AND METHODS:
Forward and backward translation was executed according to official guidelines. The final version of the FAOS was investigated in 150 patients with various foot and ankle disorders. All patients completed the FAOS, Short Form-36, numeric rating scales for pain and disability, and the Hannover questionnaire. The FAOS was re-administered after 1 week. Test-retest reliability, internal consistency, minimal detectable change, construct validity, and floor and ceiling effects were analyzed.
Test-retest reliability and internal consistency of each subscale were excellent (intraclass correlation coefficient, 0.88-0.95; Cronbach's α, 0.94-0.98). The minimal detectable changes of each subscale were 17.1-20.8 at the individual level and 2.0-2.4 at group level. There were moderate to strong correlations between FAOS subscales and physical outcomes and low to moderate correlations between FAOS subscales and mental outcomes. Floor and ceiling effects were not present.
The German version of the FAOS is a reliable and valid instrument for use in foot and ankle patients.
Arthroscopy. 2014 Apr 8
Cychosz CC, Phisitkul P, Barg A, Nickisch F, van Dijk CN, Glazebrook MA
The purpose of this study was to provide a comprehensive review of the current literature on tendoscopy of the foot and ankle and assign an evidence-based grade of recommendation for or against intervention.
A comprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopus databases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewed and assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation was assigned for tendoscopy of the tendons of the foot and ankle on which the procedure is generally performed.
There is weak evidence (grade Cf) to support the use of tendoscopy on the Achilles, flexor hallucis longus, and peroneal tendons. Insufficient evidence (grade I) exists to assign a grade of recommendation for tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus.
A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned.
At the upcoming ESSKA Congress in Amsterdam, the new book of the Achilles Tendon Study Group (ATSG) will be presented: "Achilles Tendon Disorders, A Comprehensive Overview of Diagnostics and Treamtent"
This book on Achilles tendon disorders is the fourth production of the Achilles Tendon Study Group (ATSG) and is the final part of the Current Concepts series on Achilles tendon disorders. In collaboration with world leaders in this field, the ATSG has reviewed the available literature to provide a balanced consensus on the scope of Achilles tendon disorders
The Achilles Tendon Study Group is accommodated by ESSKA as and affiliated society. Since 1984 ESSKA is devoted to education, stimulating the further development of research, and providing a forum for presentation and discussion of issues on Arthroscopy Orthopaedic Sports Medicine and Knee Surgery.
In this ‘golden edition' the previous three editions are bundled, updated and supplemented with new chapters. Therefore this production provides the reader with a state-of-the-art overview of the current concepts on all Achilles tendon related problems, both acute injuries and chronic disorders, based on the best available evidence and expert opinions.
The 2nd International Congress on Cartilage Repair of the Ankle will be held at Intercontinental Hotel in Prague, Czech Republic on 11-12 April 2014.
Based on the highly successful 2012 International Congress on Cartilage Repair of the Ankle in Dublin, Ireland, the Scientific Committee is planning a high-quality scientific programme which consists of the latest evidence and experience on diagnosis and treatment of osteochondral lesions of the talus. The program will have several highlights including keynote lectures, expert debates, case based discussions, hot topic symposia (incl. the use of biologics, tissue engineering, implants, the role of alignment and future perspectives) and live-surgery.
We expect this to be an exciting event. Please, share it with us!
For any enquires, please contact the Organizing Secretariat of OIC srl at: infoAFAS2014@oic.it
This Foot and Ankle Arthroscopy Instructional Course will combine lectures from world-renowned faculty with hands-on cadaveric training and in-depth debate. The course content will include surgical approaches and arthroscopic procedures around the ankle joint and hindfoot, tendoscopies and repair procedures.
This course targets healthcare professionals interested in foot and ankle arthroscopy and in expanding their procedural development. The course is open to surgeons at all levels of experience.
Chairman: Prof. dr. Van Dijk.
For more information
From April 2 to 4 2014 the SEROD-AEA Congress will be held in Sevilla, Spain. This is the second joint congress of SEROD-AEA (Spanish Knee Society - Spanish Arthroscopy Association). The congress will include instructional courses, a series of prerecorded surgeries performed by leading surgeons, innovative workshops and expert panels. There will be also a number of keynote lectures delivered by prestigious Spanish and foreign surgeons, who will update us on the latest trends in our field. Prof. Van Dijk will present the keynote lecture "The ankle" on Thursday April 3 at 5 pm. Look at the website for more information.
Click here for the programme
The comprehensive scientific programme during the ESSKA Congress will include:
Highlight lectures by Andrew Amis (UK), Johan Bellemans (Belgium), Michael Kjaer (Denmark), Masahiro Kurosaka (Japan), Rui Reis (Portugal) and René Verdonk (Belgium)
• 220 free papers and over 700 posters
• 18 Instructional Course Lectures
• Debates and interactive case discussions
• Live surgical demonstrations (ESSKA-AFAS, ESSKA-EKA and ESSKA-ESA)
• Star Paper Session
• Orthopaedic Sports Medicine Comprehensive Review Course (full day)
• 53 symposia and 14 key note lectures
• National Awards Session
• PT symposia and workshops
Click here for the complete scientific programme
The online registration for this congress is already open.
For more information CLICK HERE
Knee Surg Sports Traumatol Arthrosc. 2014 March 1
Wiegerinck JI, Zwiers R, van Sterkenburg MN, Maas MM, van Dijk CN.
PURPOSE: To evaluate whether the imaging features of the retrocalcaneal recess normalize on a conventional radiograph after surgery for retrocalcaneal bursitis and evaluate whether it can be reused if complaints reoccur.
METHODS: Patients who underwent an endoscopic calcaneoplasty at least 2 years before were eligible for inclusion. A lateral conventional radiograph of the surgically treated hindfoot was made to assess the retrocalcaneal recess and pre-Achilles fat pad; images were analysed, clinical complaints were registered and evaluated. Radiographs were evaluated by two experienced observers (one orthopaedic surgeon one musculoskeletal specialized radiologist), these scored the images either as "normal" (no obliteration of retrocalcaneal recess and pre-Achilles fat) or as "abnormal".
RESULTS: Thirty patients (34 heels: 28 asymptomatic and 6 recurrent complaints) were included in this study. Observer one rated 12 images as "normal" (2 symptomatic heels and 10 asymptomatic), 22 "abnormal". Observer two rated 9 "normal" (1 symptomatic heels and 8 asymptomatic), 25 "abnormal". No correlation between the radiographic appearance and complaints (n.s.) was found. Cohen's kappa for interobserver agreement was low (0.11 n.s.).
CONCLUSION: The appearance of the retrocalcaneal recess on a lateral radiograph cannot be used as a reliable diagnostic criterion for retrocalcaneal bursitis in patients who previously underwent endoscopic calcaneoplasty. This study clinical relevance is based upon the conclusion that a lateral radiograph cannot be used after endoscopic calcaneoplasty, whereas previous work reported the diagnostic value of a lateral radiograph for retrocalcaneal bursitis prior to surgery
ESSKA-AFAS (European Society of Sports Traumatology, Knee Surgery and Arthroscopy - Ankle and Foot Associates) organizes in close collaboration with the Hospital for Special Surgery the second International Congress on Cartilage Repair of the Ankle on 11 and 12 April 2014 in Prague, Czech Republic. The Scientific and Organising Committee of AFAS will present a programme on osteochondral lesions of the talus, featuring the latest advances in diagnosis and treatment at: keynote lectures;expert-led debates; case discussions; symposia; live surgeries.
C. Niek van Dijk - Congress President
John Kennedy - Congress President
Gino M.M.J. Kerkhoffs - Scientific Programme Chairman
Christopher Murawski - Scientific Programme Chairman
Milan Handl - Local Organiser
James F. Calder - Congress Budget
Daniel Haverkamp - Communication
For more information
Injury. 2014 Jan 31
Veltman ES, van den Bekerom MP, Doornberg JN, Verbeek DO4, Rammelt S, Steller EP, Schepers T
This study determined inter- and intra-observer reliability for measurement of the angles of Böhler and Gissane, for the decision between surgical or conservative management and for the three mostly used classification systems for calcaneal fractures with the use of 2D-CT imaging versus 2D- and 3D-CT imaging. A consecutive series of 38 fractures in 36 patients, treated at a level II trauma centre between 2005 and 2008, were evaluated in two rounds by five observers. We measured the inter- and intraobserver reliability for the Sanders', Zwipp and Essex-Lopresti classification systems using the kappa values as described by Cohen. The intraclass correlation coefficient as described by Shrout and Fleiss was used to analyze inter- and intra-observer reliability of the angles of Böhler and Gissane. Usage of 2D-CT imaging interobserver reliability was fair for the Sanders' and Zwipp classifications and for measurement of the angle of Gissane, and it was moderate for measurement of the Essex-Lopresti classification system and measurement of the angle of Böhler. With the addition of 3D-CT imaging, the interobserver reliability was fair for the Sanders', Zwipp and Essex-Lopresti classification systems. The intraobserver reliability was fair for measurement of the angle of Gissane and it was moderate for the Sanders', Zwipp and Essex-Lopresti classification systems and for the measurement of the angle of Böhler. The addition of three-dimensional CT imaging did not increase inter- and intraobserver reliability for the classification of calcaneal fractures. Authors commented they experienced no additional benefit from 3D-CT imaging for the assessment of calcaneal fractures.
J R Soc Interface. 2013 Dec
Tissue engineering and regenerative medicine (TERM) has caused a revolution in present and future trends of medicine and surgery. In different tissues, advanced TERM approaches bring new therapeutic possibilities in general population as well as in young patients and high-level athletes, improving restoration of biological functions and rehabilitation. The mainstream components required to obtain a functional regeneration of tissues may include biodegradable scaffolds, drugs or growth factors and different cell types (either autologous or heterologous) that can be cultured in bioreactor systems (in vitro) prior to implantation into the patient. Particularly in the ankle, which is subject to many different injuries (e.g. acute, chronic, traumatic and degenerative), there is still no definitive and feasible answer to 'conventional' methods. This review aims to provide current concepts of TERM applications to ankle injuries under preclinical and/or clinical research applied to skin, tendon, bone and cartilage problems. A particular attention has been given to biomaterial design and scaffold processing with potential use in osteochondral ankle lesions.
Br J Sports Med. 2013 Dec
OBJECTIVE: To assess and summarise the economic evidence regarding diagnostic tests, treatment and prevention for lateral ankle sprains.
METHODS: Potential studies were identified from electronic databases and trial registries and by scanning reference lists. Risk of bias and methodological quality were evaluated. Two independent reviewers screened, assessed studies and extracted data. Data were synthesised descriptively due to study heterogeneity.
RESULTS: A total of 230 records were identified; 10 studies were included. Five studies conducted a full economic evaluation and five studies involved cost analyses. Lack of blinding was the main risk of bias. The methodological quality of the full economic evaluations was fairly good. Valuation of costs, measurement of outcomes and sensitivity analysis were points for improvement. Single studies showed that the Ottawa ankle rules (OAR) was cost effective for diagnosing lateral ankle sprains in the emergency setting compared with existing hospital protocols; acute treatment with anti-inflammatory medication and the plaster cast for severe sprains appeared cost effective; and neuromuscular training was cost effective in preventing ankle re-injury.
CONCLUSIONS: Results of this current systematic review supplements the evidence provided by reviews of effectiveness. There is evidence to support the implementation of OAR in the emergency setting, the use of anti-inflammatory medication and the plaster cast in the acute phase, and the prescription of neuromuscular exercises to prevent re-injury. Although the evidence is limited due to the low number of studies, shortcomings in methodological quality and small sample sizes, the findings may be used to inform clinical practice and practice guidelines.
On December 13 2013, Arjan Bot obtained his PhD-degree at the University of Amsterdam under supervision of Professor C.N. van Dijk as promotor en Dr. D.C. Ring as his co-promotores.
This thesis studies the influence of psychological factors in illness behavior in different
hand and upper extremity conditions encountered in the practice of a hand surgeon. The
importance of the language used by the patient and the amount of shared decision making
in an orthopaedic practice is investigated. This thesis focuses also on questionnaires which
are administered to measure these psychological factors and to create and validate shorter
The overall aim is to raise awareness of 1) the importance of psychological factors as
part of illness behavior in both traumatic and nontraumatic conditions of the upper extremity;
2) the importance of informed shared decision making and increase the amount of informed
shared decision making in their practice; 3) word choice of the patients as an expression of
emotional distress; 4) which questionnaires to use and to interpret results based on the mode of
administration; 5) factors important in determining nonresponse to questionnaires or clinical
follow-up, and 6) psychology evaluation to achieve better care for the patients when patients
express psychological distress.
Eur J Pediatr. 2013 Dec
Incidence of calcaneal apophysitis in the general population
Calcaneal apophysitis, or Sever's disease, is a traction apophysitis. It is a frequent cause of heel pain in children. Knowledge about the exact incidence of calcaneal apophysitis in the general population, however, is lacking.
From 34 general practices, records of patients between 6 and 17 years old, visiting the general practitioner (GP), were analysed. Diagnoses of calcaneal apophysitis were counted using computerised registration networks of GPs in 2008, 2009 and 2010.
There were 16,383 SOAP files searched and a number of 61 children with calcaneal apophysitis were established over the years 2010, 2009 and 2008, showing an incidence of 3.7 in 1,000 registered patients.
This is the first report on incidence rates of calcaneal apophysitis in general practice. With an incidence of 3.7 in 1,000 registered patients, it is a common pathologic entity, which requires more research on pathophysiology and therapy. The actual incidence may even be higher due the strict inclusion criteria of this study
Bone Joint J. 2013 Dec
van Bergen CJ, van Eekeren IC, Reilingh ML, Sierevelt IN, van Dijk CN
We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.
On November 14 and 15 the 6th Congress of the Slovak Society of Arthroscopy and Sports Traumatology was held in Bratislava. At this congress prof. Niek van Dijk has been rewarded with an honorary membership of the Slovak Society of Arthroscopy and Sports Traumatology.
The 2-day congress was attended by over 300 participants. There were more than 50 lectures on arthroscopic and minimally invasive surgery on the ankle. Main lecturer was prof. Niek van Dijk.
Knee Surg Sports Traumatol Arthrosc. 2013 Sep 18
Reilingh ML, Kerkhoffs GM, Telkamp CJ, Struijs PA, van Dijk CN
Osteochondral talar defects are infrequent in children, and little is known about the treatment and clinical outcome of these defects. The purpose of this study was to evaluate the clinical and radiographic outcomes of conservative and primary surgically treated osteochondral talar defects in skeletally immature children.
Thirty-six (97 %) of 37 eligible patients with a symptomatic primary osteochondral talar defect were evaluated after a median follow-up of 4 years (range 1-12 years). Clinical assessment included the Berndt and Harty outcome question, Ogilvie-Harris score, Visual Analog Scale pain score (at rest, during walking and during running), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the SF-36. Weight-bearing radiographs were compared with preoperative radiographs with the use of an ankle osteoarthritis classification system.
Ninety-two per cent of the initially conservatively treated children [mean age 13 years (SD 2)] were eventually scheduled to undergo surgery. After fixation of the fragment, seven cases (78 %) reported a good Berndt and Harty outcome, and two cases (22 %) a fair outcome; the median AOFAS score was 95.0 (range 77-100). After debridement and bone marrow stimulation, 13 cases (62 %) reported a good Berndt and Harty outcome, three cases (14 %) a fair outcome, and five cases (24 %) a poor outcome; the median AOFAS score was 95.0 (range 45-100). No signs of degenerative changes were seen in both groups at follow-up.
Fixation and debridement and bone marrow stimulation of an osteochondral talar defect are both good surgical options after failed conservative treatment.
J Bone Joint Surg Am. 2013 Sep 4;95(17)
Lambers KT, van den Bekerom MP, Doornberg JN, Stufkens SA, van Dijk CN, Kloen P
There is sparse information in the literature on the outcome of Maisonneuve-type pronation-external rotation ankle fractures treated with syndesmotic screws. The primary aim of this study was to determine the long-term results of such treatment of these fractures as indicated by standardized patient-based and physician-based outcome measures. The secondary aim was to identify predictors of the outcome with use of bivariate and multivariate statistical analysis.
Fifty patients with pronation-external rotation (predominantly Maisonneuve) fractures were treated with open reduction and internal fixation of the syndesmosis utilizing only one or two screws. The results were evaluated at a mean of twenty-one years after the fracture utilizing three standardized outcomes instruments: (1) the Foot and Ankle Ability Measure (FAAM), (2) the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, and (3) the Center for Epidemiologic Studies-Depression (CES-D) Scale. Osteoarthritis was graded according to the van Dijk and revised Takakura radiographic scoring systems. Bivariate and multivariate analyses were performed to identify predictors of long-term outcome.
Forty-four (92%) of forty-eighty patients had good or excellent AOFAS scores, and forty-four (90%) of forty-nine had good or excellent FAAM scores. Arthrodesis for severe osteoarthritis was performed in two patients. Radiographic evidence of osteoarthritis was observed in twenty-four (49%) of forty-nine patients. Multivariate analysis identified pain as the most important independent predictor of long-term ankle function as indicated by the AOFAS and FAAM scores, explaining 91% and 53% of the variation in scores, respectively. Analysis of pain as the dependent variable in bivariate analyses revealed that depression, ankle range of motion, and a subsequent surgery were significantly correlated with higher pain scores. No firm conclusions could be drawn after multivariate analysis of predictors of pain.
Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. The most important predictor of long-term functional outcome was patient-reported pain rather than physician-reported function or posttraumatic osteoarthritis. There was no significant association between radiographic signs of posttraumatic osteoarthritis and perceived pain in the present series.
At the 16th ESSKA congress in Amsterdam, May 2014, the first ESSKA-AFAS production on the subject of talar osteochondral defects will be presented:
"Talar OCD: With special emphasis on Diagnosis, Planning and Rehabilitation"
The content of this book has been written by a team of experts in the field of foot and ankle surgery. Their review and opinions are based on the best currently available evidence. It is filled with the ins and outs of diagnosis, planning, treatment and rehabilitation of talar OCDs and will provide the reader with an up-to-date handbook in approaching a patient with a talar OCD.
Bone. 2011 Oct;49(4):762-8
Cox LG, Lagemaat MW, van Donkelaar CC, van Rietbergen B, Reilingh ML, Blankevoort L, van Dijk CN, Ito K
Pressurized fluid has been proposed to play an important role in subchondral bone cyst development. However, the exact mechanism remains speculative. We used an established computational mechanoregulated bone adaptation model to investigate two hypotheses: 1) pressurized fluid causes cyst growth through altered bone tissue loading conditions, 2) pressurized fluid causes cyst growth through osteocyte death. In a 2D finite element model of bone microarchitecture, a marrow cavity was filled with fluid to resemble a cyst. Subsequently, the fluid was pressurized, or osteocyte death was simulated, or both. Rather than increasing the load, which was the prevailing hypothesis, pressurized fluid decreased the load on the surrounding bone, thereby leading to net bone resorption and growth of the cavity. In this scenario an irregularly shaped cavity developed which became rounded and obtained a rim of sclerotic bone after removal of the pressurized fluid. This indicates that cyst development may occur in a step-wise manner. In the simulations of osteocyte death, cavity growth also occurred, and the cavity immediately obtained a rounded shape and a sclerotic rim. Combining both mechanisms increased the growth rate of the cavity. In conclusion, both stress-shielding by pressurized fluid, and osteocyte death may cause cyst growth. In vivo observations of pressurized cyst fluid, dead osteocytes, and different appearances of cysts similar to our simulation results support the idea that both mechanisms can simultaneously play a role in the development and growth of subchondral bone cysts.
Arthroscopy Techniques May 2013
Pietro Spennacchio, Pietro Randelli, Paolo Arrigoni, Niek van Dijk
Osteochondral defects (OCDs) of the talus are a common cause of residual pain after ankle injuries. When
conservative treatment fails, arthroscopic debridement combined with drilling/microfracturing of the lesion (bone marrow stimulation [BMS] procedures) has been shown to provide good to excellent outcomes. Not uncommonly, talar OCDs involve the borders of the talar dome. These uncontained lesions are sometimes difficult to visualize with the 30° arthroscope, with potential negative effect on the clinical outcome of an arthroscopic BMS procedure. The use of the 70° arthroscope has been described for a multitude of common knee, shoulder, elbow, and hip procedures. The purpose of this article is to show the usefulness of the 70° arthroscope in arthroscopic BMS procedures, pointing out which kinds of talar OCDs can benefit most from its use.
Osteoarthritis Cartilage. 2013 Jul 26
van Bergen CJ, Kerkhoffs GM, Ozdemir M, Korstjens CM, Everts V, van Ruijven LJ, van Dijk CN, Blankevoort L
OBJECTIVE: The purpose of this study was to evaluate the effectiveness of demineralized bone matrix (DBM) with and without platelet-rich plasma (PRP) in the treatment of osteochondral defects (OCDs) of the talus. We hypothesized that treatment with DBM would result in more bone formation than no treatment in control OCDs, and that PRP would further enhance the regenerative capacity of DBM.
METHOD: A standardized 6-mm OCD was created in each talus of 16 adult goats. According to a randomization scheme, one OCD of each goat was treated with allogeneic DBM hydrated with normal saline (n = 8) or hydrated with autologous PRP (n = 8). The contralateral OCD (n = 16) served as control. After 24 weeks, the animals were euthanized and the tali excised. Various outcome parameters were analyzed with use of macroscopic evaluation, micro-computed tomography, histology, histomorphometry, and fluorescence microscopy.
RESULTS: None of the analyses revealed statistically significant differences between the groups for any of the parameters analyzed in any volume of interest. For example, the mean bone volume fraction of the defect, as measured by micro-computed tomography, was 0.56 (95% confidence interval [CI], 0.44 - 0.68) for DBM hydrated with normal saline and 0.52 (95% CI, 0.40 - 0.65) for DBM hydrated with PRP, compared to 0.53 (95% CI, 0.45 - 0.61) and 0.54 (95% CI, 0.44 - 0.64) for the internal controls, respectively (p >0.05).
CONCLUSION: In contrast to our hypotheses, no beneficial treatment effect of DBM with or without PRP was found for OCDs of the caprine talus
Clin Orthop Relat Res. 2013 Jul 27
Kok AC, Tuijthof GJ, den Dunnen S, van Tiel J, Siebelt M, Everts V, van Dijk CN, Kerkhoffs GM
BACKGROUND: Débridement and bone marrow stimulation is an effective treatment option for patients with talar osteochondral defects. However, whether surgical factors affect the success of microfracture treatment of talar osteochondral defects is not well characterized.
QUESTIONS/PURPOSES: We hypothesized (1) holes that reach deeper into the bone marrow-filled trabecular bone allow for more hyaline-like repair; and (2) a larger number of holes with a smaller diameter result in more solid integration of the repair tissue, less need for new bone formation, and higher fill of the defect.
METHODS: Talar osteochondral defects that were 6 mm in diameter were drilled bilaterally in 16 goats (32 samples). In eight goats, one defect was treated by drilling six 0.45-mm diameter holes in the defect 2 mm deep; in the remaining eight goats, six 0.45-mm diameter holes were punctured to a depth of 4 mm. All contralateral defects were treated with three 1.1-mm diameter holes 3 mm deep, mimicking the clinical situation, as internal controls. After 24 weeks, histologic analyses were performed using Masson-Goldner/Safranin-O sections scored using a modified O'Driscoll histologic score (scale, 0-22) and analyzed for osteoid deposition. Before histology, repair tissue quality and defect fill were assessed by calculating the mean attenuation repair/healthy cartilage ratio on Equilibrium Partitioning of an Ionic Contrast agent (EPIC) micro-CT (μCT) scans. Differences were analyzed by paired comparison and Mann-Whitney U tests.
RESULTS: Significant differences were not present between the 2-mm and 4-mm deep hole groups for the median O'Driscoll score (p = 0.31) and the median of the μCT attenuation repair/healthy cartilage ratios (p = 0.61), nor between the 0.45-mm diameter and the 1.1-mm diameter holes in defect fill (p = 0.33), osteoid (p = 0.89), or structural integrity (p = 0.80).
CONCLUSIONS: The results indicate that the geometry of microfracture holes does not influence cartilage healing in the caprine talus.
CLINICAL RELEVANCE: Bone marrow stimulation technique does not appear to be improved by changing the depth or diameter of the holes.
Am J Sports Med. 2013 Jul 18
Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG
In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.
More information can be found on the website. Prof. Van Dijk will be master instructor of the "Advanced Ankle Arthroscopy" and will give a presentation "Osteochondral Defect Lesion of the Ankle".
The 13th Amsterdam Foot and Ankle Course is coming up soon. On the 13th and 14th of June, we will be happy to turn the Academic Medical Center Amsterdam into a course venue full of Cadaver Lab sessions, Lectures, Computer courses, Live surgery and much more. The faculty is ready and the preparations are in full swing. We are looking forward to have you on June 13 and 14, Amsterdam, the Netherlands.
Foot Ankle Clin. 2013 Jun
Kerkhoffs GM, Van Dijk CN
High-level athletes have significantly greater load and demand on their ankle joints than the average population. Therefore, treatment of acute lateral ankle ligament ruptures in the high-demanding athlete is a challenge. This article reviews the treatment of acute lateral ankle ruptures in athletes, with special emphasis on the role of surgical treatment.
J Foot Ankle Surg. 2013 May 7
Veltman ES, Doornberg JN, Stufkens SA, Luitse JS, van den Bekerom MPThe objective of the present study was to review the current data on the long-term outcomes of calcaneal fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2011 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of calcaneal fractures. Of 59 initially relevant studies, 25 met our inclusion criteria. A total of 1,730 fractures were identified in 1,557 patients. The mean sample size-weighted follow-up period was 4.6 years. The findings from the present review support current clinical practice that displaced calcaneal fractures are treated surgically from 1 level I evidence study, 1 level II, and multiple studies with less than level II evidence, with open reduction and internal fixation as the method of choice. If the fracture is less complex, percutaneous treatment can be a good alternative according to current level 3 and 4 retrospective data.
Foot Ankle Clin. 2013 Mar;18(1):35-47
McCollum GA, Calder JD, Longo UG, Loppini M, Romeo G, van Dijk CN, Maffulli N, Denaro V
Acute bone bruises of the talus after ankle injury need to be managed differently from osteochondral defects. Bone bruises have a benign course, but there may be persistent edema. A bone bruise should not delay rehabilitation unless symptoms persist or significant edema is close to the subchondral plate. Osteochondral defects have a less predictable prognosis, and rehabilitation should aim at promoting healing of the subchondral fracture. A period of nonweight bearing reduces the cyclical pressure load through the fissure and promotes healing. Surgery should be reserved for chronic symptomatic lesions or for those patients undergoing lateral ligament reconstruction.
J Foot Ankle Surg. 2013 Apr 27
van den Bekerom MP, Kloen P, Luitse JS, Raaymakers EL
The objective of the present study was to evaluate our complications of screw stabilization and to formulate recommendations for clinical practice. Using a prospectively collected fracture database, the data from 236 consecutive adult patients were analyzed who had undergone syndesmotic screw stabilization from January 1979 to December 2000 at our level I academic trauma center. We observed 16 complications in 15 patients. The average patient age was 37.5 years. Of the 15 patients, 1 had a Weber B fracture and 14 had a Weber C ankle fracture. These complications included tibiofibular synostosis in 11 patients, screw breakage in 4 patients, and late diastasis in 1 patient. All breakages occurred in Weber C fractures. In particular, the 3.5-mm screws, penetrating both tibial cortices, tended to break. Synostosis was observed in 3% of the Weber B fractures and 5% of the Weber C fractures. Weightbearing in a plaster cast during syndesmotic screw stabilization is a safe postoperative treatment. We suggest that the use of 3.5-mm screws and screws penetrating 2 tibial cortices have a greater risk of breakage. Because of the low complication rate and more difficult treatment of late syndesmotic diastasis, a syndesmotic screw should be placed when in doubt of the indication.
Knee Surg Sports Traumatol Arthrosc. 2013 Apr 26
Parlamas G, Hannon CP, Murawski CD, Smyth NA, Ma Y, Kerkhoffs GM, van Dijk CN, Karlsson J, Kennedy JG
The purpose of this study is to systematically review and meta-analyse the available literature on the treatment of chronic syndesmotic injuries of the ankle.
A systematic review of the PubMed/MEDLINE and EMBASE databases was conducted in August 2012 utilizing the keywords (treatment OR intervention) AND (injury OR sprain OR rupture) AND (syndesmosis OR syndesmotic OR "high ankle" OR "anterior inferior tibiofibular ligament" OR AITFL OR "posterior inferior tibiofibular ligament" OR PITFL OR tibiofibular diastasis). Studies that reported the outcomes of the surgical treatment of chronic syndesmotic injury were included in our review. Chronic was defined as symptoms longer than 6 months. Meta-analysis based on random-effects models was performed to pool the rates of success for different treatment methods.
The search yielded 416 publications from PubMed/MEDLINE and 473 publications from EMBASE. After abstract and full-text review, 15 articles were included in this review. Treatment methods were placed into three broad surgical treatment categories: screw fixation, arthrodesis and arthroscopic debridement. The most common treatment strategy employed was screw fixation. The pooled rates of success for screw fixation, arthrodesis and arthroscopic debridement were 87.9, 79.4 and 78.7 %, respectively.
The current evidence on the treatment of chronic syndesmosis injuries in the ankle is limited to prospective and retrospective case series. The pooled success rates for screw fixation, arthrodesis and arthroscopic debridement each exceeded 78 %. Future high-level studies are required to discern the most appropriate treatment strategy(ies) for chronic syndesmotic injuries of the ankle.
Zwiers R, Wiegerinck JI, Murawski CD, Smyth NA, Kennedy JG, van Dijk CN
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
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
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.
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.
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.
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.
Ekstrand J, van Dijk CN.
There is little information about Metatarsal Five (MT-5) fractures for specific sports.
To study the occurrence, the imaging characteristics, the lay-off times and healing problems of MT-5 fractures among male footballers.
Sixty-four European elite teams were monitored from 2001 to 2012. x-Rays were collected and classified by the Torg criteria.
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).
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
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.
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.
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
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!
The first combined meeting of APOSSM, the Indian Arthroscopy Association and Asia Arthroscopy Congress was held in Jaipur 8-11 November 2012. At the same venue on 9 november a leadership meeting between ESSKA and APOSSM (now APKASS) took place. ESSKA was represented by Lars Engebretsen and Niek van Dijk. Both organizations underlined the importance of a strong collaboration, sharing similar ideas and values. The APOSSM president prof Eiji Itoi explained APOSSM recently merged with Arthroscopy and Knee surgery into a new association APKASS with the aim to bring them closer to ESSKA and SLARD.
Niek van Dijk
ESSKA Past President
The first combined meeting of APOSSM, the Indian Arthroscopy Association and Asia Arthroscopy Congres was held in Jaipur 8-11 november 2012. ESSKA holds strong relations with APOSSM and was cordially invited to organise a symposium. ESSKA was represented by 2 past ESSKA Maharadjas Niek van Dijk and Lars Engebretsen sharing their thoughts on biomechnics of osteochondral defects and the London 2012 Olympics with an full main lecture hall.
In the audience were also present the 3 Esska traveling fellows together with their godfather Ferran Montserrat who ended their very succesful 3 week tour in Jaipur
Thanks to the enormous energy and drive of the 3 organisations under the inspiring leadership of congres presiden Joshi Anant and scientific Chair Dinshaw Persawala all 800 participants enjoyed a great conference with high scientific quality . 25 live surgeries, each day 6 ICL`s, 3 paralell sessions, a daily bulletin, a congres app, 3 cameras covering the lively discussions are just some of the highlights.
The social program included Eliphant polo (ESSKA team scoring 2 goals !) Bollywood dancing and Rajasthan specials.
Tissue Eng Part C Methods. 2012 Nov 9.
Osteochondral defects of the talus pose a difficult therapeutic challenge. An experimental animal model of the ankle joint is not available. The aim of this study was to test a newly developed animal model for osteochondral defects of the ankle in vivo. Osteochondral defects were created in the talus of goat hind legs using a posterolateral surgical approach. The defects were filled with either autologous cancellous bone or donor demineralized bone matrix, or left empty as control. After 12 weeks of healing, the specimens were analyzed with radiography, macroscopy, micro-computed tomography, histology, histomorphometry, and fluorescence microscopy. It was possible to create a standardized defect in each talus. The implanted material remained in place. The analyses showed that most bony tissue was generated in the defects filled with autologous bone and least in the control defects. Our findings show that a standard osteochondral defect can be created in the talus by a relatively simple procedure in a large animal that allows qualitative and quantitative evaluation. The model can be used in future experiments to investigate alternative treatment methods before they are introduced into clinical practice.
Real Madrid defender Marcelo recovering after being successfully operated for a fracture of the fifth metatarsal of his right foot by the ankle surgery specialist Prof. Niek van Dijk, of the Orthopaedic Surgery department of the Academic Medical Centre in Amsterdam.
Before the game against Zaragoza Saturday November 3, Real Madrid players were wearing a shirt with a message of support to their injured teammate Marcelo. 'Animo Marcelo' was printed on each shirt.
© Copyright Real Madrid Club de Fútbol
The 33rd SICOT & 17th PAOA Orthopadic World Conference will be held from 28 till 30 November 2012 in Dubai, United Arab Emirates.
The conference will cover the latest advances in orthopaedic and trauma care. About 2,500 abstracts from all over the globe were submitted to theconference, which shows the great interest of the entire orthopaedic surgeon community in this event. In this 3 full-day conference, there will be:
• 4 plenary lectures which will be given by Freddie Fu, Gamal Hosny, Chitranjan Ranawat, and C. Niek van Dijk;
• 11 instructional courses covering sports injuries, polytrauma, fractures, arthroscopies, failed back, paediatrics, joint replacements;
• 30 symposiums covering many aspects of orthopaedics and trauma;
• 700 free papers along with 700 e-poster presentations.
Click here for more information
The 7th International Congress of Chinese Orthopaedic Association (COA2012) will be held at the China Convention Center in Beijing, China from 15 till 18 November 2012. COA2012 in Beijing will promise to be the world's premier orthopaedic congress that brings education, research and technology under one roof. The scientific program will feature topics of the latest clinical experience and development discussions covering spine surgery, trauma joint surgery, arthroscopy, sports medicine, bone tumors, osteoporosis, foot and ankle surgery, minimally invasive surgery, microsurgery, pediatric orthopaedics, nursing and rehabilitation.
Click here for more information about the congress.
The Indian Arthroscopy Society (IAS), takes great pleasure and pride in hosting the Congress of Arthroscopy and Sports Medicine 2012 (CASM 2012), to be held in Jaipur, India from November 8th to 11th. CASM 2012 is a combined meeting of 3 sister fraternities - IAS, Asia Arthroscopy Congress (AAC) and Asia Pacific Orthopedic & Sports Medicine (APOSSM). CASM 2012 has a theme of its own - Surgery, Simplified. Lectures, discussions and debates will centre around the idea of simplifying surgical techniques to standardize and better surgical outcomes. CASM 2012 will also focus on sports medicine topics like tendinopathies, musculoskeletal imaging, pre-hab and re-hab. Specialists will share their experience and provide insights into newer developments in this specialty.
Click here for more information about the congress:
Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN
Knee Surg Sports Traumatol Arthrosc. 2012 Oct 6
Systematically search and analyse the results of surgical and non-surgical treatments for insertional Achilles tendinopathy.
A structured systematic review of the literature was performed to identify surgical and non-surgical therapeutic studies reporting on ten or more adults with insertional Achilles tendinopathy. MEDLINE, CINAHL, EMBASE (Classic) and the Cochrane database of controlled trials (1945-March 2011) were searched. The Coleman methodology score was used to assess the quality of included articles, and these were analysed with an emphasis on change in pain score, patient satisfaction and complication rate.
Of 451 reviewed abstracts, 14 trials met our inclusion criteria evaluating 452 procedures in 433 patients. Five surgical techniques were evaluated; all had a good patient satisfaction (avg. 89 %). The complication ratio differed substantially between techniques. Two studies analysed injections showing significant decrease in visual analogue scale (VAS). Eccentric exercises showed a significant decrease in VAS, but a large group of patients was unsatisfied. Extracorporeal shockwave therapy (ESWT) was superior to both wait-and-see and an eccentric training regime. One study evaluated laser CO(2), TECAR and cryoultrasound, all with significant decrease in VAS.
Despite differences in outcome and complication ratio, the patient satisfaction is high in all surgical studies. It is not possible to draw conclusions regarding the best surgical treatment for insertional Achilles tendinopathy. ESWT seems effective in patients with non-calcified insertional Achilles tendinopathy. Although both eccentric exercises resulted in a decrease in VAS score, full range of motion eccentric exercises shows a low patient satisfaction compared to floor level exercises and other conservative treatment modalities.
McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN
Knee Surg Sports Traumatol Arthrosc. 2012 Oct
Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete.
A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed.
The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete.
Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.
The 6th WSTC and the 7th EFOST Congress will take place from 17 till 20 October 2012 in London. With a comprehensive programme of parallel sessions and interactive discussions covering all aspects of sports trauma, the congress will be a platform for experts of sports traumatology to discuss, debate and inform. The congress is unique in orthopaedic sports meetings by its proud connection to the Summer Olympics Games. This Congress takes place only every 4 years, in short, an opportunity not to be missed!
The Scientific Programme Committee have strived to provide a meeting covering the latest innovative techniques, detailed exploration of topical issues and the top-ranked speaker names in orthopaedics and sports medicine. The World Sports Trauma Congress has attracted participation from leading hospitals and institutions globally to mutually contribute to a highly successful scientific meeting, offering a perfect learning environment and a platform to share experiences, latest trends in our field and the chance to meet friends and colleagues from around the world.
More information about the program
The 4th National Congress will take place from October 10th trough October 12th, 2012. To stimulate the participation of national and other national Orthopaedic Surgeons, Sports Scientists and Physicians, the scientific programme will offer not only Instructional Courses, Invited lectures and Combined meetings but also Quick Question Lectures, Mini-battles and an important free paper and poster sessions. The Symposia of our Committees will propose you the best of science in their field and focus on the state of the art, trying to give guidelines and recommendations. Workshops will inform on the latest techniques in Arthroscopy and Orthopaedic surgery. During the Congress there will be a One day Physiotherapist course.
Click here for more information
Kok AC, Dunnen SD, Tuijthof GJ, van Dijk CN, Kerkhoffs GM
J Foot Ankle Surg. 2012 Sep
Although results of bone marrow stimulation in osteochondral defects of the talus (OCLT) have been satisfactory, the technique performance has not yet been subjected to review as a prognostic factor. The aim of this systematic review is to determine whether variation within technique influences outcome of bone marrow stimulation for OCLT. Electronic databases were searched for articles on OCLT treated with bone marrow stimulation techniques, providing a technique description. Six articles on microfracture were included (198 patients). Lesion size averaged 0.9 cm(2) to 4.5 cm(2), and follow-up varied from 2 to 6 years. Key elements were removal of unstable cartilage, hole depth variation between 2 and 4 mm until bleeding or fat droplets occurred, and a distance between the created holes of 3 to 4 mm. The success rate (excellent/good results by any clinical outcome score) was 81%. There is a vast similarity in the technique with similar outcomes as in previous general reviews; therefore variation in technique as currently described in the literature does not seem to influence the outcome of bone marrow stimulation for OCLT. Whether the instruments used or the hole depth and geometry influence clinical outcome remains to be determined. Microfracture is safe and effective for OCLTs smaller than 15 mm. However, in this review, only 81% of patients obtained satisfactory results. Larger clinical trials are needed with clearly defined patient groups, technique descriptions, and reproducible outcome measures to provide insight in the specific indications and the preferred technique of bone marrow stimulation
Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
JBR–BTR, 2012, 95: 172-173
A 48-year-old woman was referred to our hospital for valuation of a soft tissue mass at her right ankle. At initial presentation, 5 years earlier, her general practitioner thought of a benign lesion and suggested to remove the mass. At the time, no additional imaging was requested. Over the years, the swelling was slowly growing but remained painless. Now, on clinical examination, a mass lesion was seen, located posterior of the lateral malleolus, consisting of a firm mass fixed to the surface underneath. The estimated size of the tumor was 2 x 6 cm,which gave rise to suspicion of a malignancy.
van Eekeren IC, Reilingh ML, van Dijk CN
Sports Med. 2012 Oct 1;42(10):857-70
An osteochondral defect (OD) is a lesion involving the articular cartilage and the underlying subchondral bone. ODs of the talus can severely impact on the quality of life of patients, who are usually young and athletic. The primary treatment for ODs that are too small for fixation, consists of arthroscopic debridement and bone marrow stimulation. This article delineates levels of activity, determines times for return to activity and reviews the factors that affect rehabilitation after arthroscopic debridement and bone marrow stimulation of a talar OD. Articles for review were obtained from a search of the MEDLINE database up to January 2012 using the search headings 'osteochondral defects', 'bone marrow stimulation', 'sports/activity', 'rehabilitation', various other related factors and 'talus'. English-, Dutch- and German-language studies were evaluated.The review revealed that there is no consensus in the existing literature about rehabilitation times or return-to-sports activity times, after treatment with bone marrow stimulation of ODs in the talus. Furthermore, scant research has been conducted on these issues. The literature also showed that potential factors that aid rehabilitation could include youth, lower body mass index, smaller OD size, mobilization and treatment with growth factors, platelet-rich plasma, biphosphonates, hyaluronic acid and pulse electromagnetic fields. However, most studies have been conducted in vitro or on animals. We propose a scheme, whereby return-to-sports activity is divided into four phases of increasing intensity: walking, jogging, return to non-contact sports (running without swerving) and return to contact sports (running with swerving and collision). We also recommend that research, conducted on actual sportsmen, of recovery times after treatment of talar ODs is warranted.
Gino MMJ Kerkhoffs, Johannes L Tol
Ankle injuries are prolific but not benign. Kerkhoffs et al1 present a consensus statement on the diagnosis and treatment of acute lateral ligament ruptures that will help us to treat the majority of our athletes in an evidence-based way. However, is it reasonable to assume that all these injuries and athletes are equal? Should we necessarily treat high-level athletes in a different way than recreational athletes or is the proposed simple functional treatment sufficient for all?
Complete cast immobilisation was the treatment of choice until the sixties, when Freeman introduced the concept of using coordination exercises to reduce the proprioceptive deficit and symptoms of the ankle ‘giving way'.2 Primary surgical repair became treatment of choice from 1966, after the PhD research of Broström.3 While Broström reported lower rates of long-term complaints after surgical intervention, he still recommended functional treatment initially due to the quicker return to work and sports.
Quick wins or long-term success
In high-level athletes, goals are often set in the short term and only the upcoming game really counts. From daily clinical practice we know that it ...
Helmerhorst GT, Lindenhovius AL, Vrahas M, Ring D, Kloen P.
Injury. 2012 Aug 16
Background: American patients are prescribed more opioid pain medication than Dutch patients after operative treatment of an ankle fracture, but it is possible that pain is undertreated in Dutch patients. This study tests if there is a difference in pain and satisfaction with pain relief between Dutch and American patients after operative treatment of ankle fractures.
Methods: Thirty American and 30 Dutch patients were enrolled in a prospective comparative study prior to operative treatment of ankle fractures. Patients rated pain and satisfaction with pain relief on postoperative day 1 (POD1) and at time of suture removal (SR). Pain and satisfaction scores were compared and multivariable analysis identified their predictors.
Results: At POD1, a third of Dutch patients used no opioids and a sixth took strong opioids. At SR, only 4 of 30 (13%) were taking tramadol and half were taking no medication. All of the American patients used strong opioid pain medication on POD1 and 19 of 30 (63%) were still taking strong opioids at SR. Patients that did not use opioids and Dutch patients had less pain and equivalent satisfaction with pain relief compared to patients that used opioids and American patients respectively. Nationality was the best predictor of pain intensity at POD1. Opioid medication was the best predictor of pain at SR and decreased satisfaction with pain management.
Conclusions: Pain and satisfaction with pain relief are culturally mediated. Patients that use non-opioid pain medication report less pain and greater satisfaction with pain relief than patients managed with opioid pain medication.
Copyright © 2012 Elsevier Ltd. All rights reserved.
On September 20 and 21, the 4th Foot and Ankle Symposium "Managing complications in Foot and Ankle Surgery" will be organized at the Balgrist University Hospital in Switzerland. Host is Norman Espinosa of the Department of Foot and Ankle Surgery and there will be an International faculty. Click here for the final program.
van Bergen CJ, Tuijthof GJ, Maas M, Sierevelt IN, van Dijk CN
Am J Sports Med. 2012 Aug 8
BACKGROUND: Anterior ankle arthroscopy is the preferred surgical approach for the treatment of osteochondral defects of the talus (OCDs). However, the ankle is a congruent joint with limited surgical access.
PURPOSE: The dual purpose of this study was (1) to quantify the anterior arthroscopic reach (defined as the proportion of the talar dome articular surface located anterior to the anterior distal tibial rim) with the ankle in full plantar flexion and (2) to identify predictive factors of the arthroscopic reach.
STUDY DESIGN: Descriptive laboratory study.
METHODS: Computed tomography scans were obtained of 59 ankles (57 patients aged 33 ± 11 years) in full plantar flexion in a nonmetallic 3-dimensional footplate. The arthroscopic reach of both the medial and lateral talar domes was assessed on sagittal reconstructions using a custom-made software routine. Intraobserver and interobserver reliability were calculated by intraclass correlation coefficients (ICCs). Various predictive factors of the arthroscopic reach were analyzed by multivariate linear regression analysis.
RESULTS: The arthroscopic reach was 48.2% ± 6.7% (range, 26.7%-60.7%) of the medial talar dome and 47.8% ± 6.5% (range, 31.2%-65.1%) of the lateral talar dome (P = .62). The intraobserver and interobserver reliability of both measurements were excellent (ICC, .99). The clinical plantarflexion angle was a statistically significant predictive factor of both the medial and lateral arthroscopic reaches (ie, increased plantar flexion corresponded to increased area of access), while joint laxity, gender, and age were not predictive.
CONCLUSION: Almost half of the talar dome is accessible anterior to the anterior distal tibial rim. The plantarflexion angle is an independent predictive factor of the arthroscopic reach both medially and laterally.
CLINICAL RELEVANCE: These results may facilitate preoperative planning of the surgical approach for OCDs.
- PMID: 22875792 [PubMed - as supplied by publisher]
van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, Kerkhoffs GM.
J Athl Train. August 2012
Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem.
OBJECTIVE: To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain.
STUDY SELECTION: Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults. Data Sources: MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually.
DATA EXTRACTION: We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models.
DATA SYNTHESIS: After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest.
CONCLUSIONS: Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.
Struijs PA, Kerkhoffs GM, Besselaar PP.
J Foot Ankle Surg. 2012 Jul 20
Dysplasia epiphysealis hemimelica is a rare entity. It is characterized by cartilage overgrowth in the epiphyses and is considered to be an epiphyseal osteochondroma. It usually presents during childhood and can cause pain and functional limitations. The aim of the present study was to describe the entity through our cases and published data and to present the results of our suggested treatment. A systematic search was performed to retrieve and describe all studies on dysplasia epiphysealis hemimelica. Studies were included if sufficient information on the patient characteristics, lesion location, treatment, and outcomes were described. In addition, we report on 7 of our patients. In our review, 48 studies were found, of which 42 could be included. Owing to the large heterogeneity in the studies, no pooling of data was performed. The studies included 138 patients with 255 lesions. Approximately 27% were female patients. The age at presentation ranged from 3 months to 66 years; however, in most, the entity was discovered before 8 years of age. No apparent guidelines were presented concerning the treatment strategy; however, most investigators performed resection because of pain or limitations in the range of motion. Most lesions were located in the ankle or foot (139 of 255). In our own cases, 5 of 7 patients experienced pain, limited range of motion, or activity restriction. The mean follow-up period was 4 years. Dysplasia epiphysealis hemimelica is a rare entity, occurring predominantly in the lower extremity of in young male patients. Its aggressive growth warrants aggressive treatment in the case of pain or functional or range of motion limitations.
van Bergen CJ, Tuijthof GJ, Blankevoort L, Maas M, Kerkhoffs GM, van Dijk CN.
Arthroscopy. 2012 Jul;28(7):985-92. Epub 2012 Feb 17.
The purpose of this study was to determine whether preoperative computed tomography (CT) of the ankle joint in full plantar flexion is a reliable and accurate tool to determine the anterior arthroscopic accessibility of talar osteochondral defects (OCDs).
Twenty consecutive patients were prospectively studied. All patients had an OCD of the talar dome and had a preoperative CT scan of the affected ankle in maximum plantar flexion. Accessibility of the OCD was defined by the distance between the anterior border of the OCD and the anterior distal tibial rim. This distance was measured on sagittal CT reconstructions by 2 investigators. The reference standard was the distance between the same landmarks measured during anterior ankle arthroscopy by an orthopaedic surgeon blinded to the CT scans. Intraobserver and interobserver reliability of CT, as well as the correlation and agreement between CT and arthroscopy, were calculated.
The measured distance between the anterior border of the OCD and the anterior distal tibial rim ranged from -3.1 to 9.1 mm on CT and from -3.0 to 8.5 mm on arthroscopy. The intraobserver and interobserver reliability of the measurements made on CT scans (intraclass correlation coefficients >0.99, P < .001), as well as the correlation between CT and arthroscopy, were excellent (r = 0.98, P < .001).
Measurements on CT scans of the ankle in full plantar flexion are a reliable and accurate preoperative method to determine the in situ arthroscopic location of talar OCDs.
Scholten PE, Breugem SJ, van Dijk CN
PURPOSE:To study the possibility of tendoscopic treatment of recurrent peroneal tendon dislocation.METHODS:The case of one patient is described including the tendoscopic technique to deepen the fibular groove. RESULTS: In this single case, there were no complications, recovery time was short, and there was no recurrence of peroneal tendon dislocation. CONCLUSION:Though it seems possible to deepen the fibular groove tendoscopically, further studies are necessary to determine the role of tendoscopy in recurrent peroneal tendon dislocation.
Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN
Strategies Trauma Limb Reconstr. 2012 Jul 6
The supination-external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.
From 6th till 8th September, EFAS (European Foot and Ankle Society) organizes the 9th EFAS International Congress in Noordwijk aan Zee. President: Jan-Willem Louwerens. International faculty. Symposia about basic science; forefoot; total ankle replacement; osteoporosis and diabetes in management of the elderly foot and ankle, sports, research, hindfoot trauma.
From 29th June till 3rd July GRECMIP organizes the 4th International Foot and Ankle Mini-Invasive Surgery Course in Barcelona. The course consists of a theorical and a practical part with a cadaver lab.
Course directors: P. Golanó and O. Laffenêtre.
For detailled information about the programme click here.
Geert Buijze, “Scaphoid Fractures; Anatomy, Diagnosis and Treatment"
June 29th 2012, 2.00 p.m., Agnietenkapel, Oudezijds Voorburgwal 231, 1012 EZ Amsterdam.
The aims of this thesis:
- to improve our understanding of the anatomy of the scaphoid bone and ligaments.
- to improve the current knowledge on diagnosing true scaphoid fractures among suspected scaphoid fractures, as well as reliably diagnosing displacement and union.
- to improve treatment of acute scaphoid fractures.
This May the 15th ESSKA Congress was held in Geneva Switserland. Professor van Dijk was the President of the ESSKA over the last two years.
As previous ESSKA congresses the 15th was another huge success and illustrated by the expansion of ESSKA-members.
A large group of the Amsterdam staff, residents and PhD fellows visited the congress. Numerous studies on Achilles PRP, ligament injury and impingement were presented.
Kars P. Valkering, Pau Golanó, C. Niek van Dijk, Gino M. M. J. Kerkhoffs
This case report presents two patients with
persisting anterior ankle impingement pain after an ankle
distortion. A web-like intra-articular fibrous band was
discovered and resected. The patients presented were, after
a 1-year follow-up, pain free.
Knee Surg Sports Traumatol Arthrosc 2012 Jun 5
Zengerink M, van Dijk CN.
To determine the complication rate for ankle arthroscopy.
A review of a consecutive series of patients undergoing ankle arthroscopy in our hospital between 1987 and 2006 was undertaken. Anterior ankle arthroscopy was performed by means of a 2-portal dorsiflexion method with intermittent soft tissue distraction. Posterior ankle arthroscopy was performed by means of a two-portal hindfoot approach. Complications were registered in a prospective national registration system. Apart from this complication registry, patient records, outpatient charts and operative reports were reviewed. Patients with a complication were asked to visit our hospital for clinical examination and assessment of permanent damage and persisting complaints.
An overall complication rate of 3.5 % in 1,305 procedures was found. Neurological complications (1.9 %) were related to portal placement. Age was a significant risk factor for the occurrence of complications. Most complications were transient and resolved within 6 months. Complications did not lead to functional limitations. Residual complaints did not influence daily activities.
Our complication rate is less than half of what has been reported in literature (3.5 vs 10.3 %). The use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications. Posterior ankle arthroscopy by means of a two-portal hindfoot approach is a safe procedure with a complication rate that compares favourably to that of anterior ankle arthroscopy.
CT Measurement of Range of Motion of Ankle and Subtalar Joints Following Two Lateral Column Lengthening Procedures
Beimers, L; Louwerens, JWK; Tuijthof, GJM Jonges, R; van Dijk, CN; Blankevoort, L
Foot & Ankle International, May 2012 (Vol.33 #5)
Lateral column lengthening (LCL) has become an accepted procedure for the operative treatment of the flexible flatfoot deformity. Hindfoot arthrodesis via a calcaneocuboid distraction arthrodesis (CCDA) has been considered a less favourable surgical option than the anterior open wedge calcaneal distraction osteotomy (ACDO), as CCDA has been associated with reduced hindfoot joint motion postoperatively. The ankle and subtalar joint ranges of motion were measured in patients who underwent an ACDO or CCDA procedure for flatfoot deformity.
CT scanning was performed with the foot in extreme positions in five ACDO and five CCDA patients. A bone segmentation and registration technique for the tibia, talus and calcaneus was applied to the CT images. Finite helical axis (FHA) rotations representing the range of motion of the joints were calculated for the motion between opposite extreme foot positions of the tibia and the calcaneus relative to the talus.
The maximum mean FHA rotation of the ankle joint (for extreme dorsiflexion to extreme plantarflexion) after ACDO was 52.2 degrees +/- 12.4 degrees and after CCDA 49.0 degrees +/- 12.0 degrees. Subtalar joint maximum mean FHA rotation (for extreme eversion to extreme inversion) following ACDO was 22.8 degrees +/- 8.6 degrees, and following CCDA 24.4 degrees +/- 7.6 degrees.
An accurate CT-based technique was used to assess the range of motion of the ankle and subtalar joints following two lateral column lengthening procedures for flatfoot deformity. Comparable results with a considerable amount of variance were found for the range of motion following the ACDO and CCDA procedures.
From August 30 till September 1, The International Cartilage Repair Society organizes in collaboration with the ESSKA and the FIFA the ICRS Focus Meeting Foot and Ankle in Zürich, Switzerland. Course directors are: Christoph Erggelet, Daniël Saris and Niek van Dijk. There will be an international faculty.
- Pain and loss of function of foot and ankle due to injury and overuse
- Osteochondritis dissecans of the talus
- Cartilage lesions due to instability
- Osteoarthritis of the first MTP joint
- Achilles tendon rupture/tendinosis
- The value of prevention programs
For more information: www.cartilage.org
Lijkele Beimers: “Subtalar joint kinematics and arthroscopy. Insight in the subtalar joint range of motion and aspects of subtalar joint arthroscopy”
On May 30 2012, Lijkele Beimers obtained his PhD-degree at the University of Amsterdam under supervision of Professor C.N. van Dijk as promotor en Dr. ir. L. Blankevoort and Dr. ir. G.J.M. Tuijthof as his co-promotores.
The aim of his thesis was firstly to obtain insight in the normal subtalar joint range of motion. Secondly, to provide knowledge of the subtalar joint range of motion following two different surgical procedures for flexible adult acquired flatfoot deformity. And finally, to enhance endoscopic treatment options for subtalar joint pathology.
Click here to read the preliminary programm
Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek PA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, Rosenbrand KC, Kuipers T, Hoogstraten JW, Dekker R, Ten Duis HJ, van Dijk CN, van Tulder MW, van der Wees PJ, de Bie RA.
Source Gino MMJ Kerkhoffs, Dutch Orthopaedic Society, Academic Medical Center, Amsterdam, the Netherlands.
Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.
PMID: 22522586 [PubMed - as supplied by publisher]
The ANKLE TRIAL (ANKLE treatment after injuries of the ankle ligaments): what is the benefit of external support devices in the functional treatment of acute ankle sprain? : a randomised controlled trial.
Witjes S, Gresnigt F, van den Bekerom MP, Olsman JG, van Dijk NC.
Department of surgery, Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch, The Netherlands. firstname.lastname@example.org.
Acute lateral ankle ligament injuries are very common problems in present health care. Still there is no hard evidence about which treatment strategy is superior. Current evidence supports the view that a functional treatment strategy is preferable, but insufficient data are present to prove the benefit of external support devices in these types of treatment. The hypothesis of our study is that external ankle support devices will not result in better outcome in the treatment of acute ankle sprains, compared to a purely functional treatment strategy. Overall objective is to compare the results of three different strategies of functional treatment for acute ankle sprain, especially to determine the advantages of external support devices in addition to functional treatment strategy, based on balance and coordination exercises.
This study is designed as a randomised controlled multi-centre trial with one-year follow-up. Adult and healthy patients (N = 180) with acute, single sided and first inversion trauma of the lateral ankle ligaments will be included. They will all follow the same schedule of balancing exercises and will be divided into 3 treatment groups, 1. pressure bandage and tape, 2. pressure bandage and brace and 3. no external support. Primary outcome measure is the Karlsson scoring scale; secondary outcomes are FAOS (subscales), number of recurrent ankle injuries, Visual Analogue Scales of pain and satisfaction and adverse events. They will be measured after one week, 6 weeks, 6 months and 1 year.
The ANKLE TRIAL is a randomized controlled trial in which a purely functional treated control group, without any external support is investigated. Results of this study could lead to other opinions about usefulness of external support devices in the treatment of acute ankle sprain.
Netherlands Trial Register (NTR): NTR2151.
The congress was a huge success, with many attendees from all over the world. Over 150 attendees were present to discuss the current state of cartilage repair of the ankle. State of the art lectures were held by the world wide leaders in the field. A "young gun" session was held in which the future leaders would address their view on ankle cartilage repair.
The organization will set-up future biannual congresses to ensure an up to date consensus on cartilage repair of the ankle and support future research in this field
More information can be found on here .
Arthroscopy. 2012 Feb 16. [Epub ahead of print]
van Bergen CJ, Tuijthof GJ, Blankevoort L, Maas M, Kerkhoffs GM, van Dijk CN.
Source Orthopedic Research Center Amsterdam, Department of Orthopedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
The purpose of this
study was to determine whether preoperative computed tomography (CT) of
the ankle joint in full plantar flexion is a reliable and accurate tool
to determine the anterior arthroscopic accessibility of talar
osteochondral defects (OCDs).
consecutive patients were prospectively studied. All patients had an OCD
of the talar dome and had a preoperative CT scan of the affected ankle
in maximum plantar flexion. Accessibility of the OCD was defined by the
distance between the anterior border of the OCD and the anterior distal
tibial rim. This distance was measured on sagittal CT reconstructions by
2 investigators. The reference standard was the distance between the
same landmarks measured during anterior ankle arthroscopy by an
orthopaedic surgeon blinded to the CT scans. Intraobserver and
interobserver reliability of CT, as well as the correlation and
agreement between CT and arthroscopy, were calculated.
measured distance between the anterior border of the OCD and the
anterior distal tibial rim ranged from -3.1 to 9.1 mm on CT and from
-3.0 to 8.5 mm on arthroscopy. The intraobserver and interobserver
reliability of the measurements made on CT scans (intraclass correlation
coefficients >0.99, P < .001), as well as the correlation between
CT and arthroscopy, were excellent (r = 0.98, P < .001).
on CT scans of the ankle in full plantar flexion are a reliable and
accurate preoperative method to determine the in situ arthroscopic
location of talar OCDs.
LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients.
Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
PMID: 22342200 [PubMed - as supplied by publisher]
Laurens Kaas, “Radial head fracture: a potentially complex injury"
10 April 2012, 2.00 p.m., Agnietenkapel, Oudezijds Voorburgwal 231, 1012 EZ Amsterdam.
Although knowledge of radial head fractures has increased over the past few decades, many aspects of this common fracture are still not clear. This thesis contains four parts, in each of which an issue relating to radial head fractures was discussed. In part I elbow anatomy, etiology, diagnosis and treatment of radial head fractures were addressed. The epidemiology of radial head fractures and their associated osseous injuries, as well as the relationship between radial head fractures and osteoporosis, were discussed in part II. Part III focused on the incidence and clinical relevance of osseous, cartigilanous, and ligamentous associated injuries in elbows with a radial head fracture. In part IV a systematic review was performed on the treatment of stable Mason type II fractures without associated fractures or elbow dislocation.
Download this thesis: www.e-pubs.nl/?epub=laurenskaas
Maayke Nadine van Sterkenburg, "Achilles tendinopathy. New insights in cause of pain, diagnosis and management"
4 April 2012 11.00 a.m., Lutherse Kerk, Singel 411, 1012 WN Amsterdam.
Chronic Achilles tendon pathology is one of the biggest problems in sports involving running and jumping. However, is is not always related to excessive physical activity. Thirty percent of patients have a sedentary lifestyle. Recalcitrant Achilles tendons may cause pain for years and often resistant to any form of treatment. The cause of pain has not yet been clarified, and therefore its treatment is challenging and often unsatisfactory. The aim of this thesis was to elucidate the cause of pain, to develop appropriate assessment tools, to invent minimally invasive treatment methods, and to optimize diagnostic and endoscopic methods for chronic Achilles tendon problems.
For more information please go to the ESSKA-AFAS website
Dr. Kim Brouwer successfully defended here PhD thesis on "Complex distal humerus trauma"
The distal humerus has an intricate osseous anatomy which makes treatment of distal humerus challenging. The quality of elbow function after fracture of the distal humerus is related to the degree to which normal anatomic relationships are restored. The general aim of this thesis is to investigate various aspects of complex distal humerus fractures.
Kim Martien Brouwer, "Complex distal humerus trauma",
14 March 2012 10.00 a.m., Agnietenkapel, Oudezijds Voorburgwal 231, 1012 EZ Amsterdam.
The distal humerus has an intricate osseous anatomy which makes treatment of distal humerus challenging. The quality of elbow function after fracture of the distal humerus is related to the degree to which normal anatomic relationships are restored. The general aim of this thesis is to investigate various aspects of complex distal humerus fractures.
ESSKA-AFAS will organize a Foot and Ankle Arthroscopy Course in September 2012. The two day course will focus on Arthroscopic Surgery of the Hindfoot & Ankle, featuring Cadaver Lab Sessions, Lectures and interactive case discussions. The Hands-on Sessions in the Cadaver Lab present the latest techniques in arthroscopic Foot and Ankle Surgery. There is a national and international faculty who will give the lectures and advice you during the Cadaver Lab Sessions. The course has a limited number of participants, allowing each participant ample opportunity to practice during the Cadaver Lab sessions and to interact with the faculty. More information can be found here.
Arthroscopy. 2012 Feb;28(2):283-93.
Surgical treatment of chronic retrocalcaneal bursitis.
Wiegerinck JI, Kok AC, van Dijk CN.
Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. email@example.com
The purpose of this systematic review was to analyze the results of surgical treatments for chronic retrocalcaneal bursitis (RB).
Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Library (1945 to December 2010) were systematically searched for the following terms: calcaneal AND (prominence OR exostosis) OR ((retrocalcaneal OR calcan(*)) AND (burs(*) OR exosto(*) OR prominence)) OR Haglund[tw] OR Haglund's[tw] OR ((retrocalcaneal OR calcan(*)) AND (ostectom(*) OR osteotom(*) OR resect(*))). Therapeutic studies on 10 or more subjects with RB were eligible. Quality was assessed by use of the GRADE scale and Downs and Black scale.
Of 876 reviewed abstracts, 15 trials met our inclusion criteria evaluating 547 procedures in 461 patients. Twelve trials reported an open surgical technique; three studies evaluated endoscopic techniques. Differences in patient satisfaction favored the endoscopic technique. The complication rate differed substantially, favoring endoscopic surgery over open surgery.
There are many different surgical techniques to treat RB. Regardless of technique, resecting sufficient bone is essential for a good outcome. Even though the level of evidence of included studies is relatively low, it can be concluded that endoscopic surgery is superior to open intervention for RB. More evidence is a necessity to be more conclusive regarding the best surgical treatment.
LEVEL OF EVIDENCE:
Level IV, systematic review of Level III and IV studies.
In collaboration with world leaders in this field, The Achilles Tendon Study Group (ATSG) has reviewed the available literature to provide a balanced consensus on the scope of insertional Achilles tendon problems. At the 2012 AAOS congress a meeting was held to discuss the finalization of the 3rd ATSG-DJO collaboration current concept works. This edition is on the disorders of the Achilles tendon insertion. The book will be presented at the upcoming ESSKA congress in Geneva. Previous publication on Achilles Tendon Rupture and Midportion Achilles Tendinopathy are still available through DJO Publication . The ATSG consensus line will be continued with a 4th publication at the ESSKA in 2014.
"International Congress on Cartilage Repair of the Ankle" which will be held in Dublin, Ireland on March 9-10, 2012.
Organized by the AFAS (Ankle & Foot ASsociation) section of ESSKA in collaboration with the Hospital for Special Surgery, this meeting has been established on the basis of requests from leaders in the field to consolidate and share information, which can collectively serve as a basis for international collaboration and innovation.
More information can be found on here.
On 23 and 24 February 2012, Smith & Nephew organizes the Global Master's Foot and Ankle Course in York, UK. Course director: Professor Dr. C. Niek van Dijk. Faculty members: James Calder, Pieter d'Hooghe, Daniël Haverkamp, Umile Giuseppe Longo, Helder Pereira. The course includes hands-on arthroscopy, anterior ankle arthroscopy, hindfoot endoscopy, ankle arthrodesis and subtalar arthrodesis, tendoscopy. Read here the detailed programme.
The biannual ESSKA meeting attracts the very best orthopaedic sports physicians in Europe and worldwide. In 2012, the ESSKA Congress will be in GENEVA/SWITZERLAND. In addition to European ESSKA members, some of the best surgeons and sports scientists from all around the world have been invited. Congress president: Daniël Fritschy, ESSKA president: C. Niek van Dijk.
The comprehensive scientific programme during the ESSKA Congress will include:
• Invited lectures by Freddie Fu (USA), Tim Hewett (USA), Pierre Chambat (France), John Feagin (USA), Jean-Noël Argenson (France) and Johnny Huard (USA)
• Free paper sessions and large poster exhibition
• 18 Instructional course lectures
• 35 symposia and 20 key note lectures
The online registration for this congress is already open. Early booking deadline: February 10, 2012. More information can be found http://www.esska-congress.org/esska2012