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

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.

LEVEL OF EVIDENCE

Level III, comparative study.

Peroneal tendons well vascularized: results from a cadaveric study

PURPOSE

Peroneal tendon tears are relatively common injuries that seem to have a poor healing tendency. The discussion goes that peroneal tendons have avascular zones, contributing to the poor healing of those tears. The purpose of this study was to provide evidence on the vascularization pattern of the peroneal tendons.

METHODS

Ten adult fresh-frozen cadavers were obtained from a university-affiliated body donation programme. The femoral artery was injected with natural coloured latex at the level of the knee. Macroscopic and microscopic dissections were performed to visualize the vascularization towards the peroneal tendons. To expose intratendinous vascularity, the tendons were cleared using a modified Spälteholz technique.

RESULTS

In all specimens, blood was mainly supplied by the peroneal artery through a posterolateral vincula connecting both tendons. Branches were bifurcated every 3.9 ± 1.8 cm, starting 24 ± 5.3 cm proximal to the tip of the fibula. Eight out of 10 (80%) specimens had poor vascularized zones in the peroneus longus tendon. No avascular zones were found in the peroneus brevis tendon.

CONCLUSION

The peroneal tendons are well vascularized by the peroneal artery, via vessels running through a common vincula for both tendons. In the peroneus brevis, no avascular zones were found. To keep the tendons well vascularized and therefore improve tendon healing, surgeons should be careful leaving the vincula intact during surgical procedures.

Symptoms of Common Mental Disorders in Professional Football (Soccer) Across Five European Countries

Evidence on the prevalence of symptoms related to distress, anxiety/depression or substance abuse/dependence, - typically referred to as symptoms of common mental disorders (CMD) - is lacking in European professional football (soccer). The aims of the present study were to investigate the prevalence of symptoms related to CMD (distress, anxiety/depression, sleeping disturbance, adverse alcohol behaviour, and adverse nutrition behaviour) in professional footballers from five European countries, and to explore associations of the outcome measures under study with life events and career dissatisfaction. A cross-sectional design was used. Questionnaires were distributed among professional footballers by the national players' unions in Finland, France, Norway, Spain and Sweden. The highest prevalence of symptoms related to common mental disorders were 18% for distress (Sweden), 43% for anxiety/depression (Norway), 33% for sleeping disturbance (Spain), 17% for adverse alcohol behaviour (Finland), and 74% for adverse nutrition behaviour (Norway). In Finland, France and Sweden, both life events and career dissatisfaction were associated with distress, anxiety/depression, adverse alcohol behaviour, and adverse nutrition behaviour. Results suggest the need for self-awareness in professional football about common mental disorders and a multidisciplinary approach by the medical team. Key pointsThe highest prevalence of symptoms related to common mental disorders were 18% for distress (Sweden), 43% for anxiety/depression (Norway), 33% for sleeping disturbance (Spain), 17% for adverse alcohol behaviour (Finland), and 74% for adverse nutrition behaviour (Norway).In Finland, France and Sweden, both life events and career dissatisfaction were associated with distress, anxiety/depression, adverse alcohol behaviour, and adverse nutrition behaviour.Our results suggest the need for self-awareness in professional football about common mental disorders and a multidisciplinary approach by the medical team.Further research based on longitudinal design should be conducted in order to acquire an insight into the causal relationship between symptoms related to common mental disorders and risk factors.

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

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 ).

Safety and efficiency of posterior arthroscopic ankle arthrodesis

PURPOSE

To study the safety and efficiency of posterior arthroscopic ankle arthrodesis.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Validation of the Dutch language version of the Foot and Ankle Outcome Score

PURPOSE

The aim of this study was to develop a Dutch language version of the Foot and Ankle Outcome Score (FAOS-DLV) and evaluate its measurement properties according to the definitions of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

METHODS

After a standard forward-backward translation procedure, the Dutch version of the FAOS was evaluated for reliability and validity in 110 patients with various hind foot and ankle complaints. Reliability was evaluated by calculation of intraclass correlation coefficients (ICC), Cronbach's alpha for internal consistency, and the smallest detectable change (SDC). Construct validity of the FAOS was assessed by calculation of Spearman's correlation coefficients with similar and dissimilar domains of the SF-36 health survey, American Orthopedic Foot and Ankle Society Ankle and Hindfoot Scale, and visual analogue scales for pain and disability. Dimensionality was tested with confirmatory factor analysis.

RESULTS

Reliability of the FAOS-DLV was good. The ICC of the subscales ranged from 0.83 to 0.88. The minimal value of Cronbach's alpha was 0.76. The SDC at individual level ranged from 18 to 21 and at group level between 2.1 and 2.5. Construct validity was supported by confirmation of 85 % of the hypothesized correlations. Unidimensionality of the FAOS-DLV domains was moderate.

CONCLUSION

The Dutch version of the FAOS seems to have acceptable measurement properties. The questionnaire can be used for functional assessment of patients with varying hindfoot and ankle symptoms. It is, however, more suitable for clinical evaluation at group level than for monitoring a specific patient.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

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

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.

Feasibility of ultrasound imaging of osteochondral defects in the ankle: a clinical pilot study

Talar osteochondral defects (OCDs) are imaged using magnetic resonance imaging (MRI) or computed tomography (CT). For extensive follow-up, ultrasound might be a fast, non-invasive alternative that images both bone and cartilage. In this study the potential of ultrasound, as compared with CT, in the imaging and grading of OCDs is explored. On the basis of prior CT scans, nine ankles of patients without OCDs and nine ankles of patients with anterocentral OCDs were selected and classified using the Loomer CT classification. A blinded expert skeletal radiologist imaged all ankles with ultrasound and recorded the presence of OCDs. Similarly to CT, ultrasound revealed typical morphologic OCD features, for example, cortex irregularities and loose fragments. Cartilage disruptions, Loomer grades IV (displaced fragment) and V (cyst with fibrous roof), were visible as well. This study encourages further research on the use of ultrasound as a follow-up imaging modality for OCDs located anteriorly or centrally on the talar dome.

Variation in joint stressing magnitudes during knee arthroscopy

PURPOSE

When performing knee arthroscopy, joint stressing is essential to increase the operative joint space. Adequate training of joint stressing is important, since high stressing forces can damage knee ligaments, and low stressing might not give sufficient operative space. As forces are difficult to transfer since they cannot be seen, simulators might be suited to train joint stressing as they can visualise the amount of applied stress. This requires the joint stressing thresholds to be validated. The purpose of this study was to measure the variation in the maximum joint stressing forces applied by various surgeons in vivo in a human population and based on that derive thresholds for safe stressing.

METHODS

From studies on ligament failure properties, we inferred a theoretical maximum stressing force of 78 N. Twenty-one patients were included, and knee arthroscopies were performed by five experienced surgeons. Forces solely performed in the varus and in valgus direction were measured. A load sensor was mounted on a belt, which was rotated along the hip to measure both varus and valgus stressing. The measurements started as soon as the interior of the knee joint was visualised using joint stressing.

RESULTS

The average maximum stressing force was 60 N (SD = 28 N). The mean first frame force was 47 N (SD = 34 N). No significant differences were found between varus and valgus stressing.

CONCLUSION

Since variation in stressing forces is high, offering training cases on simulators where the complete range of stressing forces can be experienced is recommended. Abiding to safety levels is essential to increase patient safety.

The optimal injection technique for the osteoarthritic ankle: a randomized, cross-over trial

BACKGROUND

To optimize the injection technique for the osteoarthritic ankle in order to enhance the effect of intra-articular injections and minimize adverse events.

METHODS

Randomized cross-over trial. Comparing two injection techniques in patients with symptomatic ankle osteoarthritis. Patients received an injection with hyaluronic acid using either one of the techniques. Four weeks later the second injection was given using the other technique. Primary outcome was the failure rate of the injection.

RESULTS

Seventy patients fulfilled the study. The failure rate for both injection techniques was 24%. Forty-one patients in the traction group and thirty-nine in the group without traction experienced treatment related local adverse events. Other secondary outcomes did not show any difference between injection techniques.

CONCLUSIONS

There is no significant difference comparing the two injection methods regarding any of our formulated outcome measures. The use of contrast aided fluoroscopy for injecting the severe osteoarthritic ankle can be advised at all times.

No effect of hole geometry in microfracture for talar osteochondral defects

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.

Demineralized bone matrix and platelet-rich plasma do not improve healing of osteochondral defects of the talus: an experimental goat study

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 (μCT), 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 (BV/TV) of the defect, as measured by μCT, 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.

Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of instrumented knee laxity tests

PURPOSE

The aims of this meta-analysis were to determine the sensitivity and specificity of the KT 1000 Arthrometer, Stryker Knee Laxity Tester and Genucom Knee Analysis System for ACL rupture. It was hypothesized that the KT 1000 test is the most sensitive and specific. Secondly, it was hypothesized that the sensitivity and specificity of the KT 1000 arthrometer increase when the amount of Newton force is increased.

METHODS

An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more instrumented examination tests for diagnosing acute complete ACL rupture in living human subjects to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included.

RESULTS

The sensitivity of the KT 1000 Arthrometer with 69 N was 0.54. With 89 N, the sensitivity was 0.78 and the specificity 0.92, and with maximum manual force, the sensitivity was 0.93 and the specificity 0.93. For the Stryker Knee Laxity Tester, the sensitivity was 0.82 and the specificity 0.90. And for the Genucom Knee Analysis System, the sensitivity was 0.74 and the specificity 0.82.

CONCLUSION

The KT Arthrometer performed with maximum manual force has the highest sensitivity, specificity, accuracy and positive predictive value for diagnosing ACL rupture.

LEVEL OF EVIDENCE

Meta-analysis, level I.

Sensitivity and specificity of ultrasound in detecting (osteo)chondral defects: a cadaveric study

The long-term prognosis of cartilage lesions evolving into an eroding subchondral bone defect is not known. Longitudinal monitoring using ultrasound could assist in overall understanding. The aim of the work described in this article was to determine the feasibility of using ultrasound to detect small (osteo)chondral defects. On the anterior talar surface of 10 human cadaveric ankles, at most four defects were arthroscopically created: two pure chondral defects 3 and 1.5 mm in diameter and two osteochondral defects 3 and 1.5 mm in diameter. All ankles were examined by two observers, and their ultrasound observations were validated using computed tomography scans and photographs. Overall sensitivity was 96% for observer 1 and 92% for observer 2, and specificity for both observers was 100%. Sixty-eight percent and 79% of defect sizes were within relevant limits of agreement (-0.2 ± 1.0 mm), respectively. Ultrasound imaging has the potential to detect small (osteo)chondral defects located within visible areas.

Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia

PURPOSE

The aims of this meta-analysis were to determine the sensitivity and specificity of the Lachman, pivot shift and anterior drawer test for acute complete ACL rupture in the office setting and under anaesthesia. It was hypothesized that the Lachman test is the most sensitive and the pivot shift test the most specific. Secondly, it was hypothesized that the sensitivity and specificity of all three exams increases when the examination is performed under anaesthesia.

METHODS

An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included.

RESULTS

Twenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78. For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91. The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98.

CONCLUSION

In the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, complete ACL rupture, while all three tests had comparable specificity. When the examination was performed under anaesthesia, the Lachman test still obtained the highest sensitivity, but the pivot shift test was the most specific.

LEVEL OF EVIDENCE

Meta-analysis of diagnostic test accuracy, Level II.

Waterjet drilling in porcine bone: the effect of the nozzle diameter and bone architecture on the hole dimensions

Using waterjets instead of rigid drill bits for bone drilling can be beneficial due to the absence of thermal damage and a consequent sharp cut. Additionally, waterjet technology allows the development of flexible instruments that facilitate maneuvering through complex joint spaces. Controlling the drilling depth is of utmost importance to ensure clinical safety, but is challenging given the local variations in structural properties of the bone. The goal of this study was to deduce a descriptive mathematical equation able to predict the hole depth and diameter based on the local structural properties of the bone at given waterjet diameters. 210 holes were drilled in porcine femora and tali with waterjet diameters (Dnozzle) of 0.3, 0.4, 0.5 and 0.6mm at a pressure of 700bar and a 5s jet time. Hole depths (Lhole), diameters (Dhole) and bone architectural properties were determined using microCT scans. The most important bone architectural property is the bone volume fraction (BV/TV), resulting in the significant predictive equations: Lhole=34.3 (⁎) Dnozzle(2)-17.6 (⁎) BV/TV+10.7 (R(2)=0.90, p<0.001), and hole Dhole=3.1(⁎) Dnozzle-0.45(⁎)BV/TV+0.54 (R(2)=0.58, p=0.02), with Lhole, Dhole and Dnozzle in mm. Drilling to a specific depth in bone tissue with a known BV/TV is possible, thereby contributing to the safe application of waterjet technology in orthopedic surgery.

Acute lateral ankle ligament ruptures in the athlete: the role of surgery

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.

Management of acute lateral ankle ligament injury in the athlete

PURPOSE

Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries with special emphasis on a rationale for treatment of these injuries in athletes.

METHODS

A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed.

RESULTS

It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7-10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot.

CONCLUSION

Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4-5 days to reduce pain and swelling. Initially, 10-14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.

Syndesmosis and deltoid ligament injuries in the athlete

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Postmortem imaging exposed: an aid in MR imaging of musculoskeletal structures

OBJECTIVE

To identify factors that influence the quality of postmortem magnetic resonance (MR) images of musculoskeletal (MSK) structures as described in the literature, and to evaluate the extent to which these MR images are affected.

MATERIALS AND METHODS

Four useful studies were retrieved from a PubMed and EMBASE search, covering the literature up to 1 March 2012. Three additional studies were included after a manual search from reference lists.

RESULTS

Four human studies and three animal studies are considered in this review. Postmortem MRI quality can be affected by storage temperature, repeated freezing and thawing and fixation. Provided there was an adequate, but above-freezing storage temperature, postmortem changes in fresh cadavers did not appear to affect the MR image quality of MSK structures up to 14 days after death. Image contrast, signal intensities, and relaxation times are temperature-dependent, regardless of whether the specimen was fresh or postmortem for up to 7 days. Bad image quality can occur owing to accelerated autolysis. Freezing and thawing did not affect image quality, unless repeated too often, or whenever a heating pad was used to speed up the thawing process. Conventional formalin-based fixation leads to swelling of soft tissue and fluid accumulation in joints, and therefore to deteriorated images, with image quality just sufficient to visualize gross anatomy.

CONCLUSION

Various factors were identified that affect postmortem MR image quality of MSK structures. Postmortem MR image quality was good, except for images of the fixated specimen. Freezing is the preferred method of conservation for specimens that are to be subjected to postmortem MRI.

WITHDRAWN: Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem.

OBJECTIVES

The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation.

AUTHORS' CONCLUSIONS

Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.

WITHDRAWN: Different functional treatment strategies for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified.

OBJECTIVES

The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences.

AUTHORS' CONCLUSIONS

The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up

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.