The value of MRI STIR signal intensity on return to play prognosis and reinjury risk estimation in athletes with acute hamstring injuries

OBJECTIVES

Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuries.

STUDY DESIGN

Case-control study.

METHODS

We used MRI STIR to measure intramuscular signal intensity in patients with clinically diagnosed hamstring injuries at two time points: at injury and RTP. At injury, we calculated the association of MRI STIR signal intensity with the time to RTP and reinjury risk. At RTP, the association of MRI STIR signal intensity and reinjury risk and the change in MRI STIR signal intensity over time on reinjury risk was evaluated.

RESULTS

51 patients were included. We found increased MRI STIR signal intensity: (1) at time of injury not to be associated with time to RTP, (2) at time of injury to be associated with a slightly lower risk for reinjury: odds 0.986 (0.975-0.998, p=0.02) and (3) at RTP not to be associated with reinjury risk. (4) We found no association between the change in MRI STIR signal intensity over time and reinjury risk.

CONCLUSION

Increased MRI STIR signal intensity at injury has no value in time to RTP prognosis, but is associated with a reduced reinjury risk.

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial

INTRODUCTION

Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA.

METHODS AND ANALYSIS

We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year.

ETHICS AND DISSEMINATION

The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NTR7261.

Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27 years (range 18-37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo-tendinous junction (MTJ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI, with avulsion injuries accounting for three-quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.

Interseason variability of a functional movement test, the 9+ screening battery, in professional male football players

BACKGROUND

The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.

AIM

To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.

METHODS

Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.

RESULTS

A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.

CONCLUSIONS

The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons.

Low injury rate strongly correlates with team success in Qatari professional football

Background

Although the incidence of football injuries should relate to team success there is little empirical evidence.

Objective

We investigated the relationship between injury incidence and team success in Qatar first-division football clubs.

Methods

Using a prospective cohort study design, we captured exposure and injuries in Qatar male elite football for a season. Club performance was measured by total league points, ranking, goal scored, goals conceded and number of matches won, drawn or lost.

Results

Lower injury incidence was strongly correlated with team ranking position (r=0.929, p=0.003), more games won (r=0.883, p=0.008), more goals scored (r=0.893, p=0.007), greater goal difference (r=0.821, p=0.003) and total points (r=0.929, p=0.003).

Conclusions

Lower incidence rate was strongly correlated with team success. Prevention of injuries may contribute to team success.

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Background

Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.

Aim

To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme.

Study design

Part of a 5-year follow-up of a previously conducted randomised controlled trial.

Methods

58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.

Results

In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).

Conclusion

At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study

Objective The purpose of this study was to describe the results of two treatment regimens for medial tibial stress syndrome (MTSS); a graded running programme and the same running programme with additional shockwave therapy (extracorporeal shockwave therapy; ESWT). Design A prospective observational controlled trial. Setting Two different sports medicine departments. Participants 42 athletes with MTSS were included. Intervention Patients from one hospital were treated with a graded running programme, while patients from the other hospital were treated with the same graded running programme and focused ESWT (five sessions in 9 weeks). Main Outcome Measures Time to full recovery (the endpoint was being able to run 18 min consecutively without pain at a fixed intensity). Results The time to full recovery was significantly faster in the ESWT group compared with the patients who only performed a graded running programme, respectively 59.7±25.8 and 91.6±43.0 days (p=0.008). Conclusions This prospective observational study showed that MTSS patients may benefit from ESWT in addition to a graded running programme. ESWT as an additional treatment warrants further investigation in a prospective controlled trial with the addition of randomisation and double blinding.

Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial

HYPOTHESIS

A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain.

STUDY DESIGN

Single blinded, prospective, randomised controlled trial.

METHODS

PATIENTS

Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months.

INTERVENTIONS

ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program.

PRIMARY OUTCOME

time to return to full sports participation.

SECONDARY OUTCOME MEASURES

objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks.

RESULTS

Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p = 0.043). Only 50-55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p = 0.72) or VAS during sports (p = 0.12).

CONCLUSIONS

The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

Risk factors and prognostic indicators for medial tibial stress syndrome

The objective of the study was to examine the risk factors and prognostic indicators for medial tibial stress syndrome (MTSS). In total, 35 subjects were included in the study. For the risk factor analysis, the following parameters were investigated: hip internal and external ranges of motion, knee flexion and extension, dorsal and plantar ankle flexion, hallux flexion and extension, subtalar eversion and inversion, maximal calf girth, lean calf girth, standing foot angle and navicular drop test. After multivariate regression decreased hip internal range of motion, increased ankle plantar flexion and positive navicular drop were associated with MTSS. A higher body mass index was associated with a longer duration to full recovery. For other prognostic indicators, no relationship was found.

Autologous growth factor injections in chronic tendinopathy: a systematic review

Chronic degenerative tendinopathies are frequent and difficult to treat. Tendon healing and regeneration may be improved by injecting autologous growth factors obtained from the patient's blood. Autologous growth factors can be injected with autologous whole blood or platelet-rich plasma (PRP). Electronic databases were searched for prospective clinical trials on treatment with autologous growth factors of patients with chronic tendinopathy. Chronic tendinopathy in this study included wrist extensors, flexors, plantar fasciopathy and patellar tendinopathy. Studies examining the treatment of other tendinopathies were not identified. The Physiotherapy Evidence Database score was used to examine the methodological quality of the assessment, and a qualitative analysis was performed with the levels of evidence. There are many proposed treatment options for chronic tendinopathy. Treatments in the form of injections with autologous whole blood or PRP are increasingly used in clinical practice. There are high expectations of these regenerative injections, and there is a clear need for effective conservative therapies. All studies showed that injections of autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact on improving pain and/or function over time. However, only three studies using autologous whole blood had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. At present, there is strong evidence that the use of injections with autologous whole blood should not be recommended. There were no high-quality studies found on PRP treatment. There is limited evidence to support the use of injections with PRP in the management of chronic tendinopathy. There is growing interest in the working mechanisms of autologous growth factors. The amount and mixture of growth factors produced using different cell separating systems are largely unknown and it is also uncertain whether platelet activation prior to injection is necessary. These variables should be taken into account when starting clinical studies. A good experimental model for studying tendinopathy would be helpful for basic research. Future clinical studies using a proper control group, randomization, blinding and validated disease-specific outcome measures for pain and function are needed.

Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

OBJECTIVE

A decreased range of motion (ROM) of the hip joint is known to predispose to athletic groin injury. Femoroacetabular impingement (FAI) of the hip leads to a reduced ROM. This study examined the prevalence of radiological signs of FAI in patients presenting with long-standing adductor-related groin pain (LSARGP).

DESIGN

Prospective case series.

SETTING

Outpatient Sports Medicine Department.

PATIENTS

34 athletes with LSARGP defined as pain on palpation of the proximal insertion of adductor muscle and a painful, resisted adduction test.

ASSESSMENT

A clinician blinded to the results of the radiological assessment performed a physical examination: iliopsoas length, hip ROM and anterior hip impingement test. Anteroposterior pelvic radiographs were examined by a second blinded clinician for the presence of: pistol grip deformity, centrum-collum-diaphyseal angle, femoral head neck ratio, coxa profunda, protrusio acetabuli, lateral centre edge angle, acetabular index and cross-over sign.

RESULTS

The prevalence of radiological signs of FAI was 94% (64/68). The mean number of radiological signs in hips with LSARGP was 1.84 (range 0-4, SD 1.05) and 1.96 (range 0-5, SD 1.12) in asymptomatic groins (p=0.95). The anterior hip impingement test was positive in nine cases. There was no relationship with the number of radiological signs (p=0.95). There was no correlation between hip ROM and the number of radiological signs (p=0.37).

CONCLUSION

Radiological signs of FAI are frequently observed in patients presenting with LSARGP. Clinicians should be aware of this fact and the possible lack of correlation when assessing athletes with groin pain.

One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy

OBJECTIVE

The study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic midportion Achilles tendinopathy.

DESIGN

One-year follow-up of a randomised controlled single blinded clinical trial.

SETTING

Sports medicine department in a general hospital.

PATIENTS

58 patients (70 tendons) were included.

INTERVENTIONS

All patients completed a 12-week heavy load eccentric training programme. One group received a night splint in addition to eccentric exercises.

MAIN OUTCOME MEASUREMENTS

Outcome scores were: Victorian Institute of Sport Assessment-Achilles (VISAA) score, subjective patient satisfaction and neovascularisation score measured with power Doppler ultrasonography (PDU).

RESULTS

For both groups the VISA-A score increased significantly (from 50 to 76 (p<0.01) in the eccentric group and from 49 to 78 (p<0.01) in the night splint group). No significant differences in the VISA-A score were found between the groups from baseline to one year (p = 0.32). The presence of neovessels at baseline did not predict a change in the VISA-A score after one year in the whole group (p = 0.71).

CONCLUSION

Eccentric exercises with or without a night splint improved functional outcome at one year follow-up. At follow-up there was no significant difference in clinical outcome when a night splint was used in addition to an eccentric exercise programme. Between 3 months and one year follow-up, a continuing increase in the VISA-A score was found. Assessment of the neovascularisation score with PDU at baseline has no prognostic value on long-term clinical outcome.

A manual therapy technique for chronic adductor-related groin pain in athletes: a case series

The objective was to retrospectively examine whether a manual therapy technique is effective in the treatment of chronic adductor-related groin pain in athletes. Thirty-three athletes with chronic adductor-related groin pain were approached. Thirty patients gave their consent to participate in the study. Patient satisfaction, return to activity and numeric pain score were recorded. Patients were treated after prewarming of the muscles; one hand is used to control the tension in the adductor muscles and the other hand is used to move the hip into abduction and external rotation. This flowing, circular motion stretches the adductor muscle group. The movement is repeated three times in one treatment session. Twenty-five out of 30 (83%) athletes reported a good or excellent satisfaction. Twenty-seven out of 30 (90%) athletes had resumed sport at (15/30) or below (12/30) their previous level of activity. The pain score for during or after activity decreased significantly from 8.7 to 2.2 after the treatment (P<0.01). This study shows that the manual therapy treatment might be a promising treatment for chronic adductor-related groin pain in athletes.

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial

AIM

To assess whether the use of a night splint is of added benefit on functional outcome in treating chronic midportion Achilles tendinopathy.

METHODS

This was a single-blind, prospective, single centre, randomised controlled trial set in the Sports Medical Department, The Hague Medical Centre, The Netherlands. Inclusion criteria were: age 18-70 years, active participation in sports, and tendon pain localised at 2-7 cm from distal insertion. Exclusion criteria were: insertional disorders, partial or complete ruptures, or systemic illness. 70 tendons were included and randomised into one of two treatment groups: eccentric exercises with a night splint (night splint group, n = 36) or eccentric exercises only (eccentric group, n = 34).

INTERVENTIONS

Both groups completed a 12-week heavy-load eccentric training programme. One group received a night splint in addition to eccentric exercises. At baseline and follow-up at 12 weeks, patient satisfaction, Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and reported compliance were recorded by a single-blind trained researcher who was blinded to the treatment.

RESULTS

After 12 weeks, patient satisfaction in the eccentric group was 63% compared with 48% in the night splint group. The VISA-A score significantly improved in both groups; in the eccentric group from 50.1 to 68.8 (p = 0.001) and in the night splint group from 49.4 to 67.0 (p<0.001). There was no significant difference between the two groups in VISA-A score (p = 0.815) and patient satisfaction (p = 0.261).

CONCLUSION

A night splint is not beneficial in addition to eccentric exercises in the treatment of chronic midportion Achilles tendinopathy.

Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus. Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Prospective study on diagnostic strategies in osteochondral lesions of the talus

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus.

Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Arthroscopic treatment of anterior impingement in the ankle

We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space.

[Treatment strategies in osteochondral lesions of the talus. Review of the literature]

The aim of this study was to compare the results of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from 1966 to June 2000 were systematically screened. Thirty-nine studies fulfilled our inclusion criteria. No randomized clinical trials could be identified. The results of nonoperative treatment were described in 14 studies, of excision alone in 4, of excision and curettage in 10, of excision, curettage and drilling in 21, of cancellous bone grafting in 2, of fixation in 3, and of osteochondral transplantation in 1. Good or excellent results were found in 45% of the cases. Comparison of different surgical procedures showed that excision, curettage and drilling resulted in the highest mean success rate (86%), followed by excision and curettage (76%) and excision alone (38%). From the results of this systematic review we conclude that nonoperative treatment and excision alone are not to be recommended for treatment of talar OCD. Excision, curettage and drilling produced a high percentage of good or excellent results. Further randomized, controlled trials are required to compare the outcome of these two surgical strategies for OCD of the talus.

Treatment strategies in osteochondral defects of the talar dome: a systematic review

The aim of this study was to investigate the results of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from 1966 to July 1998 were systematically screened. Based on our inclusion criteria 32 studies describing the results of treatment strategies for OCD of the talus were included. No randomized clinical trials (RCT's) were identified. Fourteen studies described the results of excision alone, 11 the results of (EC), 14 the results of (ECD), 1 the results of cancellous bone grafting after EC, 1 the results of osteochondral transplantation and 3 the results of fixation. The average success rate of non-operative treatment (NT) was 45%. Comparison of different surgical procedures shows that the average highest success rate was reached by excision, curettage and drilling (ECD) (85%) followed by excision and curettage (EC) (78%) and excision alone (38%). Based on this systematic review we conclude that NT and excision alone are not to be recommended in treating talar OCD. Both EC and ECD have been shown to lead to a high percentage good/excellent results. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further prospective randomized controlled trials are required to compare the outcome of these two surgical strategies for OCD of the talus.

MRI-induced retrocalcaneal bursitis

This case report describes a patient with acute retrocalcaneal bursitis, which developed after MRI examination of the ankle. The sagittal T2*-weighted gradient echo sequence revealed an extensive susceptibility artifact in the area surrounding the Achilles tendon near its insertion at the os calcis. This artifact was caused by postsurgical metallic particles. We postulate that these particles were mechanically stimulated by the magnetic field and induced the inflammatory response.

Value of arthrography after supination trauma of the ankle

OBJECTIVE

To investigate the merits of arthrography after supination trauma of the ankle.

DESIGN AND PATIENTS

In a group of 160 consecutive patients operative exploration was performed in cases where arthrography and/or a delayed physical examination showed positive findings. In all patients arthrography was performed within 48 h after trauma. To determine interobserver agreement, all arthrograms were independently evaluated by two radiologists, both ignorant of the first assessment.

RESULTS

The prevalence of an ankle ligament lesion was found to be 76%. Of the 122 patients with a rupture of one or more ankle ligaments, 52% had an isolated anterior talofibular ligament lesion, 3% had an isolated calcaneofibular ligament lesion, and 45% had combined lesions. The site of the lesion was predominantly intraligamentous. In the determination of the presence or absence of an ankle ligament lesion, the specificity and sensitivity of the ankle arthrogram were 71% and 96% respectively. Interobserver agreement on the arthrogram was very good (kappa 0.9). In 1% of patients a clear diagnosis was not possible by means of arthrography.

CONCLUSION

Arthrography provides information of high diagnostic quality with excellent interobserver agreement and therefore remains the gold standard for early diagnosis (within 48 h) of a lateral ankle ligament rupture.

A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement

Sixty-two consecutive patients with painful limited dorsiflexion of the ankle not responding to nonoperative treatment participated in a prospective study. All 42 men and 20 women (average age, 31 years) underwent arthroscopic surgery. Preoperative radiographs were graded according to an osteoarthritic and an impingement classification. Standardized followup took place at 4 months and 1 and 2 years after surgery. Results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs. The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally.

ARTHROSCOPY FOR PROBLEMS AFTER ANKLE FRACTURE

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer.

Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%.

Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.

Arthroscopy for problems after ankle fracture

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.