Watching a movie or listening to music is effective in managing perioperative anxiety and pain: a randomised controlled trial

PURPOSE

Despite the use of perioperative anxiolytics and pain medication, surgery can be a stressful and painful experience. Providing patients with distractions using video and/or audio tools in addition to medication may be helpful. To date, no studies have compared different distraction modalities in a same-day surgical setting in adults. This study aims to determine whether audio-visual distraction with video glasses (AVD) is more effective in reducing anxiety and pain compared to audio distraction (AD) in conscious patients undergoing orthopaedic surgery. It was hypothesised that AVD, being the more immersive modality, would be more effective than AD on the outcome parameters.

METHODS

Fifty patients undergoing orthopaedic surgery with local and/or regional anaesthesia in a clinical day-care setting were randomly assigned to receive either fixed-scenery AVD or patient-choice AD with music. Primary outcome was anxiety, as measured by the Dutch version of the Spielberger State-Trait Anxiety Inventory-6 (STAI-6) prior to and 15 min after the intervention. Secondary outcomes were pain (Numeric Rating Scale Pain [NRS-P]), systolic and diastolic blood pressure, heart rate and patient satisfaction.

RESULTS

Within each group, there was a significant reduction in anxiety (p = 0.028 for AVD, p < 0.001 for AD). In contrast to our hypothesis, listening to music without watching a video (AD group) reduced anxiety significantly more than experiencing full AVD (p = 0.018). The mean pain score did not change significantly within either user group, nor did pain scores differ between user groups.

CONCLUSION

In conscious patients undergoing surgery, watching a movie (using video glasses and a headphone set) and listening to music (using only a headphone set) are able to significantly reduce anxiety. AVD, although believed to provide higher levels of distraction, did not prove to be superior to AD. The clinical relevance of this study highlights the potential benefits of AVD or AD modalities in improving the surgical experience for conscious patients. Further research is required to examine the influence of freedom of choice in content on the aforementioned outcomes. To estimate the true value of higher immersion levels, different distraction modalities (e.g. AVD versus virtual reality) featuring the exact same scenery or content need to be compared.

LEVEL OF EVIDENCE

Level I.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis

BACKGROUND

Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis.

PURPOSE

To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks.

RESULTS

Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures.

CONCLUSION

For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections.

REGISTRATION

NTR7261 (Netherlands Trial Register).

Feasibility of Collecting Multiple Patient-Reported Outcome Measures Alongside the Dutch Arthroplasty Register

Background:

Compliance rates with patient-reported outcome measures (PROMs) collected alongside arthroplasty registries vary in the literature. We described the feasibility of a routinely collected set PROMs alongside the Dutch Arthroplasty Register.

Methods:

The longitudinal Leiden Orthopaedics Outcomes of OsteoArthritis Study is a multicenter (7 hospitals), observational study including patients undergoing total hip or total knee arthroplasty (THA or TKA). A set of PROMs: Short Form-12, EuroQol 5 Dimensions, Hip/Knee injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Score was collected preoperatively and at 6, 12, 24 months, and every 2 years thereafter. Participation rates and response rates were recorded.

Results:

Between June 2012 and December 2014, 1796 THA and 1636 TKA patients were invited, of whom 1043 THA (58%; mean age 68 years [standard deviation, SD: 10]) and 970 TKA patients (59%; mean age 71 years [SD 9.5]) participated in the study. At 6 months, 35 THA/38 TKA patients were lost to follow-up. Response rates were 90% for THA (898/1000) and 89% for TKA (827/932) participants. At 1 and 2 years, 8 and 18 THA and 17 and 11 TKA patients were lost to follow-up, respectively. The response rates among those eligible were 87% (866/992) and 84% (812/972) for THA and 84% (771/917) and 83% (756/906) for TKA patients, respectively. The 2-year questionnaire was completed by 78.5% of the included THA patients and by 77.9% of the included TKA patients.

Conclusions:

About 60% of patients undergoing THA or TKA complete PROMs preoperatively, with more than 80% returning follow-up PROMs. To increase the participation rates, more efforts concerning the initial recruitment of patients are needed.

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.

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

Effects of Pulsed Electromagnetic Fields on Return to Sports After Arthroscopic Debridement and Microfracture of Osteochondral Talar Defects: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

BACKGROUND

Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage.

HYPOTHESIS

The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively.

RESULTS

Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results.

CONCLUSION

PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups.

REGISTRATION

Netherlands Trial Register NTR1636.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, conservative or surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010.

SELECTION CRITERIA

All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).

AUTHORS' CONCLUSIONS

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, conservative or surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010.

SELECTION CRITERIA

All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).

AUTHORS' CONCLUSIONS

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

Pulsed electromagnetic fields after arthroscopic treatment for osteochondral defects of the talus: double-blind randomized controlled multicenter trial

Background

Osteochondral talar defects usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracturing. Although this is mostly successful, early sport resumption is difficult to achieve, and it can take up to one year to obtain clinical improvement. Pulsed electromagnetic fields (PEMFs) may be effective for talar defects after arthroscopic treatment by promoting tissue healing, suppressing inflammation, and relieving pain. We hypothesize that PEMF-treatment compared to sham-treatment after arthroscopy will lead to earlier resumption of sports, and aim at 25% increase in patients that resume sports.

Methods/Design

A prospective, double-blind, randomized, placebo-controlled trial (RCT) will be conducted in five centers throughout the Netherlands and Belgium. 68 patients will be randomized to either active PEMF-treatment or sham-treatment for 60 days, four hours daily. They will be followed-up for one year. The combined primary outcome measures are (a) the percentage of patients that resume and maintain sports, and (b) the time to resumption of sports, defined by the Ankle Activity Score. Secondary outcome measures include resumption of work, subjective and objective scoring systems (American Orthopaedic Foot and Ankle Society – Ankle-Hindfoot Scale, Foot Ankle Outcome Score, Numeric Rating Scales of pain and satisfaction, EuroQol-5D), and computed tomography. Time to resumption of sports will be analyzed using Kaplan-Meier curves and log-rank tests.

Discussion

This trial will provide level-1 evidence on the effectiveness of PEMFs in the management of osteochondral ankle lesions after arthroscopy.

Trial registration

Netherlands Trial Register (NTR1636)

Arthroscopic capsular shrinkage for chronic ankle instability with thermal radiofrequency: prospective multicenter trial

The study was designed as a prospective multicenter longitudinal trial. Adult patients with symptomatic mechanical chronic ankle instability, not improving with conservative therapy, were included and underwent surgery. Primary outcome measures were radiological and manually tested mechanical laxity. Secondary outcome measures were number of complications, reoperations and symptoms, range of motion, and functional (ankle) scores (Karlsson and SF-36 score). The latest follow-up was 9 months for each patient. Thirty-nine patients underwent surgery (19 male patients; 16 right ankles; median age, 27 years). Mechanical stability showed no clinically relevant improvement whereas most secondary outcome measures showed a substantial and statistically significant improvement. One surgery-related complication occurred without functional consequences, and 3 patients underwent a secondary procedure. One was considered a treatment failure, requiring an open anatomic ligament reconstruction. The second patient sustained a severe supination trauma by starting intensive training too early, also requiring an open anatomic reconstruction. The third patient had posterior ankle pain, which was successfully treated by posterior ankle arthroscopy. Arthroscopic thermal capsular shrinkage of the ankle is a safe procedure, leading to resolution of symptoms in the majority of patients with chronic ankle instability.

Reporting of outcomes in orthopaedic randomized trials: does blinding of outcome assessors matter?

BACKGROUND

Randomization, concealment of treatment allocation, and blinding are all known to limit bias in clinical research. Nonsurgical studies that fail to meet these standards have been reported to inflate the differences between treatment and control groups. While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold: (1) to examine the reporting of outcome measures in orthopaedic trials, (2) to determine the feasibility of blinding in published orthopaedic trials, and (3) to examine the association between the magnitude of treatment differences and the blinding of outcome assessors.

METHODS

We identified and reviewed thirty-two randomized, controlled trials published in The Journal of Bone and Joint Surgery (American Volume) in 2003 and 2004 for the appropriate use of outcome measures. These trials represented 3.4% of all 938 studies published during that time-period. All thirty-two trials were reviewed by two authors for (1) the outcome measures used and (2) the blinding of outcomes assessors. We calculated the magnitude of the treatment effect of the use of blinded compared with unblinded outcome assessors.

RESULTS

Ten (31%) of the thirty-two randomized controlled trials used a modified outcome instrument. Of the ten trials, four failed to describe how the outcome instrument was modified. Nine of the ten articles did not describe how the modified instrument was validated and retested. Sixteen of the thirty-two randomized controlled trials did not report blinding of outcome assessors when blinding would have been possible. Among the studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects than blinded outcomes assessment (standardized mean difference, 0.76 compared with 0.25; p = 0.01). Similarly, in the studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects than blinded outcomes assessments (odds ratio, 0.13 compared with 0.42; p < 0.001). The ratio of odds ratios (unblinded to blinded outcomes assessment) was 0.31, suggesting that unblinded outcomes assessment was associated with a potential for exaggeration of the benefit of the effectiveness of a treatment in our cohort of studies.

CONCLUSIONS

In future orthopaedic randomized controlled trials, emphasis should be placed on detailed reporting of outcome measures to facilitate generalization and the outcome assessors should be blinded, when possible, to limit bias.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, both conservative and surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer.

AUTHORS' CONCLUSIONS

In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, both conservative and surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer.

AUTHORS' CONCLUSIONS

In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

Does a "Level I Evidence" rating imply high quality of reporting in orthopaedic randomised controlled trials?

Background

The Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals.

Methods

Two assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score.

Results

We found that only the Journal of Bone and Joint Surgery – American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p > 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC = 0.80, 95%CI:0.60 to 0.90).

Conclusion

Our findings suggest that readers should not assume that 1) studies labelled as Level I have high reporting quality and 2) Level I studies have better reporting quality than Level II studies. One should address methodological safeguards individually.

Ankle instability

The ankle joint is the most congruent joint of the human body. Stability is provided by the bony configuration of the ankle mortise and the talar dome and by the ankle ligaments. During ankle motions, rotation and translation around and along the movement axes occur. Soft tissue stability is provided mainly by the ligaments. This article discusses ankle instability, injuries, and reconstruction.

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.

The anterior ankle impingement syndrome: diagnostic value of oblique radiographs

BACKGROUND

The diagnostic value of an oblique radiograph, in addition to a lateral radiograph, for detecting osteophytes in the anterior ankle impingement syndrome was evaluated in a prospective study. The hypothesis was that the application of a lateral radiograph is insufficient to detect osteophytes that are located in the anteromedial aspect of the ankle joint. Oblique anteromedial impingement (AMI) radiographs were hypothesized to be a relevant adjunct, because of their utility to detect these anteromedially located osteophytes.

METHODS

Presence or absence of tibial and talar osteophytes on both radiographs was compared with the combined findings of CT, MRI scan, and arthroscopic surgery. Estimates of test characteristics were obtained for 60 consecutive patients with an anterior ankle impingement syndrome.

RESULTS

It was shown that the sensitivity of lateral radiographs for detecting anterior tibial and talar osteophytes was 40% and 32%, respectively (specificity, 70% and 82%). When the lateral radiograph was combined with an oblique AMI radiograph, these figures increased to 85% and 73%, respectively (specificity decreased to 45% and 68%). This increase was due to the high sensitivity of the oblique AMI radiographs for detecting anteromedial osteophytes (93% for tibial and 67% for talar osteophytes).

CONCLUSION

A lateral radiograph is insufficient to detect all anteriorly located osteophytes. An oblique AMI radiograph is a useful adjunct to routine radiographs and is recommended to detect anteromedial tibial and talar osteophytes.

Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability.

Treatment of a large intraosseous talar ganglion by means of hindfoot endoscopy

We report on 2 patients with a large intraosseous ganglion of the talus who were treated by means of a 2-portal endoscopic approach of the hindfoot with the patient in the prone position. By means of this approach, it is possible to visualize, debride, and graft a large intraosseous talar lesion. In both patients, the lesions were treated successfully, with no recurrence at follow up.

Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle

In this retrospective study, we assessed the outcome in 99 patients who underwent reconstruction of the lateral ligaments of the ankle for chronic anterolateral instability with a minimum follow-up of 15 years.

Two techniques were compared: 54 patients had an anatomical reconstruction (AR group) and 45 had an Evans tenodesis (ET group). They were followed up for 19.9 ± 3.6 years and 21.8 ± 4.6 years, respectively. During follow-up, seven patients in the AR group and 17 in the ET group required a further operation (p = 0.004). At follow-up, significantly more patients (n = 15) in the ET group had limited dorsiflexion than in the AR group (n = 6, p = 0.007) and 18 in the ET group had a positive anterior drawer test compared with seven in the AR group (p = 0002). In the ET group 27 had tenderness on palpation of the ankle compared with 15 in the AR group (p = 0.001). Stress radiographs showed ligamentous laxity significantly more often in the ET group (n = 30) than in the AR group (n = 13, p < 0.001). The mean values for talar tilt and anterior talar translation were significantly higher in the ET group than in the AR group (p < 0.001, p = 0.007, respectively). There were degenerative changes on standard radiographs in 32 patients in the AR group and 35 in the ET group (p = 0.05). Four patients in the ET group had developed severe osteoarthritis compared with none in the AR group (p = 0.025). Assessment of functional stability revealed a mean Karlsson score of 83.7 ± 10.4 points in the AR group and 67.0 ± 15.8 points in the ET group (p < 0.001). According to the Good rating system, 43 patients in the AR group had good or excellent results compared with 15 in the ET group (p < 0.001).

Compared with anatomical reconstruction, the Evans tenodesis does not prevent laxity in a large number of patients. Long-standing ligamentous laxity leads to degenerative change in the ankle, resulting in chronic pain, limited dorsiflexion and further operations. The functional result deteriorates more rapidly after the Evans tenodesis than after anatomical reconstruction.

Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after follow-up for 15 to 30 years

In this retrospective study, we assessed the outcome in 99 patients who underwent reconstruction of the lateral ligaments of the ankle for chronic anterolateral instability with a minimum follow-up of 15 years. Two techniques were compared: 54 patients had an anatomical reconstruction (AR group) and 45 had an Evans tenodesis (ET group). They were followed up for 19.9+/-3.6 years and 21.8+/-4.6 years, respectively. During follow-up, seven patients in the AR group and 17 in the ET group required a further operation (p = 0.004). At follow-up, significantly more patients (n = 15) in the ET group had limited dorsiflexion than in the AR group (n = 6, p = 0.007) and 18 in the ET group had a positive anterior drawer test compared with seven in the AR group (p = 0002). In the ET group 27 had tenderness on palpation of the ankle compared with 15 in the AR group (p = 0.001). Stress radiographs showed ligamentous laxity significantly more often in the ET group (n = 30) than in the AR group (n = 13, p < 0.001). The mean values for talar tilt and anterior talar translation were significantly higher in the ET group than in the AR group (p < 0.001, p = 0.007, respectively). There were degenerative changes on standard radiographs in 32 patients in the AR group and 35 in the ET group (p = 0.05). Four patients in the ET group had developed severe osteoarthritis compared with none in the AR group (p = 0.025). Assessment of functional stability revealed a mean Karlsson score of 83.7+/-10.4 points in the AR group and 67.0+/-15.8 points in the ET group (p < 0.001). According to the Good rating system, 43 patients in the AR group had good or excellent results compared with 15 in the ET group (p < 0.001). Compared with anatomical reconstruction, the Evans tenodesis does not prevent laxity in a large number of patients. Long-standing ligamentous laxity leads to degenerative change in the ankle, resulting in chronic pain, limited dorsiflexion and further operations. The functional result deteriorates more rapidly after the Evans tenodesis than after anatomical reconstruction.

Sports activity level after surgical treatment for chronic anterolateral ankle instability. A multicenter study

The objective of this retrospective multicenter study was to determine whether anatomic reconstruction or tenodesis produces better results in athletic patients with lateral ankle instability. Forty-one patients who underwent anatomic reconstruction and 36 patients who underwent tenodesis were followed up. The median preinjury Tegner score for both groups was 9 (range, 7 to 10). At follow-up, 2 to 10 years after surgical treatment, the median Tegner score for both groups was 8 (range, 4 to 10). In the tenodesis group, 17 patients had a lower Tegner score than before the operation, but in the anatomic reconstruction group only 4 patients had lower scores. Significantly more patients in the tenodesis group (15) had limited ankle dorsiflexion than in the anatomic reconstruction group (3). Plain radiographs revealed that 11 patients in the tenodesis group had medially located osteophytes, compared with only 2 patients in the anatomic reconstruction group. Stress radiographs revealed that more patients in the anatomic reconstruction group had normal laxity values than in the tenodesis group (38 and 28, respectively). According to the rating system developed by Good et al., 36 patients in the anatomic reconstruction group had a good or excellent result, versus 21 patients in the tenodesis group. Anatomic reconstruction was found to be superior to tenodesis in all of the investigated outcome measures.

Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study

The long-term clinical outcome after anatomical reconstruction and tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicentre study. The first group (AR) consisted of 25 patients (mean age at operation 22 yrs +/- 5.7) who underwent anatomical reconstruction and the second group (TE) of 29 patients (mean age 23 yrs +/- 6.6) who underwent tenodesis. For both groups, the mean follow-up period was 12.3 yrs (AR +/- 2.5 yrs, TE +/- 2.7 yrs). At physical examination, there were significantly more patients in the TE group (n=18) with a positive anterior drawer sign as compared with the AR group (n=7) (p=0.02). Medially located degenerative changes in the ankle joint as seen on standard radiographs were seen more often in the TE group (n=7) than in the AR group (n=1) (p=0.03). The mean talar tilt, 4.7 degrees in the AR group vs 6.9 degrees in the TE group, (p=0.02) and anterior talar translation, 2.9 mm in the AR group vs 4.3 mm in the TE group, (p=0.04) were significantly higher in the TE group at radiographic stress examination. According to the rating system developed by Good et al. (1975), significantly fewer patients in the TE group (n=8) had an excellent result as compared with the AR group (n=15) (p=0.03) and more patients in the TE group (n=9) had a fair or poor result (p=0.04) as compared with the AR group (n=2). We conclude that a tenodesis procedure does not restore the normal anatomy of the lateral ankle ligaments. When compared with anatomical reconstruction, a tenodesis leads to inferior results in terms of functional and mechanical stability, as well as overall satisfaction at long-term follow-up.

A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology

We describe a 2-portal endoscopic approach of the hindfoot with the patient in the prone position. By means of this approach, it is possible to visualize and treat a variety of posterior ankle problems. Not only can pathology of the posterior ankle joint and subtalar joint be visualized and treated, but also periarticular pathology, such as calcifications or scar tissue, can be diagnosed and treated. We describe a professional ballet dancer with chronic flexor hallucis longus tendinitis and a posterior ankle impingement syndrome caused by an os trigonum of both ankles. The patient was successfully treated by removing the os trigonum and releasing the flexor hallucis longus tendon. She resumed her professional activities within 2 months after endoscopic treatment.

A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology

We describe a 2-portal endoscopic approach of the hindfoot with the patient in the prone position. By means of this approach, it is possible to visualize and treat a variety of posterior ankle problems. Not only can pathology of the posterior ankle joint and subtalar joint be visualized and treated, but also periarticular pathology, such as calcifications or scar tissue, can be diagnosed and treated. We describe a professional ballet dancer with chronic flexor hallucis longus tendinitis and a posterior ankle impingement syndrome caused by an os trigonum of both ankles. The patient was successfully treated by removing the os trigonum and releasing the flexor hallucis longus tendon. She resumed her professional activities within 2 months after endoscopic treatment.

Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study

The clinical outcome of anatomical reconstruction or tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicenter study. The anatomical reconstruction group (group A) consisted of 106 patients (mean age at operation 24 +/- 8.4 years) and the tenodesis group (group B) of 110 patients (mean age at operation 26 +/- 11.4 years). Patients were evaluated at a mean follow-up of 5.5 +/- 2.8 years in group A and 5.2 +/- 2.9 years in group B. The review protocol included patient characteristics, physical examination, two ankle scoring scales to evaluate the functional results, and standard anteroposterior and lateral radiographs to evaluate degenerative changes. Mechanical stability was evaluated using standardized stress radiographs. A larger number of reoperations was performed in group B (P = 0.008). At physical examination, more patients in group B had a smaller range of ankle motion than those in group A (P = 0.009). A larger proportion of patients in group B had medially located osteophytes, as seen on standard radiographs (P = 0.04). On stress radiographic examination, the mean talar tilt (P = 0.001) and mean anterior talar translation (P < 0.001) were seen to be significantly greater in group B than in group A. There were no differences in mean Karlsson score between the groups, but more patients in group A had an excellent result on the Good score (P = 0.011). Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments. This results in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results.