Arthroscopic repair of ankle instability with all-soft knotless anchors

In recent years, arthroscopic and arthroscopically assisted techniques have been increasingly used to reconstruct the lateral ligaments of the ankle. Besides permitting the treatment of several comorbidities, arthroscopic techniques are envisioned to lower the amount of surgical aggression and to improve the assessment of anatomic structures. We describe our surgical technique for arthroscopic, two-portal ankle ligament repair using an all-soft knotless anchor, which is made exclusively of suture material. This technique avoids the need for classic knot-tying methods. Thus it diminishes the chance of knot migration caused by pendulum movements. Moreover, it avoids some complications that have been related to the use of metallic anchors and some currently available biomaterials. It also prevents prominent knots, which have been described as a possible cause of secondary complaints.info:eu-repo/semantics/publishedVersio

Management of lateral ankle injuries: A multidimensional approach

Lateral ankle sprains are the most commonly seen musculoskeletal injury. As such, an increasing number of studies report high numbers of patients that experience posttraumatic ankle instability and limitations in activities of daily living (ADL), work and sports. Based on the findings of the studies included in this thesis treatment first and foremost should consists of functional therapy including rest, ice, compression and elevation, NSAIDs, exercise therapy and brace use. In order to increase effectiveness of treatment and prevention programs, addressing individual risk factors for sustaining recurrent lateral ankle sprains and developing chronic ankle joint instability, such as a high weight, high BMI and stability deficits, is recommended. Risk factors provide opportunity for individualised treatment and prevention strategies and will subsequently help to avoid a cascade of comorbidities, and limitations in ADL and sports. In case these treatment options prove insufficient in establishing recovery, surgical stabilisation through anatomic reconstruction or anatomic repair may be the treatment of choice. Regardless the chosen treatment, monitoring through the use of Patient Reported Outcome Measures, such as the Cumberland Ankle Instability Tool, is necessary to define whether a patient experiences recovery or whether adaptation of the treatment strategy is required. The complexity of a lateral ankle sprain concerns the composition of multiple risk factors and negative prognostic factors. These need to be addressed in prevention programs, in addition to adequate diagnosis of the extent of the injury and individualised treatment from the moment of initial presentation to warrant patient recovery

Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques

To determine the best surgical treatment for chronic ankle instability (CAI) a systematic review was performed to compare the functional outcomes between various surgical stabilization methods. A systematic search was performed from 1950 up to April 2016 using PubMed, EMBASE, Medline and the Cochrane Library. Inclusion criteria were a minimum age of 18 years, persistent lateral ankle instability, treatment by some form of surgical stabilization, described functional outcome measures. Exclusion criteria were case reports, (systematic) reviews, articles not published in English, description of only acute instability or only conservative treatment, medial ankle instability and concomitant injuries, deformities or previous surgical treatment for ankle instability. After inclusion, studies were critically appraised using the Modified Coleman Methodology Score. The search resulted in a total of 19 articles, including 882 patients, which were included in this review. The Modified Coleman Methodology Score ranged from 30 to 73 points on a scale from 0 to 90 points. The AOFAS and Karlsson Score were the most commonly used patient-reported outcome measures to assess functional outcome after surgery. Anatomic repair showed the highest post-operative scores [AOFAS 93.8 (SD ± 2.7; n = 119); Karlsson 95.1 (SD ± 3.6, n = 121)], compared to anatomic reconstruction [AOFAS 90.2 (SD ± 10.9, n = 128); Karlsson 90.1 (SD ± 7.8, n = 35)] and tenodesis [AOFAS 86.5 (SD ± 12.0, n = 10); Karlsson 85.3 (SD ± 2.5, n = 39)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SD ± 6.8, n = 128); Karlsson 51.6 (SD ± 5.5, n = 35) compared to anatomic repair [AOFAS 31.8 (SD ± 5.3, n = 119); Karlsson 40.9 (SD ± 2.9, n = 121)] and tenodesis [AOFAS 19.5 (SD ± 13.7, n = 10); Karlsson 29.4 (SD ± 6.3, n = 39)] (p < 0.005). Anatomic reconstruction and anatomic repair provide better functional outcome after surgical treatment of patients with CAI compared to tenodesis reconstruction. These results further discourage the use of tenodesis reconstruction and other non-anatomic surgical techniques. Future studies may be required to indicate potential value of tenodesis reconstruction when used as a salvage procedure. Not optimal, but the latter still provides an increase in functional outcome post-operatively. Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. This has to be kept in mind when choosing between reconstruction and repair in the treatment of CAI. I

The effectiveness of interprofessional classroom-based education in medical curricula: A systematic review

As collaborative practice is progressively being introduced into our health care systems, interprofessional education (IPE) is being implemented in medical curricula as an effective preparation. However, the extent of the effect of IPE on program specific learning outcomes in medical students is not yet fully known. To assess the effectiveness of classroom-based interprofessional education in undergraduate medical education, a systematic review was performed. Searches were performed in EMBASE, Cochrane, Medline and PubMed. The eligibility criteria were: (1) any form of interprofessional learning; (2) sample including pre-clinical students from medicine and other health care professions; (3) pre- and post-intervention assessment; (4) a clear description of the learning objectives; (5) publication in English; and (6) (non-)experimental quantitative study designs. Exclusion criteria were: (1) unidisciplinary interventions; (2) postgraduate and/or clinical phase students; and (3) interventions not tested in an educational setting. The initial search yielded 3498 articles of which 7 articles were included. Included studies exhibit relatively low quality when subjected to Cochrane instruments measuring internal validity. Training formats include multiple techniques, ranging from traditional lectures to peer group assignments. Data on learning objectives show overlapping concepts of IPE, mainly focusing on teamwork and interprofessional collaboration (n = 6). A variety of instruments were used to assess learning objectives, including validated questionnaires and self-perception questionnaires. Positive results were shown in students’ attitudes towards learning (n = 4), and interprofessional collaboration (n = 3). Qualitative data presented in the studies, collected using focus groups, interviews, and surveys (n = 5), suggest educational (n = 5) and social gains (n = 4). Most reported concerns related to difficulties of IPE implementation (n = 3). Studies on interprofessional learning report positive outcomes of teaching pre-clinical students from medicine and other health care professions. Due to the variety of objectives, the lack of constructive alignment, and the impaired methodological quality of included studies, firm conclusions about IPE effectiveness cannot be formulated. To advance interprofessional collaboration in clinical and educational practice, more insight is required into the design of effective IPE curricula and set-up of IPE research

Good clinical outcome after osteochondral autologous transplantation surgery for osteochondral lesions of the talus but at the cost of a high rate of complications: a systematic review

Importance: Osteochondral autologous transplantation surgery (OATS) is one of many treatment modalities for osteochondral lesions of the talus (OLT). OATS uses bone-cartilage cylinder grafts from a non-weight bearing portion of another joint and transplants these on the site of the defect. This may cause complications of the donor site and the ankle. Overall, there is scarce knowledge concerning the clinical outcome and complication rate after OATS. Objective: To determine the clinical outcome and complications of OATS for the treatment of OLT. Evidence review: The data sources are PubMed and EMBASE. Studies were included if they were written in English and were level I–IV clinical studies. Excluded were level V publications, systematic reviews and the use of osteoperiosteal grafts. All participants of included studies were treated for their OLT using OATS. An electronic search was performed to find clinical studies published on OATS from 2005 until March 2016. All titles and abstracts were independently evaluated by 2 researchers. Full texts that met the inclusion criteria were subsequently assessed for quality using the Coleman Methodology score as modified by Kon. To analyse clinical outcome, from each article, demographic information, patient history, study design, clinical variables, patient-reported outcomes and complications were extracted. Findings: The initial search identified 578 studies. A total of 24 articles were selected for the final analysis. Of 24 included articles, 1 was classified as level I, 3 as level III and 20 as level IV studies. The mean modified Coleman Methodology score for all trials was 40.9 (SD 11.0). The 24 studies included a total of 643 patients with a mean age ranging from 22 to 48 years. 11 studies, including a total of 310 patients, evaluated surgery outcome using the American Orthopaedic Foot and Ankle Society (AOFAS) both preoperatively and postoperatively, showing a mean improvement of 51.9–85.4 points. A total of 278 complications were reported including 173 ankle joint complications, 35 donor site-related complications and 70 general complications. Conclusions and relevance: OATS provides good clinical outcome in patients with OLT as both primary and secondary surgical treatment. It is, however, associated with complications related to the ankle joint and donor site. Level of evidence: Level IV, systematic review of level I–IV studies.info:eu-repo/semantics/publishedVersio

Difference in orientation of the talar articular facets between healthy ankle joints and ankle joints with chronic instability

Since both the talocrural and subtalar joints can be involved in chronic ankle instability, the present study assessed the talar morphology as this bone is the key player between both joint levels. The 3D orientation and curvature of the superior and the posteroinferior facet between subjects with chronic ankle instability and healthy controls were compared. Hereto, the talus was segmented in the computed tomography images of a control group and a chronic ankle instability group, after which they were reconstructed to 3D surface models. A cylinder was fitted to the subchondral articulating surfaces. The axis of a cylinder represented the facet orientation, which was expressed by an inclination and deviation angle in a coordinate system based on the cylinder of the superior talar facet and the geometric principal axes of the subject's talus. The curvature of the surface was expressed as the radius of the cylinder. The results demonstrated no significant differences in the radius or deviation angle. However, the inclination angle of the posteroinferior talar facet was significantly more plantarly orientated (by 3.5°) in the chronic instability group (14.7 ± 3.1°) compared to the control group (11.2 ± 4.9°) (p < 0.05). In the coronal plane this corresponds to a valgus orientation of the posteroinferior talar facet relative to the talar dome. In conclusion, a more plantarly and valgus orientated posteroinferior talar facet may be associated to chronic ankle instability

The effect of foot rotation on measuring ankle alignment using simulated radiographs: a safe zone for pre-operative planning

AIM: To assess whether variation in foot rotation, in relation to camera position, affects the reliability of measurement of hindfoot alignment on radiographs and to define a “safe zone” where measurement of the alignment axis and thus preoperative planning is not affected by foot rotation. MATERIALS AND METHODS: Healthy volunteers were recruited of whom double-sided lower-leg weight-bearing computed tomography (CT) was acquired. Weight-bearing was simulated by means of providing axial compression force equal to the weight of the healthy volunteers. The scans were uploaded into custom-made three-dimensional analysis software to create digitally reconstructed radiographs. For each CT examination, a coordinate system was determined, which defines the neutral position of the leg. Rotation about the z-axis of this coordinate system simulates endo- and exorotation of the foot. Subsequently, radiographs were reconstructed for the leg between 30° of endorotation and 45° of exorotation, and the relation between the observed alignment axis and foot rotation was determined. RESULTS: A total of 20 healthy volunteers were included, 10 males (mean age 37.7±11.1) and 10 females (mean age 34±10.3). Per 5° of leg rotation, the alignment axis translated with a mean of 6.86% (SD ±13.1). No significant difference in position of the alignment axis was seen between 10° of endorotation and 10° of exorotation compared to the neutral ankle position. CONCLUSION: The “safe zone” for imaging the hindfoot alignment axis, is between 10° endo- and 10° exorotation of the foot

Lower leg symmetry: a Q3D-CT analysis

Purpose: In fracture and realignment surgery, the contralateral unaffected side is often used as a model or template for the injured bone even though clinically valuable quantitative data of bilateral symmetry are often unavailable. Therefore, the objective of the present study was to quantify and present the bilateral symmetry of the tibia and fibula. Methods: Twenty bilateral lower-leg CT scans were acquired in healthy volunteers. The left and right tibia and fibula were segmented resulting in three-dimensional polygons for geometrical analyses (volume, surface and length). The distal and proximal segment of the right tibia of each individual was subsequently matched to the left tibia to quantify alignment differences (translation and rotation). Bone symmetry on group level was assessed using the Student’s t test and intra-individual differences were assessed using mixed-models analyses. Results: Intra-individuals differences were found for tibia volume (5.2 ± 3.3 cm3), tibia surface (5.2 ± 3.3 cm2), translations in the lateral (X-axis; 9.3 ± 8.9 mm) and anterior direction (Y-axis; 7.1 ± 7.0 mm), for tibia length (translation along Z-axis: 3.1 ± 2.4 mm), varus/valgus (φz: 1.7o ± 1.4°), and endotorsion/exotorsion (φz: 4.0o ± 2.7°). Conclusion: This study shows intra-individual tibia asymmetry in both geometric and alignment parameters of which the surgeon needs to be aware in pre-operative planning. The high correlation between tibia and fibula length allows the ipsilateral fibula to aid in estimating the original tibia length post-injury. Future studies need to establish whether the found asymmetry is clinically relevant when the contralateral side is used as reference in corrective surgery. Level of evidence: III cohort study

Translation of 3D Anatomy to 2D Radiographic Angle Measurements in the Ankle Joint: Validity and Reliability

Background: The objective consisted of 2 elements, primarily to define 2 bone geometry variations of the ankle that may be of prognostic value on ankle instability and secondly to translate these bone variations from a 3D model to a simple 2D radiographic measurement for clinical use. Methods: The 3D tibial and talar shape differences derived from earlier studies were translated to two 2D radiographic parameters: the medial malleolar height angle (MMHA) and talar convexity angle (TCA) respectively to ensure clinical use. To assess validity, the MMHA and TCA were measured on 3D polygons derived from lower leg computed tomographic (CT) scans and 2D digitally reconstructed radiographs (DRRs) of these polygons. To assess reliability, the MMHA and TCA were measured on standard radiographs by 2 observers calculating the intraclass correlation coefficient (ICC). Results: The 3D angle measurements on the polygons showed substantial to excellent agreement with the 2D measurements on DRR for both the MMHA (ICC 0.84-0.93) and TCA (ICC 0.88-0.96). The interobserver reliability was moderate with an ICC of 0.58 and an ICC of 0.64 for both the MMHA and TCA, respectively. The intraobserver reliability was excellent with an ICC of 0.96 and 0.97 for the MMHA and the TCA, respectively. Conclusion: Two newly defined radiographic parameters (MMHA and TCA) are valid and can be assessed with excellent intraobserver reliability on standard radiographs. The interobserver reliability was moderate and indicates training is required to ensure uniformity in measurement technique. The current method may be used to translate more variations in bone shape prior to implementation in clinical practice. Level of Evidence: Level III, cohort study