Gino M. M. J. Kerkhoffs

No superior treatment for primary osteochondral defects of the talus

PurposeThe purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.MethodsA literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle–Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.ResultsFifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78–86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66–85%].ConclusionsFor primary talar osteochondral defects, none of the treatment options showed any superiority over others.Level of evidenceIV.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PurposeTo determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.MethodsA literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.ResultsEleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1–5); graft diameter ranged from 2.6 to 11xa0mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0–0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00–0.06). There were no significant differences between both harvest techniques (n.s.).ConclusionsDonor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.Level of evidenceLevel IV, systematic review of level IV studies.

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay.

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström–Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

No superior surgical treatment for secondary osteochondral defects of the talus

Purpose The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery.Methods A literature search was conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle–Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined.ResultsTwenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% [CI 82–95%] for the osteochondral autograft transfer procedure, 65% [CI 46–81%] for mosaicplasty and 55% [CI 40–70%] for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% [CI 39–77%]) and matrix-associated chondrocyte implantation (success rate of 73% [CI 56–85%]).Conclusions Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery.Level of evidenceIV.

There is no simple lateral ankle sprain

sprains remain the single most frequent injury in modern sports. With the growing knowledge on ankle joint disorders, it appears that this injury causes more damage to the ankle joint than was previously assumed. Previously, few papers have investigated the concomitant injuries that may be associated with a “simple lateral ankle sprain”. The editors have selected peer-reviewed articles for this current special edition, which present updated scientific information on the pathologies associated with an ankle sprain. We hope that the reader will be in a position, after reading this edition, to incorporate this information into common daily practice when managing ankle injuries and in this way reduce the morbidity associated with this seemingly innocuous condition. The cornerstone of clinical practice is sound knowledge of surgical anatomy. For this reason, we have decided to republish Golano’s article on the anatomy of the ankle ligaments as the leading paper in this issue with an addendum from one of Golano’s former co-workers, Mik Dalmau Pastor, representing the Barcelona School of Orthopaedic Surgical Anatomy [5]. KSSTA is proud to present a special issue on ankle joint disorders following a lateral ankle sprain. Lateral ankle

X-shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure

PurposeThe inferior extensor retinaculum (IER) is an aponeurotic structure located in the anterior aspect of the ankle. According to the literature, it can be used to reinforce a repair of the anterior talofibular ligament in ankle instability. Despite its usual description as an Y-shaped structure, it is still unclear which part of the retinaculum is used for this purpose, or if it is instead the crural fascia that is being used. The purpose of this study is to define the anatomical characteristics of the IER to better understand its role in the Broström–Gould procedure.MethodsTwenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded.ResultsSeventeen (81%) of the IER in this study had an X-shaped morphology, with the presence of an additional oblique superolateral band. This band, by far the thinnest of the retinaculum, is supposed to be used to reinforce the repair of the anterior talofibular ligament. The intermediate dorsal cutaneous nerve (lateral branch of the superficial peroneal nerve) was found to cross the retinaculum in all cases.ConclusionsThe IER is most commonly seen as an X-shaped structure, but the fact that the oblique superolateral band is a thin band of tissue probably indicates that it may not add significant strength to ankle stability. Furthermore, the close relationship of the retinaculum with the superficial peroneal nerve is another factor to consider before deciding to perform a Broström–Gould procedure. These anatomical findings advise against the use of the Gould augmentation.

Reply to the letter to the editor: comment on “No superior treatment for primary osteochondral defects of the talus”

resulting in solely selecting a minimal number of studies and not including studies that yielded promising clinical results at long-term follow-ups, such as the cell-based therapies [1, 4, 7, 8]. It should be mentioned that the aim of the research team was to design the study protocol for the systematic review in such an inherent manner that the highest number of publications could be included for descriptive and numerical analysis. Apart from this, it was chosen to distinguish between primary and non-primary lesions of the talus, so that one could adhere to a clear separation of the different lesions with distinctive prognostic factors. This distinction resulted in the fact that a substantial amount of research needed to be excluded from the analysis, as a large percentage of potential inclusions contained a patient population consisting of both primary defects and those that had failed prior surgical intervention(s). In order to overcome this methodological difficulty, the review adhered to a strict and extensive author contact protocol; authors were contacted to provide separate data for patients with primary lesions only and/or for patients ≥ 18 years old. When no reply was reported, contact was sought by two reminder e-mails and, in case of no response, the specific article needed to be excluded. The research team approached 127 authors in order to acquire suitable data for the review, and this methodological characteristic of unexclusive nature subsequently resulted in including an additional 33 publications. A mere unfortunate consequence was that a similar number of articles—31 in total—were obliged to be excluded. Another valid point from the Italian group was the comment on the inclusion criterion of a minimal follow-up period of 6 months, from their perspective being a too short of a follow-up time to reliably evaluate bone–cartilage treatment. Although we agree on this matter in all respects, it can be appreciated from Figure 3 that solely one study from the 52 in total described a follow-up period of 6 months [3]. The Dear Editor,

Not Physical Activity, but Patient Beliefs and Expectations are Associated With Return to Work After Total Knee Arthroplasty

BACKGROUNDnAfter total knee arthroplasty (TKA), 17%-60% of the patients do not or only partially return to work (RTW). Reasons for no or partial RTW remain unclear, warranting further research. Physical activity (PA) has proven beneficial effects on work participation. Therefore, we hypothesized that preoperative PA is associated with RTW after TKA.nnnMETHODSnWorking TKA patients participating in an ongoing prospective cohort study were included. Preoperatively and 1 year postoperatively, patients were asked to define their work status and PA level according to the Dutch Recommendation for Health-Enhancing PA and the Fitnorm. Multivariate logistic regression analysis was performed to assess the effect of PA on RTW, taking into account established prognostic factors for RTW among TKA patients.nnnRESULTSnOf 283 eligible patients, 266 (93%) completed the questionnaires sufficiently. Preoperatively, 141 patients (54%) performed moderate PA for ≥5 d/wk and 42 (16%) performed intense PA for ≥3 d/wk. Concerning RTW, 178 patients (67%) reported full RTW, 59 patients (22%) partial RTW, and 29 patients (11%) no RTW. Preoperative PA was not associated with RTW. Patients who reported that their knee symptoms were not or only partially work-related had lower odds of no RTW (odds ratio 0.37, 95%xa0confidence interval 0.17-0.81). Also, for each additional week patients expected to be absent from work, the likelihood of no RTW increased (odds ratio 1.11, 95% confidence interval 1.03-1.18).nnnCONCLUSIONnNo association between preoperative PA and RTW after TKA was found. Patient beliefs and preoperative expectations did influence RTW and should be addressed to further improve RTW after TKA.

Low-dose dexamethasone during arthroplasty

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI). The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty. We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a ‘pro’ and ‘con’ discussion. After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27u2009205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone. Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI. Conversely, animal studies showed that high dose dexamethasone inhibits wound healing. A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk–benefit ratio of peri-operatively applied steroids for individual arthroplasty patients. We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies. Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

The ankle in football

Anatomy of the Ankle.- Interview 1: Raul Gonzalez Bravo - Real Madrid ( Player).- Epidemiology & Mechanisms of Ankle Pathology in Football.- Interview 2: Dr Ricardo Pruna - First Team Dr. FC Barcelona.- Prevention of Ankle Injuries.- Interview 3: Frank De Bleeckere - Referee.- Ankle Ligament Lesions.- Interview 4: Jan Wouters - Active Coach.- Osteochondral Defects in the Ankle Joint.- Interview 5: Boran Milutinovic - Veteran Coach.- Anterior Ankle Impingement.- Interview 6: Eva Blewanus - Female Sports Physiotherapist.- Posterior Ankle Impingement.- Interview 7: Ron Spelbos - Football Scout.- Ankle Fractures, Including Avulsion Fractures.- Interview 8: Leonne Stentler - Female Player.- Fifth Metatarsal Stress Fractures in Football.- Acute Achilles Tendon Rupture.- Achilles Tendinopathy.- Peroneal and Posterior Tibial Tendon Pathology.- The Footballers Inlay Sole: An Individualized Approach.- Rehabilitation After Ankle Football Injuries.- Taping Techniques and Braces in Football.- Ankle Osteoarthritis in Former Elite Football Players: What Do We Know?.