Hélder Pereira

Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert

PurposeThe purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions.MethodsA questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects.ResultsThirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3–6xa0months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered.ConclusionsMost surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI.Level of evidenceV.

Notch morphology is a risk factor for ACL injury: a systematic review and meta-analysis

Importance Several bone morphological parameters have been identified in the scientific literature as risk factors for sustaining an anterior cruciate ligament (ACL) injury; however, a clear consensus on which are the most predisposing factors is still missing. Aim This systematic review and meta-analysis aims to investigate the association between bone morphological parameters and the risk of sustaining an ACL injury. Evidence review We conducted a comprehensive search using PubMed, Cochrane Library, Scopus, CINAHL and SPORTDiscus databases from 2005 until 2015. Two authors independently searched for relevant studies that assessed the association between bone morphology and ACL injury. Other search sources were used for hand-searching additional potential studies and the reference list of recent studies was screened. The methodological quality of the included studies was assessed through an adapted scale for radiological studies. A fixed-effects or random-effects model was used accordingly to estimate the mean differences with 95% CIs regarding the association of ACL injury with intercondylar notch (ICN) width, notch width index (NWI) and tibial slopes. Findings 23 studies were included for analysis comprising a total of 3452 participants, 1681 with an ACL injury and 1763 with an intact ACL. The ACL-injured individuals had narrower ICN width (p<0.001), smaller NWI (p=0.005) and steeper tibial slope (p<0.001). Conclusions On the basis of the current scientific literature, narrower ICN widths, smaller NWI and increased tibial slopes put the individual at higher risk of injuring the ACL. Future research should focus on developing indexes for different parameters rather than absolute measurements.

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

PurposeTo 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.MethodsA 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 18xa0years, 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.ResultsThe 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 (SDxa0±xa02.7; nxa0=xa0119); Karlsson 95.1 (SDxa0±xa03.6, nxa0=xa0121)], compared to anatomic reconstruction [AOFAS 90.2 (SDxa0±xa010.9, nxa0=xa0128); Karlsson 90.1 (SDxa0±xa07.8, nxa0=xa035)] and tenodesis [AOFAS 86.5 (SDxa0±xa012.0, nxa0=xa010); Karlsson 85.3 (SDxa0±xa02.5, nxa0=xa039)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SDxa0±xa06.8, nxa0=xa0128); Karlsson 51.6 (SDxa0±xa05.5, nxa0=xa035) compared to anatomic repair [AOFAS 31.8 (SDxa0±xa05.3, nxa0=xa0119); Karlsson 40.9 (SDxa0±xa02.9, nxa0=xa0121)] and tenodesis [AOFAS 19.5 (SDxa0±xa013.7, nxa0=xa010); Karlsson 29.4 (SDxa0±xa06.3, nxa0=xa039)] (pxa0<xa00.005).ConclusionAnatomic 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.Level of evidenceIV.

Tenodesis reconstruction in patients with chronic lateral ankle instability is associated with a high risk of complications compared with anatomic repair and reconstruction: a systematic review and meta-analysis

Importance Chronic lateral ankle instability (CAI) is a common entity in current orthopaedic practice. In case a patient is eligible for surgery, several types of procedure can be performed. Complications and recurrence rates may influence treatment choice. Objective To determine which stabilisation technique provides the lowest complication and recurrence rates in the surgical treatment of CAI. Evidence review PubMed, Embase, Medline and Cochrane from 1950 up to April 2016 were searched. The inclusion criteria were reporting complications and/or recurrence rates, minimum age of 18 years, isolated CAI unresponsive to conservative treatment and surgical stabilisation. Articles were excluded in case of reviews, case reports, non-English published articles, medial instability, concomitant pathology or joint deformity. The Modified Coleman Methodology Score (0–90 points) was used to assess article methodology. For the analysis, patient demographics, surgical procedure, complications, complication and recurrence rates, and time to recurrence were extracted. From these data the weighted mean, SD and 95% CI were calculated. Findings The search resulted in 654 articles, of which 27 were eligible and remained for qualitative and quantitative analyses. These articles included a total of 1133 patients with a mean age of 28.1 (SD±4.4) years. The mean Coleman score was 46.9 points (SD±13.1). Complications were reported for 16.5% (n=183) and recurrence was reported for 9.8% (n=44) of patients. The comparison of the OR of complications per technique showed that the tenodesis technique (OR: 1.9; 95%u2009CI: 1.2 to 2.8) had the highest risk of complications. There was no significant difference in complication risk among anatomic repair, anatomic reconstruction and capsular shrinkage. Overall complication rates ranged from 9.1% to 21.0%. Risk at recurrence did not differ among the techniques (OR: 0.7–2.0; 95%u2009CI: 0.4 to 6.3). This study is mainly limited due to inconsistent reporting of complication and recurrence rates. Conclusions and relevance Tenodesis provides the highest risk of postoperative complications. Among anatomic repair, anatomic reconstruction and capsular shrinkage, there is no difference in complication risk. Conclusions on recurrence of instability are not solid due to under-reporting. To increase current knowledge and reliability of results, more homogenous studies are required with adequate reporting of complications and recurrence. Level of evidence III

Return to sport following lateral ankle ligament repair is under-reported: a systematic review

Importance Ankle sprains are the most commonly occurring musculoskeletal injury. Reconstruction of the lateral ligament complex is often required for athletes with recurrent instability, or high-grade acute sprains, in order to return to their pre-injury level of sport. Objective The purpose of this systematic review was to evaluate the spectrum, prevalence and quality of evidence regarding return to sport timeline following lateral ligament surgery. Evidence review A search was conducted of Embase and Medline databases from the earliest possible entry to November 2016. Studies reporting a timeline regarding return to play (RTP) following lateral ankle ligament reconstruction were included in this review. Findings Of 3184 total articles, 20 articles evaluating 489 athletes met the criteria and were included for review. Thirteen of the 20 papers were used to calculate a weighted mean time to RTP of 4.7 months. Overall, both the frequency and quality of RTP criteria and reporting were very low. Conclusions and relevance The current review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative RTP timeline following lateral ankle ligament repair. Published studies vary considerably in the metrics used for measuring patient-reported outcomes, and very few actually track them. Further studies on outcomes following ankle ligament repair should include clear and consistent metrics for return to sport and level of play. Standardised and reproducible criteria for reporting RTP for athletes will improve the utility and applicability of outcomes data as surgical and rehabilitative techniques continue to advance. Level of evidence Systematic review of level I–IV studies, level IV.

CPR 11: a mobile application that can help in saving lives (Mobile App User Guide)

CPR 11.nnHealth.nnIOS (iPhone 4 and above), Android (versions 2.3.3 and above), Windows Phone.nnFree.nnIn just 11 steps, the CPR 11 mobile application presents a simple plan, with clear and precise instructions, on how to recognise a sudden cardiac arrest (SCA), provide immediate and adequate response with efficient compressions and ventilations, how to use the automated external defibrillator (AED) and how to transfer the player from the field of play.nnWith the help of text and voice messages, each of the 11 steps includes a brief, clear video that aims to make it possible for anyone, even those with no previous first aid or medical training, to be able to recognise a SCA and meet the objective of starting resuscitation manoeuvres in the first minute and defibrillation in …

Posterior Compartment of the Ankle Joint: A Focus on Arthroscopic Treatment (ICL 17)

Arthroscopic approach of the posterior ankle compartment has experienced great development since the beginning of the twenty-first century. The anatomical research of Pau Golano has been of paramount importance for the development of a “safe”, reliable and reproducible approach (particularly the two portals technique with the patient in prone position).

MRI-Based Laxity Measurement for Return to Play

The objective measurement of knee sagittal and rotation laxity upon the anterior cruciate ligament (ACL) lesion has an essential role in the knee stability assessment. These measurements can further be evaluated through magnetic resonance imaging (MRI), which in combination with instrumented assessment and physical examination can correlate both the “anatomy” and “function” of the ligament. The Porto-Knee Testing Device (PKTD) is a knee laxity testing device compatible with MRI that is capable of measuring the posterior-anterior tibial translation and tibial internal and external rotation. In this sense, the PKTD is a useful tool for the assessment of knee sagittal and rotatory laxity in the follow-up of football players that underwent ACL reconstruction. Hence, this tool may allow to identify individuals presenting residual knee laxity with increased risk of sustaining secondary ACL injuries and assist in the planning of secondary prevention programs.

Management of Cartilage Injuries of the Foot and Ankle in Handball

In prospective season-long observation studies of handball, the lower extremity is marginally more frequently affected compared with the upper limb [1]. As with many other sports where physical contact occurs, the incidence of injury during match play of 13.5 injuries per 1000 h far exceeds training 0.8 injuries per 1000 h [2].

Management of Chronic Ankle Instability in the Handball Player

Handball is a fast contact sport, resulting in high loading forces to both the upper and the lower limbs, leading to both acute and chronic injuries. Surveys from international and national multisport events have shown handball to be among those with the highest injury rate [1–3].