Ruben Zwiers

Posterior Hindfoot Arthroscopy A Review

In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.

Treatment of midportion Achilles tendinopathy: an evidence-based overview.

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.Level of evidenceIV.

Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature

PURPOSE To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. METHODS A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. RESULTS Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. CONCLUSIONS Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. LEVEL OF EVIDENCE Level IV, systematic review of Level II and IV studies.

Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial.

Background: Calcaneal apophysitis is a frequent cause of heel pain in children and is known to have a significant negative effect on the quality of life in affected children. The most effective treatment is currently unknown. The purpose of this study is to evaluate 3 frequently used conventional treatment modalities for calcaneal apophysitis. Methods: Three treatment modalities were evaluated and compared in a prospective randomized single-blind setting: a pragmatic wait and see protocol versus a heel raise inlay (ViscoHeel; Bauerfeind) versus an eccentric exercise regime under physiotherapeutic supervision. Treatment duration was 10 weeks. Inclusion criteria: age between 8 and 15 years old, at least 4 weeks of heel pain complaints due to calcaneal apophysitis based, with a minimal Faces Pain Scale-Revised of 3 points. Primary exclusion criteria included other causes of heel pain and previous similar treatment. Primary outcome was Faces Pain Scale-Revised at 3 months. Secondary outcomes included patient satisfaction and Oxford Ankle and Foot Questionnaire (OAFQ). Points of measure were at baseline, 6 weeks, and 3 months. Analysis was performed according to the intention-to-treat principles. Results: A total of 101 subjects were included. Three subjects were lost to follow-up. At 6 weeks, the heel raise subjects were more satisfied compared with both other groups (P<0.01); the heel raise group improved significantly compared with the wait and see group for OAFQ Children (P<0.01); the physical therapy group showed significant improvement compared with the wait and see group for OAFQ Parents (P<0.01). Each treatment modality showed significant improvement of all outcome measures during follow-up (P<0.005). No clinical relevant differences were found between the respective treatment modalities at final follow-up. Conclusions: Treatment with wait and see, a heel raise inlay, or physical therapy each resulted in a clinical relevant and statistical significant reduction of heel pain due to calcaneal apophysitis. No significant difference in heel pain reduction was found between individual treatment regimes. Calcaneal apophysitis is effectively treated by the evaluated regimes. Physicians should deliberate with patients and parents regarding the preferred treatment. Level of Evidence: Level 1—therapeutic randomized controlled trial.

Taping Techniques and Braces in Football

The aim of the chapter is to give an overview of the different taping techniques and types of braces used in football, conjunct with the evidence in literature of their use as treatment and prevention of ankle ligament injuries. The prevention and treatment of ankle ligament lesions are extensively discussed in the Chapters “Prevention of ankle ligament lesions” and “Treatment of acute ankle ligament lesions”.

Endoscopic treatment for posterior ankle impingement: high patient satisfaction and low recurrence rate at long-term follow-up

Objectives Good short-term outcomes have been described for endoscopic treatment of posterior ankle impingement. However, long-term outcome is unknown. The aim of this study is to determine the long-term patient satisfaction after endoscopic treatment and evaluate the recurrence rate of posterior ankle impingement. In addition, the aim of this study is to identify factors associated with favourable long-term outcome. Methods A consecutive series of patients treated endoscopically for posterior ankle impingement between 2000 and 2011 in the Academic Medical Centre in Amsterdam were retrospectively reviewed. Primary outcome was patient satisfaction. Secondary outcome measures were function, pain, recurrence rate and Foot Ankle Outcome Scores. In addition, factors associated with long-term outcome were identified. Results Two-hundred and three patients with 5–15 years of follow-up were included. Median satisfaction score was 8/10 and for 9/10 for function . Patients had no pain at follow-up. Outcome was similar for different types of impingement and type or level of sport participation. Symptoms recurred in 5% of the patients. In a multivariable analysis, additional flexor hallucis longus (FHL) tendinopathy was associated with lower satisfaction and a higher recurrence rate. Conclusion Long-term outcome of endoscopic treatment for posterior ankle impingement demonstrated good results, with high patient satisfaction, good functional outcome scores and a low rate of recurrence for all types of posterior ankle impingement. Type and level of sports did not influence outcome. Only the presence of FHL tendinopathy was associated with lower satisfaction and a higher recurrence rate. Level of evidence Level IV.

Prevalence of Os Trigonum on CT Imaging

Background: The os trigonum is known as one of the main causes of posterior ankle impingement. In the literature, a wide variation of occurrence has been reported. Methods: All foot and/or ankle computed tomography (CT) scans made between January 2012 and December 2013 were reviewed. CT images were assessed, blinded for patient characteristics, for the presence of an os trigonum, size of the os trigonum, and type of os trigonum. In addition, the shape of the lateral tubercle of the posterior talar process was assessed. Results: A total of 628 patients (1256 ankles) were included. In 32.5% of the patients of the cohort, an os trigonum was present. In 14.3% of these patients, it was present bilaterally. In a subgroup of patients without posterior ankle impingement the prevalence was 30.3%. Of the nonaffected ankles, an os trigonum was present in 23.7%. Patients with posterior ankle impingement were more likely to have an os trigonum (adjusted odds ratio [OR], 1.86). Afro-Caribbean/Surinamese/Central African origin was associated with a lower rate of occurrence of os trigonum (adjusted OR 0.43). In the ankles without an os trigonum, an enlarged lateral tubercle of the posterior talar process was found in 34.9% and 36.5% of the ankles. Conclusion: This study showed that os trigonum is a common accessory bone. With a prevalence of 30.3% in a population of patients with CT imaging of both ankles and 23.7% of the nonaffected ankles, the os trigonum is more common than previously reported. Patients with posterior ankle impingement complaints had a higher prevalence of an os trigonum. In one-third of the patients without an os trigonum, there was an enlarged lateral tubercle of the posterior talar process. Level of Evidence: Level III, retrospective comparative study.

Pain Relief After Operative Treatment of an Extremity Fracture: A Noninferiority Randomized Controlled Trial

Background: Opioid pain medication is frequently given to patients recovering from a surgical procedure for an extremity fracture in spite of evidence that acetaminophen may be adequate. The aim of this study was to determine whether prescription of step 1 pain medication (acetaminophen) is noninferior to step 2 pain medication (acetaminophen and tramadol) after operative treatment of an extremity fracture. Methods: Fifty-two patients with a single extremity fracture were randomized from July 2012 to March 2015 in this 2-week follow-up, noninferiority trial in a level-I trauma center in the Netherlands. Patients were randomly assigned to receive step 1 (acetaminophen) or step 2 (acetaminophen and tramadol) medication in standard doses on an as-needed basis on discharge. Intention-to-treat and per-protocol analyses were conducted. The primary outcome was self-reported satisfaction with pain relief measured on an 11-point ordinal scale. The hypothesis being tested was formulated before the collection of data. The mean differences between the groups were reported for intention-to-treat and per-protocol analyses. Results: A total of 52 patients, with equal baseline characteristics, were analyzed in this study; the step 1 group consisted of 27 subjects and the step 2 group consisted of 25 subjects. The mean satisfaction with pain management was 8.3 for step 1 and 8.5 for step 2 medications. This mean difference of 0.2 point (95% confidence interval [CI], −0.78 to 1.30 points) did not exceed the noninferiority margin of 2.0 points, indicating that step 1 was noninferior to step 2. A similar result was found in the per-protocol analysis (mean difference, 0.2 point [95% CI, −1.03 to 1.57 points]). Conclusions: This study offers evidence to suggest that prescription of acetaminophen is not inferior compared with acetaminophen and tramadol in patients who underwent operative treatment for an extremity fracture. Given that tramadol has more side effects and is potentially habit-forming, acetaminophen should be considered the mainstay for pain relief in patients recovering from extremity fracture surgical procedures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Treatment of Osteochondral Talar Defects

Introduction Arthroscopic debridement and bone marrow stimulation (i.e., drilling or microfracturing) is considered the primary surgical treatment of osteochondral defects of the talus. Step 1 Position the Patient For anterior ankle arthroscopy, position the patient supine; for posterior arthroscopy, position the patient prone. Step 2 Arthroscopic Approach For anterior ankle arthroscopy, place the portals medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon at the level of the ankle joint; for posterior arthroscopy, place the portals lateral and medial to the Achilles tendon just above the level of the tip of the lateral malleolus. Step 3 Debridement and Bone Marrow Stimulation Fully debride the osteochondral defect and create multiple microfractures in the bottom of the defect. Step 4 Closure and Postoperative Care Prescribe partial weight-bearing for six weeks. Results A systematic review of the literature identified eighteen studies on bone marrow stimulation that included a total of 388 patients3. The study weighted success rate was 85% (range, 46% to 100%). What to Watch For IndicationsContraindicationsPitfalls & Challenges.