Knees with anteromedial osteoarthritis show a substantial phenotypic variation prior and following medial unicompartmental knee arthroplasty.

PURPOSE: The primary aim of this study was to evaluate the phenotypic variation using the Coronal Plane Alignment of the Knee (CPAK) classification among 1000 knees with anteromedial osteoarthritis (OA) both prior to and following medial unicompartmental knee arthroplasty (UKA). The secondary aim of this study was to investigate whether knees maintained their preoperative CPAK phenotype and to evaluate the phenotypic alterations following medial UKA. METHODS: The CPAK classification was used to analyze 1000 knees that underwent medial UKA as treatment for anteromedial OA. Knees were categorized into nine distinct CPAK phenotypes based on their arithmetic hip-knee-ankle angle (aHKA), which estimates the pre-arthritic alignment, and joint line obliquity (JLO), both pre- and postoperatively. Phenotypic variation was analyzed by sex and age, and the phenotypic alterations following medial UKA were evaluated by phenotype. RESULTS: Preoperatively, CPAK phenotype I had the highest prevalence (45.0%). Among males, the preoperative prevalence of CPAK phenotype I was significantly higher compared to females (53.2% vs. 35.0%, respectively; p ≤ .001), whereas females exhibited a significantly higher occurrence of CPAK phenotype V compared to males (9.8% vs. 4.4%, respectively; p ≤ .015). Following medial UKA, CPAK phenotype II had the highest prevalence (53.3%). Overall, 45.1% of knees maintained their preoperative CPAK phenotype following medial UKA, which was most frequently observed among CPAK phenotype II (67.7%) and III (65.8%). CONCLUSION: There is a substantial variation in CPAK phenotypes among knees with anteromedial OA, as well as following treatment with medial UKA. This variability challenges the assumption of uniform characteristics among knees with an identical wear pattern associated with anteromedial OA and emphasizes the complexity and variability of this specific form of OA. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study.

PURPOSE: Portable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress. METHODS: Ten fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior-inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior-inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy. RESULTS: When assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy. CONCLUSION: P-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis.

PURPOSE: The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis. METHODS: Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol. RESULTS: The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions. CONCLUSION: Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers. LEVEL OF EVIDENCE: Level II.

Adequate union rates for the treatment of acute proximal fifth metatarsal fractures.

PURPOSE: To compare the bone healing, clinical, and return to daily activity outcomes after either surgical or conservative management of acute zone 1, 2, and 3 fifth metatarsal fractures. METHODS: A literature search was performed to identify studies published from the earliest record to January 2019 using EMBASE (Ovid), MEDLINE via PubMed, CINAHL, and Web of Science. All articles assessing clinical outcomes of acute proximal fifth metatarsal fractures were included. Bone healing and clinical outcomes were thereafter calculated using a simplified pooling method. RESULTS: Thirty-two articles comprising of a total of 1,239 fractures were included, of which one was a randomized controlled trial, seven were prospective studies, and 24 were retrospective studies. 627 zone 1 fractures demonstrated union rates of 93.2% following conservative treatment and 95.1% following surgical treatment. Conservatively managed zone 1 fractures were displaced 49.5% of the time, compared to a rate of 92.8% for the surgically treated cases. For Jones' (zone 2) fractures, bone healing outcomes of conservative versus surgical treatment showed union rates of 77.4% versus 96.3%, refracture rates of 2.4% versus 2.1%, and mean time to union of 11.0 weeks versus 9.4 weeks, respectively. Only ten proximal diaphyseal (zone 3) fractures were reported, with a mean return to work of 8.2 weeks. CONCLUSION: Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. In contradistinction, acute zone 2 fractures demonstrate higher union rates and faster time to union when treated surgically. The outcomes of acute zone 3 fractures are rarely reported in the literature, so treatment recommendations remain unclear. Further research of proximal fifth metatarsal fractures is warranted to provide more definitive conclusions, but current findings can aid surgeons during the shared clinical decision making process. LEVEL OF EVIDENCE: IV.

Ceramic-on-ceramic articulation in press-fit total hip arthroplasty as a potential reason for early failure, what about the survivors: a ten year follow-up.

PURPOSE: In press-fit total hip arthroplasty (THA), primary stability is needed to avoid micromotion and hereby aseptic loosening, the main reason for early revision. High aseptic loosening revision rates of the seleXys TH+ cup (Mathys Medical) with Ceramys ceramic-on-ceramic (CoC) bearing are seen in literature. Since CoC is presumed to overcome long-term wear-related revisions, the reason for early failure of this cup is important to clarify. The aim is to investigate its ten year outcomes and differentiate between potential causes and identify risk factors for aseptic loosening. METHODS: Retrospective screening of a prospectively documented series of 315 THAs was performed. Primary outcome was cumulative incidence of cup revision due to aseptic loosening. Secondary outcomes were component revision and reoperation. Additionally, potential predictive factors for aseptic loosening were evaluated. RESULTS: At the median follow-up of 9.7 years [IQR 4.4; 10.3], 48 TH+ (15.2%) were revised due to aseptic loosening. Competing risk analysis showed a ten year cumulative incidence of cup revision due to aseptic loosening of 15.6% (95% CI 12.0-20.2). Stabilization of early revision rates was observed, following a high rate of respectively 81.3% (n = 39) and 95.8% (n = 46) within the first two and three years. No significant predictive factors for aseptic loosening were found. CONCLUSION: The ten year results of seleXys TH+ cup with Ceramys CoC bearing showed an unacceptable high aseptic loosening rate, which stabilized over time after a high early failure incidence. This could be attributed to a problem with osseointegration during the transition of primary to definitive stability.

It's a thin line: development and validation of Dixon MRI-based semi-quantitative assessment of stress-related bone marrow edema in the wrists of young gymnasts and non-gymnasts.

PURPOSE: To assess reliability and clinical utility of evaluating stress-related metaphyseal water distribution using a semi-quantitative Dixon MRI-based method for early diagnosis of physeal stress injuries in adolescent gymnasts. METHODS: Twenty-four gymnasts with clinically suspected overuse injury of the distal radial physis, 18 asymptomatic gymnasts, and 24 non-gymnast controls aged 12 ± 1.5 years prospectively underwent hand radiographs and 3T MRI of the wrist including coronal T1-weighted and T2-weighted Dixon sequences. Two raters measured metaphyseal water signal fraction in 13 radial and ulnar regions of interest (ROI). Inter- and intrarater reliability, interslice (between 3 middle radial slices), and inter-ROI (between 3 ROIs on same level) reliability were assessed using intraclass correlation coefficients (ICC). Water signal fractions and their within-person ratios in distal versus most proximal ROIs were compared between groups using one-way analysis of variance. RESULTS: Inter- and intrarater ICCs were 0.79-0.99 and 0.94-1.0 for T1-weighted, and 0.88-1.0 and 0.88-1.0 for T2-weighted Dixon. Interslice and inter-ROI ICCs were 0.55-0.94 and 0.95-0.97 for T1-weighted, and 0.70-0.96 and 0.96-0.97 for T2-weighted Dixon. Metaphyseal water signal fraction in symptomatic gymnasts was higher in six distal ROIs compared with asymptomatic gymnasts and in nine ROIs compared with non-gymnasts (p < 0.05). Metaphyseal water score (ratio of distal versus most proximal ROIs) was 1.61 in symptomatic gymnasts and 1.35 in asymptomatic gymnasts on T2-weighted Dixon (p < 0.05). CONCLUSION: Semi-quantitative Dixon MRI-based water signal fraction assessment has good to excellent reproducibility and shows increased metaphyseal water scores in symptomatic gymnasts compared with asymptomatic gymnastic peers. KEY POINTS: • The proposed Dixon MRI-based semi-quantitative method for assessment of metaphyseal bone marrow water content is reliable, with off-the-shelf availability and short scan times. • The metaphyseal water score allows comparisons between gymnasts using a within-person reference area for unaffected metaphyseal bone. • As metaphyseal water score was increased in symptomatic gymnasts compared with asymptomatic gymnasts, this semi-quantitative method can potentially be used as an indicator of bone marrow edema in the early diagnosis of gymnastic physeal stress injury.

A step-by-step arthroscopic examination of the anterior ankle compartment.

PURPOSE: Despite the increased use of ankle dorsiflexion without distraction, no reports have specifically addressed the arthroscopic anatomy of the ankle in this position. The purpose of this study was to describe the normal arthroscopic anatomy of the ankle joint, when using the ankle dorsiflexion and the dynamic distraction technique, and to propose an arthroscopic examination system for the anterior ankle compartment. METHODS: Ankle arthroscopy was performed in 20 fresh frozen specimens. Arthroscopic examination was performed with the arthroscope introduced through the anteromedial portal. The anterior compartment was examined in ankle dorsiflexion without distraction. The compartment was examined in four steps: (1) lateral area including the lateral gutter; (2) the central area of the anterior tibial rim; (3) the medial area including the medial gutter; (4) the talar neck. Next, distraction was applied to visualise the anterior compartment again and to examine the central and posterior ankle compartments. RESULTS: Anatomic intra-articular structures were visualised in all specimens. Four intra-articular fat pads, one anteromedial, two syndesmotic and another posteromedial, were constantly observed. A description of the normal arthroscopic anatomy of the ankle using the ankle dorsiflexion and the dynamic distraction technique is detailed for the anterior, central and posterior compartments. CONCLUSION: The ankle arthroscopic procedure without distraction allows constant visualisation of the ATFL's superior fascicle on the floor of the lateral gutter, the ATiFL's distal fascicle laterally and the most anterior margin of the deltoid ligament in the medial gutter (anterior tibiotalar ligament). However, ankle distraction is required to observe the central and posterior compartments, but it does not provide optimal visualisation of the anterior ankle compartment structures. LEVEL OF EVIDENCE: V.

Redefining anterior ankle arthroscopic anatomy: medial and lateral ankle collateral ligaments are visible through dorsiflexion and non-distraction anterior ankle arthroscopy.

PURPOSE: A thorough understanding of the arthroscopic anatomy is important to recognise pathological conditions. Although some ankle ligaments have been described as intra-articular structures, no studies have assessed the full visibility of these structures. The purpose of this study was to assess arthroscopic visibility of medial and lateral ankle collateral ligaments. METHODS: Arthroscopy was performed in 20 fresh frozen ankles. The arthroscope was introduced through the anteromedial portal and the anterior compartment was explored in ankle dorsiflexion without distraction. Intra-articular structures were tagged using a suture-passer introduced percutaneously and they were listed in a table according to the surgeon's identification. After the arthroscopic procedure, the ankles were dissected to identify the suture-tagged structures. RESULTS: According to the suture-tagged structures, 100% correlation was found between arthroscopy and dissection. In the anterior compartment, the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament on the medial side were observed. The deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament were tagged at the posterior compartment. CONCLUSION: Ankle dorsiflexion and non-distraction arthroscopic technique allows full visualisation of the medial and lateral ankle collateral ligaments: the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament. When using distraction, posterior structures as the deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament can be observed with anterior arthroscopy.

Anatomic lectures on structures at risk prior to cadaveric courses reduce injury to the superficial peroneal nerve, the commonest complication in ankle arthroscopy.

PURPOSE: To assess the effectiveness of cadaveric ankle arthroscopy courses in reducing iatrogenic injuries. METHODS: A total of 60 novice surgeons enrolled in a basic cadaveric ankle arthroscopy course were divided into two groups. Group A (n = 32) was lectured on portal placement and use of the arthroscope, whereas group B (n = 28) was in addition lectured on specific portal-related complications. Following the performance of anterior ankle arthroscopy and hindfoot endoscopy, the specimens were dissected and carefully assessed for detection of any iatrogenic injuries. RESULTS: The rate of injury to the superficial peroneal nerve (SPN) was reduced from 25 to 3.6%, in group A compared with B (p = 0.033). Injuries to the peroneus tertius or extensor digitorum longus, the flexor hallucis longus and the tibial nerve or the Achilles tendon were also reduced in group B. Overall, the number of uninjured specimens was 50% (n = 30) and higher in group B (57%) than group A (44%). Lesions to the plantaris tendon, the sural nerve or the posterior tibial artery were more common in group B, however, without reaching statistical significance. Overall, 25 (13.9%) anatomic structures were injured in anterior arthroscopy compared to 18 (5%) in hindfoot endoscopy, out of a potential total of 180 and 360, respectively (p = 0.001). CONCLUSION: Dedicated lectures on portal-related complications have proven useful in reducing the risk of injury to the SPN, the commonest iatrogenic injury encountered in ankle arthroscopy. Hindfoot endoscopy is significantly safer than anterior ankle arthroscopy in terms of injury to anatomical structures.

The anterior tibiofibular ligament has a constant distal fascicle that contacts the anterolateral part of the talus.

PURPOSE: The anterior tibiofibular ligament (ATiFL) and its distal fascicle have been the subject of numerous studies, mainly due to the involvement of this ligament in anterolateral soft-tissue impingement of the ankle. There is currently no firm evidence related to the incidence of the distal fascicle or the frequency with which it is in contact with the talus, or whether this is a constant anatomic finding. In addition, the terminology used to refer to this structure is not accurate and varies widely in previous studies. The purpose of this study was to perform an anatomic study on a large number of specimens to clarify the anatomy of the anterior tibiofibular ligament, and specifically its distal fascicle, and its possible role in anterior ankle impingement syndrome. METHODS: During a 7-year period (2010-2016), cadaveric ankle specimens dissected at our Anatomy Department were included in this study, accounting for a total of 154 ankles. The incidence of the distal fascicle and its contact with the talus were documented. RESULTS: One hundred and seventeen ankles were included [78 men, 39 women, with a median age of 79.3 years (range 51-100 years)]. The ATiFL was found to have a distal fascicle in 100% of ankles, contacting the anterolateral part of the talus in all cases. The contact was increased in plantarflexion and reduced in dorsiflexion and finally disappeared completely in maximum dorsiflexion. CONCLUSIONS: The ATiFL has a constant distal fascicle that is in contact with the talus in the neutral position and in plantar flexion. Contact disappears in maximum dorsiflexion.

Medial closing wedge high tibial osteotomy for valgus tibial deformities: good clinical results and survival with a mean 4.5 years of follow-up in 113 patients.

PURPOSE: A varus-producing medial closing wedge high tibial osteotomy (MCWHTO) is an uncommon procedure. The aim of this retrospective study was to assess the survivorship and prevalence of post-operative subjective knee laxity and satisfaction in a large cohort of patients with a MCWHTO performed without a MCL-reefing procedure. METHODS: All patients (n = 176) who underwent a MCWHTO in our clinic between 2008 and 2016 were approached to participate. After review of patient charts, questionnaires were sent to willingly patients. Primary outcome was the survivorship of the MCWHTO; secondary outcome was patient-reported instability and satisfaction. RESULTS: One-hundred and thirteen patients participated in the study. The 5-year survival rate of the MCWHTO was almost 80%. A total of 77% of the patients was satisfied with the treatment. With regard to post-operative subjective knee laxity, 26% of the patients experienced instability of the knee post-operation. Instability was significantly correlated with the KOOS domains, the Lysholm score, the IKDC knee function score and the Physical and Mental Health Domains of the SF-36. CONCLUSION: Medial closing wedge high tibial osteotomy provides good results regarding survivorship and patient satisfaction for patients with a valgus deformity which is located in the proximal tibia. Clinically relevant is that in the surgical technique without MCL-reefplasty instability is significantly correlated with worse patient-reported outcome measures. The addition of a MCL reefing procedure will improve outcome in selected patients. LEVEL OF EVIDENCE: III.

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.

Measurement properties of the most commonly used Foot- and Ankle-Specific Questionnaires: the FFI, FAOS and FAAM. A systematic review.

PURPOSE: In the foot and ankle literature, a wide range of patient-reported outcome measures (PROMs) is used, however, consensus as to which PROMs are preferred is lacking. Selection of a PROM is among other reasons, often based on measurement properties without considering the methodological quality of the studies that evaluate these measurement properties. The aim of current study was first to identify the most frequently used foot and ankle-specific PROMs in recent orthopaedic foot and ankle literature, and second to conduct a systematic review to synthesize and critically appraise the measurement properties of these PROMS. METHODS: Six PubMed indexed journals focussing on foot and ankle research were screened to identify most commonly used foot and ankle-specific PROMs over a 2 year period (2015-2016). Subsequently, a systematic literature search was performed in PubMed, EMBASE, SPORTDiscus and Scopus to identify relevant studies on their measurement properties. Methodological quality assessment was performed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist, criteria for good measurement properties were applied, and a level of evidence was determined for the measurement properties of each domain of the questionnaires. RESULTS: The three most frequently reported PROMs were the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Activity Measure (FAAM). Among 2046 unique citations, 50 studies were included evaluating these PROMs. Evidence to support the measurement properties of the FFI was mainly lacking due to poor methodological quality. More evidence was available for the measurement properties of the FAOS and the FAAM, but overall evidence supporting all measurement properties is not yet sufficient. CONCLUSION: The best available evidence retrieved in this review showed that the FAOS and the FAAM are promising outcome measures for evaluation of patients with foot and ankle conditions, but their shortcomings should be taken into account when interpreting results in clinical setting or trials. LEVEL OF EVIDENCE: I.

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

PURPOSE: The 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. METHODS: Twenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded. RESULTS: Seventeen (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. CONCLUSIONS: The 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.

Severe musculoskeletal time-loss injuries and symptoms of common mental disorders in professional soccer: a longitudinal analysis of 12-month follow-up data.

PURPOSE: Psychological factors have shown to be predictors of injury in professional football. However, it seems that this is a two-way relationship, as severe musculoskeletal time-loss injuries have shown to be associated with the onset of symptoms of common mental disorders (CMD). There is no longitudinal study performed exploring this interaction between symptoms of CMD and injuries. The purpose of this study was to explore the interaction between severe musculoskeletal time-loss injuries and symptoms of CMD in professional football players over a 12-month period. METHODS: Players were recruited by their national players' unions in five European countries. Symptoms of CMD included in the study were related to distress, anxiety/depression, sleep disturbance and adverse alcohol use. RESULTS: A total of 384 professional football players were enrolled in the study, of whom 262 (68%) completed the 12-month follow-up period. The mean age of the participants at baseline was 27 ± 5 years, and they had played professional football for 8 ± 5 years on average. Symptoms of CMD at baseline were not associated with the onset of severe musculoskeletal time-loss injuries during the follow-up period with relative risks (and 95% CI) ranging from 0.6 (0.3-1.0) to 1.0 (0.5-2.2). In contrast, severe musculoskeletal time-loss injuries reported at baseline were associated with the onset of symptoms of CMD during the follow-up period with relative risks ranging from 1.8 (0.8-3.7) to 6.9 (4.0-11.9). CONCLUSION: No relationship was found between symptoms of CMD and the onset of severe musculoskeletal time-loss injuries. However, professional football players who suffered from severe musculoskeletal time-loss injuries are likely to develop subsequent symptoms of CMD. This study emphasizes the need for an interdisciplinary medical approach, which not only focuses on the physical but also on the mental health of professional football players. An early identification of players at risk of symptoms of CMD, such as those suffering from severe musculoskeletal injuries, creates the opportunity for an interdisciplinary clinical medical team to treat the players timely and adequately. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Safety in the operating room during orthopedic trauma surgery-incidence of adverse events related to technical equipment and logistics.

BACKGROUND: Safety in the operating room is widely debated. Adverse events during surgery are potentially dangerous for the patient and staff. The incidence of adverse events during orthopedic trauma surgery is unknown. Therefore, we performed a study to quantify the incidence of these adverse events. Primary objective was to determine the incidence of adverse events related to technical equipment and logistics. The secondary objective was to evaluate the consequences of these adverse events. METHODS: We completed a cross-sectional observational study to assess the incidence, consequences and preventability of adverse events related to technical equipment and logistics during orthopedic trauma surgery. During a 10 week period, all orthopedic trauma operations were evaluated by an observer. Six types of procedures were differentiated: osteosynthesis; arthroscopy; removal of hardware; joint replacement; bone grafting and other. Adverse events were divided in six categories: staff dependent factors; patient dependent factors; anaesthesia; imaging equipment; operation room equipment and instruments and implants. Adverse events were defined as any factor affecting the surgical procedure in a negative way. RESULTS: Hundred-fifty operative procedures were included. In 54% of the procedures, at least one adverse event occurred. In total, 147 adverse events occurred, with a range of 1-5 per procedure. Most adverse events occurred during joint replacement procedures. Thirty-seven percent of the incidents concerned defect, incorrect connected or absent instruments. In 36% of the procedures adverse events resulted in a prolonged operation time with a median prolongation of 10.0 min. CONCLUSION: In more than half of orthopedic trauma surgical procedures adverse events related to technical equipment and logistics occurred, most of them could easily be prevented. These adverse events could endanger the safety of the patient and staff and should therefore be reduced. LEVEL OF EVIDENCE: 4.

Large variation in use of patient-reported outcome measures: A survey of 188 foot and ankle surgeons.

BACKGROUND: There is an increasing interest in the use of patient reported outcome measures (PROMs). However, there is a large variety of PROMs and a lack of consensus regarding preference for their use. Aim of this study is to determine how often PROMS are used for foot and ankle disorders, for what purpose PROMs are used, and what the preferences of the foot and ankle surgeons are, when choosing a PROM to use. METHODS: Members of the Ankleplatform Study Group-Science of Variation Collaborative were invited to participate in this survey by email. The online survey consisted of six questions on the use and preferences regarding foot and ankle PROMs. RESULTS: 188 participants completed the questionnaire. Of the respondents 17% reported not to use PROMs, 72% stated to use PROMS for research, 39% routinely for patient care and 34% for registration or quality assessment. The respondents were familiar with 30 different outcome measures, of which 20 were PROMs. One of the excluded outcome measures, the AOFAS Hindfoot scale was most commonly reported as preferred outcome measure. FAOS and MOXFQ were the preferred PROMs, reported by 9.7% of the surgeons. Subsequently followed by the FFI (4.3%), the FAAM (3.7%) and the VAS-FA (3.7%). CONCLUSIONS: A large majority of the foot and ankle surgeons uses PROMs. The AOFAS hindfoot scale is mentioned as the most preferred outcome measure, while in fact this is not a PROM. Of the twenty different PROMs mentioned in this study, most reported were the FAOS and MOXFQ both supported by only 9.7% of the surgeons. For proper comparison between patients in clinical practice and research, consensus is needed on which easy-to-use PROM with adequate clinimetric properties should be used. Therefore more evidence in the field of clinimetrics of foot and ankle outcome measures is needed.

The dimensions of the tarsal sinus and canal in different foot positions and its clinical implications.

This study presents a reference for the dimensions of the tarsal sinus and canal in healthy adults in different foot positions to facilitate understanding of the kinematics of the subtalar joint, the effect of an implant, and other clinical issues. In a 3D CT stress test on 20 subjects, the right foot was forced into a neutral and eight different extreme foot positions while CT scans were obtained. The bones were segmented in the neutral foot position. The kinematics of the bones in the extreme positions were determined relative to the neutral position. The dimensions of the tarsal sinus and canal were calculated by determining the radii of the maximal inscribed spheres at 20 equidistant locations along an axis in 3D surface models of the tali and calcanei in each foot position. The radii were small on the medial side and increased laterally. Medial from the middle, the radii were small and not significantly different among the various foot positions. At the lateral side, the dimensions were affected mainly by eversion or inversion and less by dorsiflexion or plantarflexion. The pattern was reproducible among subjects, but there were between-subject differences. The dimensions are mostly determined by rotation in the frontal plane. A pivot point was found medial from the middle. These data serve as a reference and model for predicting the effect of sinus implants and understanding such clinical problems as sinus tarsi syndrome. Between-subjects differences have to be taken into account. Clin. Anat. 30:1049-1057, 2017. © 2017 Wiley Periodicals, Inc.

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.