Effects of medical interventions on health-related quality of life in chronic disease - systematic review and meta-analysis of the 19 most common diagnoses.

Introduction: The demographic shift leads to a tremendous increase in age-related diseases, which are often chronic. Therefore, a focus of chronic disease management should be set on the maintenance or even improvement of the patients' quality of life (QoL). One indicator to objectively measure QoL is the EQ-5D questionnaire, which was validated in a disease- and world region-specific manner. The aim of this study was to conduct a systematic literature review and meta-analysis on the QoL across the most frequent chronic diseases that utilized the EQ-5D and performed a disease-specific meta-analysis for treatment-dependent QoL improvement. Materials and methods: The most common chronic disease in Germany were identified by their ICD-10 codes, followed by a systematic literature review of these ICD-10 codes and the EQ-5D index values. Finally, out of 10,016 independently -screened studies by two persons, 538 studies were included in the systematic review and 216 studies in the meta-analysis, respectively. Results: We found significant medium to large effect sizes of treatment effects, i.e., effect size >0.5, in musculoskeletal conditions with the exception of fractures, for chronic depression and for stroke. The effect size did not differ significantly from zero for breast and lung cancer and were significantly negative for fractures. Conclusion: Our analysis showed a large variation between baseline and post-treatment scores on the EQ-5D health index, depending on the health condition. We found large gains in health-related quality of life mainly for interventions for musculoskeletal disease. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020150936, PROSPERO identifier CRD42020150936.

A systematic review of studies on the diagnostics and classification system used in surgically treated, acute, isolated, unstable syndesmotic injury: a plea for uniform definition of syndesmotic injuries.

Objective: To this day, diagnostic standards and uniform definition for acute, isolated syndesmotic injuries are missing. The aim of the current study was to conduct a systematic review of the classification systems and diagnostics currently applied and to propose a best evidence diagnostic approach. Methods: Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials, and Embase were searched from inception to June 5, 2022, for studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. First, all classifications used in the eligible studies were identified and illustrated according to the individual syndesmotic structures injured. Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intra-operatively), was analyzed, including the applied cutoff criteria. Results: Ten out of 4190 studies, comprising 317 acute ligamentous syndesmotic injuries, met the inclusion criteria. Seven studies facilitated one of the three different classification systems (Calder, West Point, or Sikka classification). Eight studies based their indication for surgery on a combination of clinical and radiographic examinations and two on radiographs only. The most applied clinical tests were the external rotation stress test and squeeze test. The most common radiologic diagnostics were plain radiographs and MRI. Intraoperatively, instability was verified most commonly using arthroscopy. Conclusion: Current classifications and diagnostics for syndesmotic injuries are heterogeneous, often cannot be attributed to the ligaments injured. An evidence-based diagnostic algorithm based on noninvasive diagnostics and an anatomy-based classification for acute syndesmotic instability is presented.

Fracture pattern analysis of fractures to the diaphysis of the fifth metatarsal.

BACKGROUND: Fractures to the fifth's metatarsal (MT-V) diaphysis are common. These are inconsistently referred to as diaphyseal-, shaft-, or Dancer's fractures. A comprehensive analysis of the MT-V fracture morphology is missing. The aim was to qualitatively and quantitatively analyze fracture patterns of MT-V diaphyseal fractures. HYPOTHESIS: Fractures to the shaft of the fifth metatarsal feature specific fracture morphologies. MATERIALS AND METHODS: Retrospective, radiologic database study. Included were all acute, isolated MT-V shaft fractures (including the proximal [Lawrence and Botte (L&B) III] and distal meta-diaphysis). Demographics and fracture characteristics were assessed. Each proximal fracture line was drawn, scaled, and a qualitative and quantitative fracture line analysis was conducted. The quantitative fracture line analysis aimed at identifying dens clusters with arbitrary shape using the DBSCAN algorithm. Data are presented as mean±standard deviation. RESULTS: Out of 704 eligible MT-V fractures, 156 met the inclusion criteria. Patient's mean age was 46±19 years and 94% suffered a low energy trauma. Qualitative and quantitative fracture line analysis revealed three distinct fracture patterns. The proximal (30%) and distal (5%) meta-diaphyseal clusters showed a predominant transverse fracture pattern. The vast majority of diaphyseal fractures (56%) were spiral/oblique fractures, progressing from the proximal lateral meta-diaphyseal region in an oblique course at 61±9° to the medial distal diaphyseal cortex. Seven percent of diaphyseal fractures showed a transverse fracture pattern. DISCUSSION: Based on a qualitative and quantitative analysis of all MT-V shaft fractures, three distinct fracture clusters were identified with homogeneous fracture patterns. MT-V shaft fractures should therefore be classified as proximal meta-diaphyseal (L&B Type III), diaphyseal (oblique or transverse) and distal meta-diaphyseal. LEVEL OF PROOF: IV; retrospective database study.

Recurrence rates for surgically treated insertional Achilles tendinopathy.

INTRODUCTION: Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery. MATERIALS AND METHODS: The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed. RESULTS: Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence. CONCLUSION: IAT recurrence after primary surgery occurs in up to 14% of patients. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Pedobarographic evaluation of five commonly used orthoses for the lower extremity.

INTRODUCTION: Orthoses are designed to achieve immobilization or off-loading of certain regions of the foot. Yet, their off-loading capacity for the specific regions has not yet been studied. Therefore, the aim of this study was to analyze the plantar pressure distribution of five commonly applied orthoses for foot and ankle in a healthy population. MATERIALS AND METHODS: Five orthoses (postoperative shoe, forefoot relief shoe, short walker boot, high walker boot, and calcaneus fracture orthosis) were compared pedobarographically using insoles on a treadmill to a ready-made running shoe in eleven healthy subjects (median age 29 years). Peak pressure, maximum force, force-time integral, contact time, and contact area were evaluated separately for the forefoot, midfoot, and hindfoot. RESULTS: The forefoot relief shoe, the short- and high walker boot significantly reduced the peak pressure at the forefoot with no significant differences between these orthoses. None of the five orthoses off-loaded the midfoot, but the calcaneus fracture orthosis and the short walker boot instead increased midfoot load. For the hindfoot, the calcaneus fracture orthosis was the only device to significantly reduce the peak pressure. CONCLUSIONS: This is the first study to investigate the specific off-loading capacities of different orthoses for specific foot regions in a healthy collective. The knowledge of absolute and relative load shifts for the different orthoses is of fundamental interest for targeted clinical decision-making of physicians.

Acute, isolated fractures of the metatarsal bones: an epidemiologic study.

INTRODUCTION: Although metatarsal fractures are common, the significance of previous epidemiologic studies is limited to specific fracture entities, subpopulations, or heterogeneous fracture aetiologies. The aim of the study was to assess the epidemiology of isolated metatarsal fractures in an adult population at a level-1 trauma centre. MATERIALS AND METHODS: Radiological and clinical databases were searched for a five-year period. Eligible were all patients with acute isolated metatarsal fractures over the age of 18 years with radiographs in two planes available. Stress fractures, injuries affecting Lisfranc joint stability, and concomitant injuries to other regions than the metatarsals were excluded. Data collection included general demographics, mechanism of injury, season of the trauma and fracture details. RESULTS: Out of 3259 patients, 642 patients met the inclusion criteria and were included for the analysis. The patients' mean age was 44.5 ± 18.9 years, 50.6% were female. 83.3% suffered an isolated, 16.7% multiple metatarsal fractures. Single metatarsal fractures occurred predominantly at the fifth metatarsal bone (81.3%), their frequency decreased with increasing age, with a seasonal peak during the summer. Patients suffering multiple metatarsal fractures were significantly older (51.6 ± 21.2 vs. 43.0 ± 18.1 years; p < 0.001) and the injury resulted significantly more often from a high-energy trauma (6.7% vs. 23.4%; p < 0.001). Multiple metatarsal fractures occurred evenly throughout all metatarsals but revealed a focus on female population with no seasonal differences. CONCLUSION: Single metatarsal fractures predominantly occurred at the fifth metatarsal bone and showed a seasonal, gender and age dependency. Multiple metatarsal fractures were homogeneously distributed between the different metatarsals with distinct age-dependent gender differences. LEVEL OF EVIDENCE: Level III.

Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis.

BACKGROUND: Hallux valgus is the most common foot deformity and affects 23% to 35% of the general population. More than 150 different techniques have been described for surgical correction. Recently, there has been increasing interest in the use of minimally invasive surgery to correct hallux valgus deformities. A variety of studies have been published with differing outcomes regarding minimally invasive surgery. However, most studies lack sufficient power and are small, making it difficult to draw adequate conclusions. A meta-analysis can therefore be helpful to evaluate and compare minimally invasive and open surgery. QUESTIONS/PURPOSES: We performed a systematic review and meta-analysis of randomized controlled trials and prospective controlled studies to answer the following question: Compared with open surgery, does minimally invasive surgery for hallux valgus result in (1) improved American Orthopaedic Foot and Ankle Society (AOFAS) scores and VAS scores for pain, (2) improved radiologic outcomes, (3) fewer complications, or (4) a shorter duration of surgery? METHODS: The systematic review and meta-analysis was conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Intervention and the Preferred Reporting Items for Systematic Reviews and Meta-analyses. A search was performed in the PubMed, Embase, Scopus, CINAHL, and CENTRAL databases on May 3, 2022. Studies were eligible if they were randomized controlled or prospective controlled studies that compared minimally invasive surgery and open surgery to treat patients with hallux valgus. We defined minimally invasive surgery as surgery performed through the smallest incision required to perform the procedure accurately, with an incision length of approximately 2 cm at maximum. Open surgery, on the other hand, involves a larger incision and direct visualization of deeper structures. Seven studies (395 feet), consisting of six randomized controlled studies and one prospective comparative study, were included in the qualitative and quantitative data synthesis. There were no differences between the minimally invasive and open surgery groups regarding age, gender, or severity of hallux valgus deformity. Each included study was assessed for the risk of bias using the second version of the Cochrane tool for assessing the risk of bias in randomized trials or by using the Newcastle-Ottawa Scale for comparative studies. Most of the included studies had intermediate quality regarding the risk of bias. We excluded one study from our analysis because of its high risk of bias to avoid serious distortions in the meta-analysis. We performed a sensitivity analysis to confirm that our meta-analysis was robust by including only studies with a low risk of bias. The analyzed endpoints included the AOFAS score (range 0 to 100), where higher scores represent less pain and better function; the minimum clinically important difference on this scale was 29 points. In addition, the VAS score was analyzed, which is based on a pain rating scale (range 0 to 10), with higher scores representing greater pain. Radiologic outcomes included the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle. Complications were qualitatively assessed and evaluated for differences. A random-effects model was used if substantial heterogeneity (I 2 > 50%) was found; otherwise, a fixed-effects model was used. RESULTS: We found no clinically important difference between minimally invasive and open surgery in terms of the AOFAS score (88 ± 7 versus 85 ± 8, respectively; mean difference 4 points [95% CI 1 to 6]; p < 0.01). There were no differences between the minimally invasive and open surgery groups in terms of VAS scores (0 ± 0 versus 0 ± 1, respectively; standardized mean difference 0 points [95% CI -1 to 0]; p = 0.08). There were no differences between the minimally invasive and open surgery groups in terms of the hallux valgus angle (12° ± 4° versus 12° ± 4°; mean difference 0 points [95% CI -2 to 2]; p = 0.76). Radiographic measurements of the intermetatarsal angle did not differ between the minimally invasive and open surgery groups (7° ± 2° versus 7° ± 2°; mean difference 0 points [95% CI -1 to 1]; p = 0.69). In addition, there were no differences between the minimally invasive and open surgery groups in terms of the distal metatarsal articular angle (7° ± 4° versus 8° ± 4°; mean difference -1 point [95% CI -4 to 2]; p = 0.28). The qualitative analysis revealed no difference in the frequency or severity of complications between the minimally invasive and the open surgery groups. The minimally invasive and open surgery groups did not differ in terms of the duration of surgery (28 ± 8 minutes versus 40 ± 10 minutes; mean difference -12 minutes [95% CI -25 to 1]; p = 0.06). CONCLUSION: This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the source studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. Given the associated learning curves-during which patients may be harmed by surgeons who are gaining familiarity with a new technique-we are unable to recommend the minimally invasive approach over traditional approaches, in light of the absence of any clinically important benefits identified in this meta-analysis. Future research should ensure studies are methodologically robust using validated clinical and radiologic parameters, as well as patient-reported outcome measures, to assess the long-term outcomes of minimally invasive surgery.

Rerupture and wound complications following Achilles tendon repair: A systematic review.

Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.

Revision Surgery and Wound Complications with Minimally Invasive Compared to Open Achilles Tendon Repair: A Retrospective Comparative Study of 116 Patients.

The current study analyzed revision surgery rate and wound complications of patients with Achilles tendon ruptures that received either minimally invasive repair or open standard repair. A retrospective chart review of patients that had Achilles tendon repair performed using either an open or minimally invasive technique was conducted. Primary outcomes were revision surgery rate and wound complication rate. Twenty-nine (25.0%) patients had the minimally invasive approach, while 87 (75.0%) had the open approach. On average there were 0.16 additional surgeries per patient in the open group versus none in the minimally invasive group (p = 0.003). There were 13 wound-related complications, all of which were in the open group (p = 0.06). Revision surgery rates are significantly higher for patients treated with open Achilles repair versus those treated with a minimally invasive technique. Patients may benefit from a minimally invasive as opposed to open technique. (Journal of Surgical Orthopaedic Advances 32(3):173-176, 2023).

"High ankle block" for surgery at the ankle joint.

BACKGROUND: Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region. METHODS: The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach. RESULTS: The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia. CONCLUSIONS: The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

Anatomical and biomechanical evaluation of the lateral calcaneo-cuboid and bifurcate ligaments.

BACKGROUND: This study aims to analyze the ligaments of the dorso-lateral calcaneo-cuboid joint and to assess the biomechanical relevance of the bifurcate ligament. METHODS: 16 specimens were analyzed for their ligamentous anatomy of the dorso-lateral calcaneo-cuboid joint and side-alternating assigned to two groups with varying ligamentous dissection order. The Chopart joint was stressed in plantar, medial, and lateral direction measuring the displacement by an 3D motion tracker for every dissection step. RESULTS: 37.5% of specimens had all ligaments (lateral calcaneo-cuboid, dorsal calcaneo-cuboid, bifurcate calcaneo-cuboid, bifurcate calcaneo-navicular), 37.5% were lacking bifurcate´s calcaneo-cuboid-portion, and 25% presented without dorsal calcaneo-cuboid. Biomechanical testing revealed no significant displacement within the calcaneo-cuboid or talo-navicular joint for any stressed state except for axial compression with dissected dorsal talo-navicular joint capsule in Group 2. CONCLUSION: Broad morphological variability and missing significant displacement regardless of its integrity, make the bifurcate ligament appear of limited biomechanical relevance.

[Open or arthroscopic arthrodesis of the ankle joint : Which is better?] / Offene oder arthroskopische Arthrodese des Sprunggelenks : Was ist besser?

Due to the change in the age structure in Germany and the steadily increasing number of fractures, arthrosis of the upper ankle joint, mainly caused by posttraumatic conditions, is becoming more and more relevant in routine trauma surgery and orthopedics. Patients suffer from reduced functionality and quality of life as well as immobilizing pain. In addition to an ankle joint prosthesis arthrodesis of the upper ankle joint offers an alternative for the treatment of advanced arthrosis. When performing an arthrodesis there is basically the option of both open and arthroscopic procedures to prepare the joint and remove the cartilage. In both procedures the upper ankle joint is usually fixed with 2-3 cannulated compression screws. Comparative studies to date have shown an advantage of the arthroscopic technique in terms of complication rate, length of hospitalization, proportion of ossification and functional outcome. The indications for arthroscopic fusion should be strictly considered, especially in the case of malalignment, as major axis corrections are difficult to perform. In such cases, open fusion of the upper ankle joint still seems superior to the arthroscopic method.

Trends of incidence and treatment strategies for operatively treated distal fibula fractures from 2005 to 2019: a nationwide register analysis.

INTRODUCTION: Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years. MATERIALS AND METHODS: Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy. RESULTS: During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail. CONCLUSIONS: Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.

Do pre-operative radiologic assessment predict postoperative outcomes in patients with insertional Achilles tendinopathy?: a retrospective database study.

INTRODUCTION: Diagnosis and treatment of insertional tendinopathy of the Achilles tendon (IAT) remains a challenge. The aim of this study was to assess the influence of pre-operative radiological pathologies on the patient-reported outcomes following open debridement of all pathologies for IAT. MATERIALS AND METHODS: In this IRB-approved retrospective correlation and comparative study, patients with pre-operative imaging were identified from the authors' retrospective IAT database comprising of 118 patients. All were treated by a standardized surgical treatment strategy utilizing a midline, transachillary approach and debridement of all pathologies. A total of fifteen radiologic parameters were measured on radiographs (RX) and MRI. The patient-reported outcomes were assessed using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G) and the general health questionnaire SF-12 at a minimum follow-up of 12 months. The data are presented as mean ± SD (95% CI). RESULTS: 88 patients (74.6%) with an average age of 50 ± 12 (47-52) years were included. Radiographs were available in 68 patients and MRI in 53. The mean follow-up was 3.8 ± 1.9 (3.4-4.3) years. The overall VISA-A-G was 81 ± 22 (77-86), the SF-12 PCS 54 ± 7 (52-55), and the SF-12 MCS 52 ± 9 (50-54) points. None of the assessed radiological parameters had a significant influence on the patient-reported outcome following surgical treatment for IAT. CONCLUSION: In this retrospective correlation study, no significant association was found between preoperative radiographic and MRI radiologic parameters for IAT and postoperative patient-reported outcomes (VISA-A-G and SF-12).

Fifth Metatarsal Fracture­A Systematic Review of the Treatment of Fractures of the Base of the Fifth Metatarsal Bone.

BACKGROUND: Metatarsal fractures are among the most common foot and ankle injuries, with an annual incidence of 6.7 per 100 000 persons. Approximately 30% of metatarsal fractures affect the base of the fifth metatarsal bone. Nevertheless, no evidence-based treatment recommendations are available to date. METHODS: The three fracture localizations according to Lawrence and Botte (zone I, proximal to the intermetatarsal joint between the fourth and fifth metatarsal bones; zone II, in the area of the joint; zone III, at the distal end of the joint) are analyzed on the basis of a systematic literature search. Studies were included that compared the treatment of two types of fracture in the same manner, or that compared two different treatments for a single type of fracture. RESULTS: Nine studies compared different treatments of zone I fractures. Two of these were randomized controlled trials (RCTs); in one RCT, patients given functional therapy returned to work much sooner than those treated with immobilization (11 vs. 28 days; p = 0.001), with otherwise similar outcomes. The non-randomized studies revealed a faster return to full function (33 vs. 46 days; p<0.05) with early functional therapy, and similar outcomes for immobilization and surgery. One RCT that compared functional therapy with immobilization for zone II fractures revealed no statistically significant difference. Five studies compared fractures in zones I and II that were treated in the same manner, revealing similar outcomes. One RCT compared surgery and immobilization for zone III fractures: surgery led to statistically significant improvement of the outcome in all of the measured parameters. CONCLUSION: Fractures in zones I and II should be treated with early functional therapy. There seems to be no reason to consider zone I and II fractures as two separate entities, as the outcomes in the two groups are similar. In contrast, fractures in zone III should primarily be treated surgically.

Patient-Reported Outcomes of Surgically Treated Insertional Achilles Tendinopathy.

BACKGROUND: The aim of this study was to assess the patient-reported outcome measures (PROMs) in patients with insertional Achilles tendinopathy (IAT) treated surgically by debridement of all pathologies through a midline-incision trans-achillary approach (MITA). METHODS: This is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, with at least 12 months of follow-up were included. Demographics, medical history, surgical details, and complications were recorded. Patient-reported outcomes were assessed using the Foot Function Index (FFI), Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G), visual analog scale foot and ankle (VAS-FA), and 12-Item Short-Form Health Survey (SF-12). Longitudinal FFI data were available for 48% of the patients. RESULTS: A total of 118 patients (63.4%) with a mean follow-up of 50 ± 25 months were included. The FFI improved from 53 (24) preoperatively to 2 (11) points at the final follow-up. The final VISA-A-G score was 93 (26), the VAS-FA score 93 (15), the SF-12 Physical Component Summary 56 (8), and the SF-12 Mental Component Summary 55 (12) points. There was an additional FFI improvement between 12 months and the final follow-up. Up to 47% (VISA-A-G) of patients had residual symptoms. A postoperative shoe conflict was the only parameter negatively affecting the PROMs (P < .001). CONCLUSION: Addressing all pathologies of IAT by the MITA resulted in overall good postoperative PROMs after 4 years. But up to 47% of patients remained impaired. The only parameter correlating with an impaired PROM was a postoperative shoe conflict. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies.

PURPOSE: Although simultaneous arthroscopy for the surgical treatment of acute isolated, unstable syndesmotic injuries has been recommended, little knowledge is present about the actual frequency of intra-articular pathologies for this injury. The aim of this study was to investigate the frequency and severity of intra-articular pathologies detected during arthroscopy and their subsequent treatment in acute isolated, unstable syndesmotic injuries. METHODS: A retrospective chart review of patients treated by arthroscopic-assisted stabilization for acute isolated, syndesmotic instability was performed. The primary outcome parameter was the frequency of intra-articular pathologies. Secondary outcome parameters were the type of syndesmotic lesion (ligamentous/bony), severity of chondral lesions, MRI findings, treatment details, complications and the identification of factors associated with intra-articular pathologies. RESULTS: Twenty-seven patients, 19% female, with a mean age of 37 ± 12 years met the inclusion criteria. 70% suffered isolated ligamentous injuries, the remaining suffered avulsion fractures of the syndesmosis. Chondral lesions occurred in 48% (ICRS grade II: 33%; ICRS grade IV 15%) and intra-articular loose bodies in 11% of patients. Overall, arthroscopy revealed intra-articular pathologies necessitating further treatment in 19% of patients. Neither the type of syndesmotic injury (bony vs. ligamentous; ns) nor the degree of ligamentous instability (West Point IIB vs. III; ns) had a significant influence on the occurrence of chondral lesions. One complication (SSI) occurred. Pre-operative MRI revealed a sensitivity/specificity of 100/79% for chondral lesions and 50/93% for loose bodies. CONCLUSION: Intra-articular pathologies in acute isolated, unstable syndesmotic injuries occur in up to 50% of patients, 19% necessitated additional treatment. Simultaneous arthroscopy, independent of the pre-operative MRI findings, appears reasonable in highly active patients. LEVEL OF EVIDENCE: Level III.

Propensity Score-Matched Analysis of Arthroscopically Assisted Ankle Facture Treatment Versus Conventional Treatment.

BACKGROUND: The aim of this study was to assess the prospective, longitudinal outcome after arthroscopically assisted open reduction and internal fixation (AORIF) and to compare the results with open reduction and internal fixation (ORIF) in complex ankle fractures. METHODS: Acute, closed, bimalleolar equivalent, bimalleolar, or trimalleolar ankle fractures were included. The AORIF cohort was enrolled prospectively. The ORIF group was identified from a retrospective database. The same inclusion and exclusion criteria were applied. The only difference was the additional arthroscopy in the AORIF cohort. The patient-reported outcome measurement (PROM) following AORIF was assessed at 1 and 4 years of follow-up using the Olerud and Molander Ankle Score (OMAS) and Tegner activity scale (TAS). The AORIF cohort was propensity score matched (nearest-neighbor matching) to the ORIF database. The OMAS and Foot and Ankle Ability Measure (FAAM) were compared between the resulting groups. Nonparametric statistics were applied; values are presented as median (interquartile range). Twenty-six AORIF patients had a prospective 4-year follow-up. RESULTS: No significant differences (1 year vs 4 years) were identified for the OMAS (90 [10] vs 90 [11]) and TAS (4 [2] vs 5 [2]). The severity of the cartilage lesions (International Cartilage Repair Society [ICRS] grade <4 vs ICRS of 4) had no significant influence on the PROMs. Twenty-five patients per cohort (AORIF vs ORIF) were matched. The OMAS (90 [13] vs 75 [40]; P = .008) and FAAM Activities of Daily Living (ADL; 96 [11] vs 88 [30]; P = .034) revealed significantly better outcomes for AORIF. More patients in the AORIF cohort returned to sport (96% vs 77%; P = .035), with a higher FAAM Sports score (88 [37] vs 56 [47]; P = .008). CONCLUSION: AORIF for complex ankle fractures led to consistently good to excellent results. The propensity score-matched analysis revealed a significantly better outcome 4 years after surgery for AORIF compared with ORIF. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Complications Associated With Midline Incision for Insertional Achilles Tendinopathy.

BACKGROUND: The midline-incision trans-achillary approach (MITA) is frequently used for addressing all pathologies of insertional Achilles tendinopathy (IAT). The aim of this study was to assess the complication rate and possible influencing factors following a MITA for IAT treatment. METHODS: Presented is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, between January 2010 and October 2016 at a single reference center with at least 12 months of follow-up were included. General demographics (age, sex, and body mass index), medical history, surgical details (individual and sum of pathologies addressed), and duration of in-hospital stay were assessed. Patient satisfaction, shoe conflict, current employment status, time to return to sports, and type of sports were recorded using a custom questionnaire. Standard statistics, chi-square, and t tests were performed using SPSS. A total of 118 patients (follow-up, 63.4%) with a mean age (± SD) of 50 ± 12 years and a mean final follow-up time (± SD) of 4.2 ± 2.1 were included. RESULTS: Fourteen percent of patients had a minor complication, the majority (75%) of which were surgical site infections. Forty-one percent were limited in their shoe selection, and 32% reported a shoe conflict. Seventy-eight percent were very satisfied, and 89% would recommend the surgery. Neither the individual surgical procedures, their sum, nor any other parameter showed a significant influence on the complication rate. The only factor negatively affecting patient satisfaction was a shoe conflict (P < .001). CONCLUSION: The MITA for IAT treatment showed a moderate minor complication rate with good midterm patient satisfaction. However, the approach might predispose patients to shoe conflict, which negatively influences their satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.