Beneficial and limiting factors in return to work after primary total knee replacement: Patients' perspective.

BACKGROUND: Return to work (RTW) is an important outcome in Total Knee Arthroplasty (TKA). At present, 70-80%of TKA patients return to work within three to six months. OBJECTIVE: What are patients' perspectives regarding beneficial and limiting factors in RTW after TKA? METHODS: Focus groups were formed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Three major topics were explored: 1. What was beneficial for RTW after TKA; 2. What was limiting for RTW after TKA; and 3. What additional care would benefit RTW after TKA? RESULTS: Data saturation was reached after four focus groups, comprising 17 participants-nine men and eight women (median age 58, range 52-65). The focus group study identified four main themes that contributed to a successful RTW namely rehabilitation (medical) like post-operative physical therapy, patient characteristics (personal), like motivation to RTW, occupational characteristics (work-related) like build-up in work tasks and medical support (medical) like availability of a walker or crutches. CONCLUSION: According to participants, factors within the following four themes can contribute to a successful return to work: occupational, patient, rehabilitation and medical care. Incorporating these factors into the integrated care pathway for the "young" TKA patients may increase the chances of a successful RTW.

Increasing consensus on terminology of Achilles tendon-related disorders.

PURPOSE: Aims of this study are to evaluate the current terminology and assess the influence of the latest proposals on the terminology used for Achilles tendon-related disorders in both daily practice and literature. METHODS: (1) All orthopedic surgeons experienced in the field of foot and ankle surgery of the Ankleplatform Study Group were invited to participate in this survey by email. They were requested to fill out a survey on terminology in six typical cases with Achilles tendon-related disorders. (2) A systematic literature search of Achilles tendon-related disorders was performed in eight foot and ankle journals in Medline, Embase (Classic) from 2000 to 2016. All extracted terms were counted and compared to the terminology proposals, based on anatomic location, symptoms, clinical findings and histopathology. RESULTS: (1) In total, 141 of the 283 (50%) orthopedic surgeons responded to the survey. In five out of six cases with Achilles tendon-related disorders, the majority gave an answer according to latest proposals. (2) An overview of terminology used for Achilles tendon-related disorders from 2000 to 2016 shows an increase in use of terminology according to the latest proposals based on anatomic location, symptoms, clinical findings and histopathology. CONCLUSION: The revised terminology for Achilles tendon-related disorders based on anatomic location, symptoms, clinical findings and histopathology is used by the majority of orthopedic surgeons and is increasingly used in the literature. However, the indistinct Haglund eponyms are still frequently used in Achilles tendon-related terminology. LEVEL OF EVIDENCE: Level IV.

LOUPE: observing Earth from the Moon to prepare for detecting life on Earth-like exoplanets.

LOUPE, the Lunar Observatory for Unresolved Polarimetry of the Earth, is a small, robust spectro-polarimeter for observing the Earth as an exoplanet. Detecting Earth-like planets in stellar habitable zones is one of the key challenges of modern exoplanetary science. Characterizing such planets and searching for traces of life requires the direct detection of their signals. LOUPE provides unique spectral flux and polarization data of sunlight reflected by Earth, the only planet known to harbour life. These data will be used to test numerical codes to predict signals of Earth-like exoplanets, to test algorithms that retrieve planet properties, and to fine-tune the design and observational strategies of future space observatories. From the Moon, LOUPE will continuously see the entire Earth, enabling it to monitor the signal changes due to the planet's daily rotation, weather patterns and seasons, across all phase angles. Here, we present both the science case and the technology behind LOUPE's instrumental and mission design. This article is part of a discussion meeting issue 'Astronomy from the Moon: the next decades'.

Cryotherapy after Total Knee Arthroplasty provides faster recovery and better ranges of motion in short term follow up. Results of a prospective comparative study.

Cryotherapy is applied in Total Knee Arthroplasty (TKA) to improve functional outcome. The aim of this study is to investigate whether an advanced cryotherapy device does not increase the risk of complications and improves knee function or decreases swelling. A prospective cohort of TKA patients was formed by a cryotherapy group and a control group. The primary outcome was complication ratio. Our secondary outcomes were functional results and swelling. No significant differences were found in complication ratio between 31 patients in the cryotherapy group and 31 patients in the control group. The cryotherapy group showed a significant better knee flexion and less swelling in the early rehabilitation phase. No differences were found at the other follow-up moments or in the other outcomes. This advanced cryotherapy device is safe in respect of postoperative complications, improves knee function and decreases swelling in the early rehabilitation phase. However, it is questionable if an advanced cryotherapy device with its additional costs is necessary to provide the desired effects of cryotherapy.

The accuracy of an injection technique for Flexor hallucis longus tendon sheath: A cadaveric study.

BACKGROUND: Corticosteroid injections are used in the conservative treatment of Flexor hallucis longus (FHL) tendinopathy. Studies for imaging guided injection are done, however, the accuracy of blind injection has not yet been studied. PURPOSE: The aim of this study was to determine the accuracy of a blind injection technique into the FHL tendon sheath. HYPOTHESIS: We hypothesize that a blind injections technique into the FHL tendon sheath based on clinical examination has a high accuracy. STUDY DESIGN: Descriptive cadaveric study. METHODS: Ten ankles of human cadavers were blindly injected with radiologic contrast mixed with methylene blue into the FHL tendon sheath. After injection, a CT scan of each ankle was performed to evaluate the location of contrast material. CT scans were reviewed by an experienced musculoskeletal radiologist blinded to the procedure. Anatomic dissection was undertaken to assess the location of the injection fluid. RESULTS: In nine ankles the radiological contrast was injected in the FHL tendon sheath. In one cadaver there was a technical problem and was therefore excluded. CONCLUSION: This study shows that the FHL tendon sheath can be blindly injected based on only clinical examination with high accuracy. LEVEL OF EVIDENCE: Descriptive cadaveric study.

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.

Complications and reoperations after surgery for 647 patients with spine metastatic disease.

BACKGROUND CONTEXT: Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival. PURPOSE: We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers. OUTCOME MEASURES: Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death. METHODS: We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival. RESULTS: From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49-0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00-2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97-2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02-2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06-5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07-2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17-1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09-1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery. CONCLUSIONS: Three or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.

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.

Reliability and validation of the Dutch Achilles tendon Total Rupture Score.

PURPOSE: Patient-reported outcome measures (PROMs) have become a cornerstone for the evaluation of the effectiveness of treatment. The Achilles tendon Total Rupture Score (ATRS) is a PROM for outcome and assessment of an Achilles tendon rupture. The aim of this study was to translate the ATRS to Dutch and evaluate its reliability and validity in the Dutch population. METHODS: A forward-backward translation procedure was performed according to the guidelines of cross-cultural adaptation process. The Dutch ATRS was evaluated for reliability and validity in patients treated for a total Achilles tendon rupture from 1 January 2012 to 31 December 2014 in one teaching hospital and one academic hospital. Reliability was assessed by the intraclass correlation coefficients (ICC), Cronbach's alpha and minimal detectable change (MDC). We assessed construct validity by calculation of Spearman's rho correlation coefficient with domains of the Foot and Ankle Outcome Score (FAOS), Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) and Numeric Rating Scale (NRS) for pain in rest and during running. RESULTS: The Dutch ATRS had a good test-retest reliability (ICC = 0.852) and a high internal consistency (Cronbach's alpha = 0.96). MDC was 30.2 at individual level and 3.5 at group level. Construct validity was supported by 75 % of the hypothesized correlations. The Dutch ATRS had a strong correlation with NRS for pain during running (r = -0.746) and all the five subscales of the Dutch FAOS (r = 0.724-0.867). There was a moderate correlation with the VISA-A-NL (r = 0.691) and NRS for pain in rest (r = -0.580). CONCLUSION: The Dutch ATRS shows an adequate reliability and validity and can be used in the Dutch population for measuring the outcome of treatment of a total Achilles tendon rupture and for research purposes. LEVEL OF EVIDENCE: Diagnostic study, Level I.

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

PURPOSE: To 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. METHODS: A 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 18 years, 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. RESULTS: The 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 (SD ± 2.7; n = 119); Karlsson 95.1 (SD ± 3.6, n = 121)], compared to anatomic reconstruction [AOFAS 90.2 (SD ± 10.9, n = 128); Karlsson 90.1 (SD ± 7.8, n = 35)] and tenodesis [AOFAS 86.5 (SD ± 12.0, n = 10); Karlsson 85.3 (SD ± 2.5, n = 39)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SD ± 6.8, n = 128); Karlsson 51.6 (SD ± 5.5, n = 35) compared to anatomic repair [AOFAS 31.8 (SD ± 5.3, n = 119); Karlsson 40.9 (SD ± 2.9, n = 121)] and tenodesis [AOFAS 19.5 (SD ± 13.7, n = 10); Karlsson 29.4 (SD ± 6.3, n = 39)] (p < 0.005). CONCLUSION: Anatomic 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 EVIDENCE: IV.

Posterior talar process as a suitable cell source for treatment of cartilage and osteochondral defects of the talus.

Osteochondral defects of the ankle are common lesions affecting the talar cartilage and subchondral bone. Current treatments include cell-based therapies but are frequently associated with donor-site morbidity. Our objective is to characterize the posterior process of the talus (SP) and the os trigonum (OT) tissues and investigate their potential as a new source of viable cells for application in tissue engineering and regenerative medicine. SP and OT tissues obtained from six patients were characterized by micro-computed tomography and histological, histomorphometric and immunohistochemical analyses. Proliferation and viability of isolated cells were evaluated by MTS assay, DNA quantification and live/dead staining. The TUNEL assay was performed to evaluate cell death by apoptosis. Moreover, the production of extracellular matrix was evaluated by toluidine blue staining, whereas cells phenotype was investigated by flow cytometry. Characterization of ankle explants showed the presence of a cartilage tissue layer in both SP and OT tissues, which represented at least 20%, on average, of the explant. The presence of type II collagen was detected in the extracellular matrix. Isolated cells presented a round morphology typical of chondrocytes. In in vitro studies, cells were viable and proliferating for up to 21 days of culture. No signs of apoptosis were detected. Flow-cytometry analysis revealed that isolated cells maintained the expression of several chondrocytic markers during culture. The results indicated that the SP and OT tissues were a reliable source of viable chondrocytes, which could find promising applications in ACI/MACI strategies with minimal concerns regarding donor zone complications. Copyright © 2015 John Wiley & Sons, Ltd.

Surgical treatment for midportion Achilles tendinopathy: a systematic review.

PURPOSE: The aim of this study was to systematically evaluate the available literature on surgical treatment for midportion Achilles tendinopathy and to provide an overview of the different surgical techniques. METHODS: A systematic review of the literature available in MEDLINE, EMBASE and the Cochrane database of controlled trials was performed. The primary outcome measure in terms of patient satisfaction and the secondary outcome measures that consisted of complication rate, pain score, functional outcome score and success rate were evaluated. The Downs & Black checklist and the Coleman methodology scale were used to assess the methodological quality of included articles. RESULTS: Of 1090 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 1285 procedures in 1177 patients. The surgical techniques were divided into five categories. Eleven studies evaluated open surgical debridement, seven studies described minimally invasive procedures, three studies evaluated endoscopic procedures, one study evaluated open gastrocnemius lengthening, and one study reported on open autologous tendon transfer. Results regarding patient satisfaction (69-100 %) and complication rate (0-85.7 %) varied widely. CONCLUSIONS: This study demonstrates the large variation in surgical techniques available for treatment of midportion Achilles tendinopathy. None of the included studies compared surgical intervention with nonsurgical or placebo intervention. Minimally invasive and endoscopic procedures yield lower complication rates with similar patient satisfaction in comparison with open procedures. Minimally invasive and endoscopic procedures might therefore prove to be the future of surgical treatment of Achilles midportion tendinopathy. LEVEL OF EVIDENCE: IV.

What Factors are Associated With Quality Of Life, Pain Interference, Anxiety, and Depression in Patients With Metastatic Bone Disease?

BACKGROUND: It would be helpful for the decision-making process of patients with metastatic bone disease to understand which patients are at risk for worse quality of life (QOL), pain, anxiety, and depression. Normative data, and where these stand compared with general population scores, can be useful to compare and interpret results of similar patients or patient groups, but to our knowledge, there are no such robust data. QUESTIONS/PURPOSES: We wished (1) to assess what factors are independently associated with QOL, pain interference, anxiety, and depression in patients with metastatic bone disease, and (2) to compare these outcomes with general US population values. METHODS: Between November 2011 and February 2015, 859 patients with metastatic bone disease presented to our orthopaedic oncology clinic; 202 (24%) were included as they completed the EuroQOL-5 Dimension (EQ-5DTM), PROMIS® Pain Interference, PROMIS® Anxiety, and PROMIS® Depression questionnaires as part of a quality improvement program. We did not record reasons for not responding and found no differences between survey respondents and nonrespondents in terms of age (63 versus 64 years; p = 0.916), gender (51% men versus 47% men; p = 0.228), and race (91% white versus 88% white; p = 0.306), but survey responders were more likely to be married or living with a partner (72%, versus 62%; p = 0.001). We assessed risk factors for QOL, pain interference, anxiety, and depression using multivariable linear regression analysis. We used the one-sample signed rank test to assess whether scores differed from US population averages drawn from earlier large epidemiologic studies. RESULTS: Younger age (ß regression coefficient [ß], < 0.01; 95% CI, 0.00-0.01; p = 0.041), smoking (ß, -0.12; 95% CI, -0.22 to -0.01; p = 0.026), pathologic fracture (ß, -0.10; 95% CI, -0.18 to -0.02; p = 0.012), and being unemployed (ß, -0.09; 95% CI, -0.17 to -0.02; p = 0.017) were associated with worse QOL. Current smoking status was associated with more pain interference (ß, 6.0; 95% CI, 1.6-11; p = 0.008). Poor-prognosis cancers (ß, 3.8; 95% CI, 0.37-7.2; p = 0.030), and pathologic fracture (ß, 6.3; 95% CI, 2.5-7.2; p = 0.001) were associated with more anxiety. Being single (ß, 5.9; 95% CI, 0.83-11; p = 0.023), and pathologic fracture (ß, 4.4; 95% CI, 0.8-8.0; p = 0.017) were associated with depression. QOL scores (0.68 versus 0.85; p < 0.001), pain interference scores (65 versus 50; p < 0.001), and anxiety scores (53 versus 50; p = 0.011) were worse for patients with bone metastases compared with general US population values, whereas depression scores were comparable (48 versus 50; p = 0.171). CONCLUSIONS: Impending pathologic fractures should be treated promptly to prevent deterioration in QOL, anxiety, and depression. Our normative data can be used to compare and interpret results of similar patients or patient groups. Future studies could focus on specific cancers metastasizing to the bone, to further understand which patients are at risk for worse patient-reported outcomes. LEVEL OF EVIDENCE: Level III, prognostic study.

"Turn laterally to the left!". The need for uniform C-arm communication terminology during orthopaedic trauma surgery.

To avoid disturbed teamwork, unnecessary radiation exposure, and procedural delays, we designed and tested a uniform communication language for use in fluoroscopy-assisted surgical procedures. Input of surgeons and radiographers was used to create a set of commands. The potential benefit of this terminology was explored in an experimental setting. There was a tremendous diversity in the currently used terminology. Use of the newly designed terminology showed a reduction of procedural time and amount of images needed. Our first standardized Dutch language terminology can reduce total fluoroscopy time, number of images acquired, and potentially radiation exposure. For Dutch speaking colleagues, the developed terminology is freely available for use in their OR.

Return to sports after arthroscopic debridement and bone marrow stimulation of osteochondral talar defects: a 5- to 24-year follow-up study.

PURPOSE: Osteochondral defects (OCD) often have a severe impact on the quality of life due to deep ankle pain during and after weight bearing, which prevents young patients from leading an active life. Arthroscopic debridement and bone marrow stimulation are currently the gold standard treatment. The purpose of this study was to evaluate the number of patients that resume and maintain sports to their pre-injury activity level after arthroscopic debridement and bone marrow stimulation. METHODS: This retrospective study evaluated patients treated with arthroscopic debridement and bone marrow stimulation between 1989 and 2008. All patients who were participating in sports before injury were included. The Ankle Activity Scale (AAS) was used to determine activity levels during specific time points (before injury, before operation, after operation and at the time of final follow-up). RESULTS: Ninety-three patients were included. Fifty-seven (76%) patients continued participating in sports at final follow-up. The median AAS before injury of 8 (range 3-10) significantly decreased to 4 (range 2-10) at final follow-up. CONCLUSION: It is shown that 76% of the patients were able to return to sports at long-term follow-up after arthroscopic debridement and bone marrow stimulation of talar OCDs. The activity level decreased at long-term follow-up and never reached the level of that before injury. The data of our study can be of importance to inform future patients on expectations after debridement and bone marrow stimulation of a talar OCD. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Effects of Pulsed Electromagnetic Fields on Return to Sports After Arthroscopic Debridement and Microfracture of Osteochondral Talar Defects: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial.

BACKGROUND: Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage. HYPOTHESIS: The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively. RESULTS: Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results. CONCLUSION: PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups. REGISTRATION: Netherlands Trial Register NTR1636.

Validation of the PASSPORT V2 training environment for arthroscopic skills.

PURPOSE: Virtual reality simulators used in the education of orthopaedic residents often lack realistic haptic feedback. To solve this, the (Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment) PASSPORT simulator was developed, which was subjected to fundamental changes: improved realism and user interface. The purpose was to demonstrate its face and construct validity. METHODS: Thirty-one participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task, which was timed. Face validity, educational value and user-friendliness were determined with two representative exercises and by asking participants to fill out the questionnaire. A value of 7 or greater was considered sufficient. RESULTS: Construct validity was demonstrated between experts and novices. Median task time for the fifth trial was 55 s (range 17-139 s) for the novices, 33 s (range 17-59 s) for the intermediates, and 26 s (range 14-52 s) for the experts. Median task times of three trials were not significantly different between the novices and intermediates, and none of the trials between intermediates and experts. Face validity, educational value and user-friendliness were perceived as sufficient (median >7). The presence of realistic tactile feedback was considered the biggest asset of the simulator. CONCLUSION: Proper preparation for arthroscopic operations will increase the quality of real-life surgery and patients' safety. The PASSPORT simulator can assist in achieving this, as it showed construct and face validity, and its physical nature offered adequate haptic feedback during training. This indicates that PASSPORT has potential to evolve as a valuable training modality.

Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury.

PURPOSE: Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury (ALALI) in favour of immobilization treatment. There is no single most effective functional treatment (tape, semi-rigid brace or lace-up brace) based on currently available randomized trials. METHODS: This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grades II and III ALALIs. The Karlsson score and the FAOS were evaluated at 6-month follow-up. RESULTS: One hundred and ninety-three patients (52% males) were randomized, 66 patients were treated with tape, 58 patients with a semi-rigid brace and 62 patients with a lace-up brace. There were no significant differences in any baseline characteristics between the three groups. Mean age of the patients was 37.3 years (35.1-39.5; SD 15.3). Ninety-five males (49%) were included. One hundred and sixty-one (59 + 50 + 52) patients completed the study through final follow-up; 32% lost at follow-up. In two patients treated with tape support, the treatment was changed to a semi-rigid brace because of dermatomal blisters. Except for the difference in Foot and Ankle Outcome Score sport between the lace-up and the semi-rigid brace, there are no differences in any of the outcomes after 6-month follow-up. CONCLUSION: The most important finding of current study was that there is no difference in outcome 6 months after treatment with tape, semi-rigid brace and a lace-up brace. LEVEL OF EVIDENCE: I.