Explore the vast range of titles available.

Purpose To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to 50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL). Methods A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis–Weber and/or Lauge–Hansen classification) was calculated and pooled. Two-sided p values of less than 0.05 were considered statistically significant. Results Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% ( n  = 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge–Hansen categories ( p  = 0.049). Post hoc pairwise comparisons between Lauge–Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.). Conclusion OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery. Level of evidence IV.

ObjectiveThe role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques.Materials and methodsFifteen patients with a mean age of 44 years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4 years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio.ResultsThe mean incisura depth (M = 4.7 mm, SD = 1.1 mm), incisura height (M = 36.1 mm, SD = 5.3 mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8 mm, SD = 1.1 mm; M = 31.9 mm, SD = 3.2 mm; M = 143.2°, SD = 8.3°) (P < 0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (P > 0.05).ConclusionOur three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.

Background Hindfoot malalignment is a recognized cause of foot and ankle disability. For preoperative planning and clinical follow-up, reliable radiographic assessment of hindfoot alignment is important. The long axial radiographic view and the hindfoot alignment view are commonly used for this purpose. However, their comparative reliabilities are unknown. As hindfoot varus or valgus malalignment is most pronounced during mid-stance of gait, a unilateral weight-bearing stance, in comparison with a bilateral stance, could increase measurement reliability. The purpose of this study was to compare the intra- and interobserver reliability of hindfoot alignment measurements of both radiographic views in bilateral and unilateral stance. Materials and methods A hindfoot alignment view and a long axial view were acquired from 18 healthy volunteers in bilateral and unilateral weight-bearing stances. Hindfoot alignment was defined as the angular deviation between the tibial anatomical axis and the calcaneus longitudinal axis from the radiographs. Repeat measurements of hindfoot alignment were performed by nine orthopaedic examiners. Results Measurements from the hindfoot alignment view gave intra- and interclass correlation coefficients (CCs) of 0.72 and 0.58, respectively, for bilateral stance and 0.91 and 0.49, respectively, for unilateral stance. The long axial view showed, respectively, intra- and interclass CCs of 0.93 and 0.79 for bilateral stance and 0.91 and 0.58 for unilateral stance. Conclusion The long axial view is more reliable than the hindfoot alignment view or the angular measurement of hindfoot alignment. Although intra-observer reliability is good/excellent for both methods, only the long axial view leads to good interobserver reliability. A unilateral weight-bearing stance does not lead to greater reliability of measurement.

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4–5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

Purpose To assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints. Methods During a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded. Results Eleven joints in 10 patients (four males, age range 35 – 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases. Conclusions Needle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

Purpose The purpose of the present study was to assess the overall clinical success rate of non-operative management for osteochondral lesions of the talus (OLT). Methods A literature search was conducted in the PubMed (MEDLINE), COCHRANE and EMBASE (Ovid) databases. Clinical success rates per separate study were calculated at the latest moment of follow-up and were defined as successful when a good or excellent clinical result at follow-up was reported in a qualitative manner or when a post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score at or above 80 was reached. When clinical outcomes were based on other clinical scoring systems, outcomes reported as good or excellent were considered as clinical success. Studies methodologically eligible for a simplified pooling method were combined to calculate an overall pooled clinical success rate. Radiological changes over the course of conservative treatment were assessed either considering local OLT changes and/or overall ankle joint changes. Results Thirty articles were included, including an overall of 868 patients. The median follow-up of the included studies was 37 months (range: 3–288 months). A simplified pooling method was possible among 16 studies and yielded an overall pooled clinical success rate of 45% (95% CI 40–50%). As assessed with plain radiographs, progression of ankle joint osteoarthritis was observed in of 9% (95% CI 6–14%) of the patients. As assessed through a Computed Tomography (CT) scan, focal OLT deterioration was observed in 11% (95% CI 7–18%) of the patients. As assessed with a Magnetic Resonance Imaging (MRI) scan, focal OLT deterioration was observed in 12% (95% CI 6–24%) of the patients. An unchanged lesion was detected on plain radiographs in 53% (48/91; CI 43–63%), 76% (99/131; 95% CI 68–82%) on a CT scan and on MRI in 84% (42/50; 95% CI 71–92%) of the patients. Conclusion The current literature on non-operative management of OLTs is scarce and heterogeneous on indication and type of treatment. Promising clinical results are presented but need to interpreted with caution due to the heterogeneity in indication, duration and type of treatment. Further studies need to focus on specific types on conservative management, indications and its results. Level of evidence Systematic review, Level IV.

Purpose The purpose of the present study was to evaluate the clinical and radiological outcomes of arthroscopic bone marrow stimulation (BMS) for the treatment of osteochondral lesions of the talus (OLTs) at long-term follow-up. Methods A literature search was conducted from the earliest record until March 2021 to identify studies published using the PubMed, EMBASE (Ovid), and Cochrane Library databases. Clinical studies reporting on arthroscopic BMS for OLTs at a minimum of 8-year follow-up were included. The review was performed according to the PRISMA guidelines. Two authors independently conducted the article selection and conducted the quality assessment using the Methodological index for Non-randomized Studies (MINORS). The primary outcome was defined as clinical outcomes consisting of pain scores and patient-reported outcome measures. Secondary outcomes concerned the return to sport rate, reoperation rate, complication rate, and the rate of progression of degenerative changes within the tibiotalar joint as a measure of ankle osteoarthritis. Associated 95% confidence intervals (95% CI) were calculated based on the primary and secondary outcome measures. Results Six studies with a total of 323 ankles (310 patients) were included at a mean pooled follow-up of 13.0 (9.5–13.9) years. The mean MINORS score of the included studies was 7.7 out of 16 points (range 6–9), indicating a low to moderate quality. The mean postoperative pooled American Orthopaedic Foot and Ankle Society (AOFAS) score was 83.8 (95% CI 83.6–84.1). 78% (95% CI 69.5–86.8) participated in sports (at any level) at final follow-up. Return to preinjury level of sports was not reported. Reoperations were performed in 6.9% (95% CI 4.1–9.7) of ankles and complications related to the BMS procedure were observed in 2% (95% CI 0.4–3.0) of ankles. Progression of degenerative changes was observed in 28% (95% CI 22.3–33.2) of ankles. Conclusion Long-term clinical outcomes following arthroscopic BMS can be considered satisfactory even though one in three patients show progression of degenerative changes from a radiological perspective. These findings indicate that OLTs treated with BMS may be at risk of progressing towards end-stage ankle osteoarthritis over time in light of the incremental cartilage damage cascade. The findings of this study can aid clinicians and patients with the shared decision-making process when considering the long-term outcomes of BMS. Level of evidence Level IV.

Purpose Technical innovation now offers the possibility of 2-mm diameter operative arthroscopy: an alternative to conventional arthroscopy that no longer uses inner rod-lenses. The purpose of this study was to assess whether all significant structures in the ankle could be visualized and surgically reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage. Methods A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh-frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed. Results All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage. Conclusion 2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.

Level of evidence Editorial, Level V.

Purpose Despite the use of perioperative anxiolytics and pain medication, surgery can be a stressful and painful experience. Providing patients with distractions using video and/or audio tools in addition to medication may be helpful. To date, no studies have compared different distraction modalities in a same-day surgical setting in adults. This study aims to determine whether audio-visual distraction with video glasses (AVD) is more effective in reducing anxiety and pain compared to audio distraction (AD) in conscious patients undergoing orthopaedic surgery. It was hypothesised that AVD, being the more immersive modality, would be more effective than AD on the outcome parameters. Methods Fifty patients undergoing orthopaedic surgery with local and/or regional anaesthesia in a clinical day-care setting were randomly assigned to receive either fixed-scenery AVD or patient-choice AD with music. Primary outcome was anxiety, as measured by the Dutch version of the Spielberger State–Trait Anxiety Inventory-6 (STAI-6) prior to and 15 min after the intervention. Secondary outcomes were pain (Numeric Rating Scale Pain [NRS-P]), systolic and diastolic blood pressure, heart rate and patient satisfaction. Results Within each group, there was a significant reduction in anxiety ( p  = 0.028 for AVD, p  < 0.001 for AD). In contrast to our hypothesis, listening to music without watching a video (AD group) reduced anxiety significantly more than experiencing full AVD ( p  = 0.018). The mean pain score did not change significantly within either user group, nor did pain scores differ between user groups. Conclusion In conscious patients undergoing surgery, watching a movie (using video glasses and a headphone set) and listening to music (using only a headphone set) are able to significantly reduce anxiety. AVD, although believed to provide higher levels of distraction, did not prove to be superior to AD. The clinical relevance of this study highlights the potential benefits of AVD or AD modalities in improving the surgical experience for conscious patients. Further research is required to examine the influence of freedom of choice in content on the aforementioned outcomes. To estimate the true value of higher immersion levels, different distraction modalities (e.g. AVD versus virtual reality) featuring the exact same scenery or content need to be compared. Level of evidence Level I.