Most elite athletes return to preinjury competitive activity after surgical treatment for medial malleolus stress fractures.

PURPOSE: To provide return-to-performance outcomes after surgical treatment for medial malleolus stress fractures in the elite athlete. Additionally, to describe an individualised surgical approach in the management of medial malleolus stress fractures. METHODS: Five athletes (six ankles) underwent surgical treatment for a medial malleolus stress fracture. The surgical technique was based on the extent of the fracture line in steps with first arthroscopic debridement of bony spurs, microfracturing of the fracture line and screw fixation. Return-to-performance data included time to return to sport-specific training, normal training, first competitive activity, performance and the return-to-performance rate. RESULTS: Patients returned to sport-specific training at a median of 10 weeks. They started normal training at 16 weeks postoperatively and returned to their first competitive activity after 19 weeks. All patients had bony spurs on the distal tibia which were arthroscopically debrided. One patient received arthroscopic debridement of bony spurs alone. Four patients received additional microfracturing of the fracture line and three patients received screw fixation. All patients achieved clinical and radiographic union on follow-up computed tomography scan at 3 months postsurgery. At latest follow-up, no refractures nor hardware complications, nor any other complications were observed. CONCLUSION: Arthroscopic debridement of bony spurs, debridement and microfracturing of the fracture line and screw fixation are all viable surgical tools in the management of medial malleolus stress fractures in elite athletes. The surgical approach containing these options should be tailored to the individual athlete based on the fracture line in the sagittal plane. While most athletes return to full competitive activity in 3-4 months, time to self-reported return to full performance is often much longer. LEVEL OF EVIDENCE: Level IV.

Methodology for Online Reliability Studies: A Primer for Orthopedic Surgeons.

In orthopedic surgery, there is an increasing number of papers about online studies on the reliability of classification systems. Useful classification systems need to be reliable and valid. Measurement of validity can be variable and is prone to observer bias. These online collaboratives derive adequate power to study reliability by having a large group of trained surgeons review a small number of cases instead of the "classic" reliability studies in which a small number of observers evaluate many cases. Large online interobserver studies have advantages (i.e., less than 15 minutes to complete the survey, the ability to randomize, and the ability to study factors associated with reliability, accuracy, or decision-making). This 'handbook' paper gives an overview of current methods for online reliability studies. We discuss the study design, sample size calculation, statistical analyses of results, pitfalls, and limitations of the study design.

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models.

OBJECTIVES: To evaluate 2 prognostic models for mortality after a fracture of the hip, the Nottingham Hip Fracture Score and Hip Fracture Estimator of Mortality Amsterdam and to compare their predictive performance to physician assessment of mortality risk in hip fracture patients. DESIGN: Prospective cohort study. SETTING: Two level-2 trauma centers located in the Netherlands. PATIENTS: Two hundred forty-four patients admitted to the Emergency Departments of both hospitals with a fractured hip. INTERVENTION: Data used in both prediction models were collected at the time of admission for each individual patient, as well as predictions of mortality by treating physicians. MAIN OUTCOME MEASURES: Predictive performances were evaluated for 30-day, 1-year, and 5-year mortality. Discrimination was assessed with the area under the curve (AUC); calibration with the Hosmer-Lemeshow goodness-of-fit test and calibration plots; clinical usefulness in terms of accuracy, sensitivity, and specificity. RESULTS: Mortality was 7.4% after 30 days, 22.1% after 1 year, and 59.4% after 5 years. There were no statistically significant differences in discrimination between the prediction methods (AUC 0.73-0.80). The Nottingham Hip Fracture Score demonstrated underfitting for 30-day mortality and failed to identify the majority of high-risk patients (sensitivity 33%). The Hip fracture Estimator of Mortality Amsterdam showed systematic overestimation and overfitting. Physicians were able to identify most high-risk patients for 30-day mortality (sensitivity 78%) but with some overestimation. Both risk models demonstrated a lack of fit when used for 1-year and 5-year mortality predictions. CONCLUSIONS: In this study, prognostic models and physicians demonstrated similar discriminating abilities when predicting mortality in hip fracture patients. Although physicians overestimated mortality, they were better at identifying high-risk patients and at predicting long-term mortality. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis.

BACKGROUND: Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain. PURPOSE: The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications. STUDY DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications. RESULTS: A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively. CONCLUSION: We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.

Corticosteroid Injections in Posterior Ankle Impingement Syndrome: A Survey of Professional and Elite Student Ballet Dancers.

Posterior ankle impingement syndrome (PAIS) involves pain at the posterior as- pect of the ankle, due in dancers largely to repetitive hyperplantarflexion. In daily practice, corticosteroid injection is often used to relieve the pain of PAIS, but little has been recorded with regard to its effectiveness. The primary objective of this study was to determine the ef- fect on pain of corticosteroid injections in professional and elite student ballet dancers with PAIS. The secondary ob- jectives were to evaluate the prevalence of PAIS, the duration of the effect of injection, patient satisfaction with the effect of injection, time to return to class and performance, and ability to dance after injection. All members of the Dutch National Ballet and the National Ballet Academy Amsterdam received a self-administered questionnaire focused on the use and effect of corticosteroid injections in the treatment of PAIS. The response rate was 61% (77 of 126). Of the included dancers, 38% (29 of 77) had suffered from PAIS, and 38% (11 of 29) had received at least one injection. The numeric rating scale (NRS) was used to assess the severity of pain before and 2 and 6 weeks after injections. The median NRS pain before injection was 9.0 (IQR 8.0-9.5), 3.0 (IQR 0.5-6.5) 2 weeks after injection, and 3.0 (IQR 0.5-6.0) 6 weeks after injection. Overall median NRS satisfaction with the effect of injection was 7.0 (IQR 0-10), and satisfaction with the duration of the effect was 5.0 (IQR 2.0-10). It is concluded that there is a high prevalence of PAIS in ballet dancers and corticosteroid injections are regularly used for pain reduction with good results.

Geometrical characteristics of the symptomatic and non-symptomatic ossa trigona.

BACKGROUND: Posterior ankle impingement is strongly associated with the presence of an os trigonum, however, most patients with an os trigonum will never develop symptoms. It is hypothesized that the os trigonum is larger in the symptomatic ankle than in the non-symptomatic ankle, the distance between os trigonum and tibia is smaller and there are more degenerative changes in ankles with symptoms of posterior impingement. In this study the geometrical characteristics of the ipsilateral and contralateral os trigonum are compared in patients with a bilateral os trigonum and unilateral posterior impingement symptoms. METHODS: Patients with a bilateral os trigonum and unilateral posterior impingement complaints were included. Comparison between the symptomatic and asymptomatic ankles was done within each patient. From the CT-scan of each ankle, the tibia, fibula, calcaneus, talus and os trigonum were segmented and a geometric model was created. Based on these bone models, the volume of the os trigonum and talus, the size of the os trigonum, the distance between os trigonum and surrounding bones (talus, calcaneus, fibula and tibia) were calculated. In addition, the CT images were assessed for the type of os trigonum, the presence of cysts, irregular synchondrosis, calcifications and whether the os trigonum consisted of more than one fragment. RESULTS: A total of 22 patients were included in this study. In seventeen of the 22 patients, the symptomatic os trigonum was larger in comparison with the non-symptomatic side in terms of length (median Δ 2.4 mm, 8.9 versus 10.6 mm) and relative volume (median Δ 0.09%, 0.30 versus 0.45% of talar volume). Distances between the ossa trigona and surrounding bones were not statistically significantly different between both sides. Calcifications were more frequently found around the os trigonum in the symptomatic side (10 versus 3/22). CONCLUSIONS: The findings in this study support the hypothesis that symptomatic ossa trigona are larger in comparison with asymptomatic ossa trigona. Calcifications around the os trigonum were found more frequently in symptomatic than in non-symptomatic ossa trigona. LEVEL OF EVIDENCE: III.

High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis.

PURPOSE: The primary objective of this study was to determine the degree of patient satisfaction at a minimum of 5 years of follow-up after endoscopic calcaneoplasty. The secondary objectives were to assess functional outcome measures, pain scores, analysis of bone removal, reformation of exostosis at follow-up and correlation of the size of the exostosis and recurrent or persisting complaints. METHODS: This study evaluated patients who underwent endoscopic calcaneoplasty, between January 1st 2000 and December 31st 2010, for the diagnosis of retrocalcaneal bursitis. The evaluation consisted of PROMs (patient-reported outcome measures), a questionnaire and a visit to the outpatient clinic for physical examination and a standard lateral weight-bearing radiograph of the ankle. Patient satisfaction, functional outcomes and pain scores were measured by use of a numeric rating scale (NRS). Size of the posterosuperior calcaneal exostosis was measured on a standard lateral weight-bearing radiograph using parallel pitch lines (PPL) and the Fowler-Philip angle (PFA). RESULTS: The response rate was 28 out of 55 (51%) and the median time to follow-up was 101(IQR 88.5-131.8) months. The median satisfaction score for treatment results was 8.5 out of 10 (IQR 6-10). FAOS symptoms 84.5 (IQR 58.0-96.4), FAOS pain 90.3 (IQR 45.1-100.0), FAOS ADL 94.9 (IQR 58.1-100.0), FAOS sport 90.0 (IQR 36.3-100.0) and FAOS QOL 71.9 (IQR 37.5-93.8) and median AOFAS was 100 (IQR 89-100). The median PLL difference between before operation and 2 weeks after the operation was - 4 mm (IQR-6 and -1) and the median PLL difference between 2 weeks after the operation and at follow-up was 1 mm (0-2). The median PFA was 65 (63-69) at baseline, 66.5 (60.8-70.3) 2 weeks after the operation and 64 (60.8-65.3) at follow-up. CONCLUSION: Despite the limited response rate, this study shows high patient satisfaction and good long-term functional outcome in patients affected by retrocalcaneal bursitis who underwent endoscopic calcaneoplasty. LEVEL OF EVIDENCE: Level IV.

Surgical treatment for posteromedial talar process fractures.

PURPOSE: The first descriptions on medial talar tubercle fractures are attributed to Cedell. He described avulsion fractures of the insertion of the posterior talotibial ligament. However the true etiology has not been established. Since little is known about these fractures, they are easily misdiagnosed as simple ankle sprains. Untreated, these fractures may lead to chronic ankle pain. To improve the understanding of the etiology and outcome of these fractures a systematic review was conducted of all cases of isolated fractures of the medial tubercle of the posterior talar process. In addition we present the first series of competitive athletes treated by means of the two-portal hindfoot approach for isolated medial talar tubercle fractures. METHODS: A systematic search was performed to identify all cases of medial tubercle fractures. Data on trauma mechanism, clinical presentation, imaging and treatment were extracted. In addition we retrospectively report on the results of endoscopically treated patients in our institution over the last fifteen years. Of all patients Numeric Rating Scores (NRS) for Satisfaction, Pain and Function, Foot Ankle Outcome Scores (FAOS), return to sport and complications were reported. RESULTS: Eightteen articles were included reporting on 33 patients with an isolated fracture or avulsion of the posteromedial talar process. Most of the fractures occurred during sport activities (58%), followed by motor vehicle accidents (21%) and fall from height (12%). Of the activities during sport, 73% resulted following an ankle sprain. Reasonable to good outcomes are described in cases treated with immobilization, open reduction internal fixation or open excision. Of the nine patients treated in our institution, five were male and the median age was 29. All were participating in sports at a competitive level, with four of them being a professional athlete. In most patients the diagnosis was made more than a year after initial trauma. Ankle sprain was most common trauma mechanism. In some patients it was evident the avulsion was part or the deep portion of the deltoid ligament, however in two cases it was more likely an avulsion of the flexor hallucis longus (FHL) retinaculum. The median follow-up was 69 months (IQR 12.0-94.3). At final follow-up patients had little pain, NRS 1. Median NRS for satisfaction and function were 7 and 8, respectively. All patients did resume sport activities, however only four reached the preinjury level. Of the five patients that did not return to their pre-injury level of activity, two were professional athletes at the end of their career, and retired not due to ankle complaints. One complication was reported. CONCLUSION: Fractures of the medial tubercle are rare and based on the available literature there is not one distinct trauma mechanism. Based on literature no recommendation for treatment can be made. Our results show endoscopic excision of the fragment as a save alternative for open surgical treatment.

Endoscopic Treatment of Mid-Portion Achilles Tendinopathy: A Retrospective Case Series of Patient Satisfaction and Functional Outcome at a 2- to 8-Year Follow-up.

PURPOSE: To evaluate the results of endoscopic treatment in patients affected by mid-portion Achilles tendinopathy, by release of the paratenon combined with a resection of the plantaris tendon, regarding patient satisfaction, functional outcome, and pain scores. METHODS: This retrospective study evaluated patients endoscopically treated for mid-portion Achilles tendinopathy between 2000 and 2013. Patient satisfaction, functional outcome, pain scores, and health-related quality of life were measured by the use of a numeric rating scale, the Foot and Ankle Outcome Score, the Victorian Institute of Sport assessment for the Achilles tendon, the numeric rating scale for pain during running and during sports, and the EuroQol 5D (EQ-5D-3L) standardized questionnaire. Additional questions were asked on the effectiveness of the treatment and sport participation. RESULTS: The response rate was 76.3% (45 of 59). Thirty-five (78%) patients were treated unilaterally and 10 (22%) patients were treated bilaterally. For the unilaterally treated patients, the median time to follow-up was 67 months (interquartile range [IQR] 48-99 months), and for the bilaterally treated patients, it was 89.5 months (IQR 37.5-161.75 months). The median satisfaction score for treatment results was 9 out of 10 (IQR 7-10) and 9.5 (IQR 7-10), respectively. The median Foot and Ankle Outcome Score subscales were scored 75 to 99 and 75 to 97, the median Victorian Institute of Sport assessment for the Achilles tendon scored 81 (IQR 47-90) and 97 (IQR 87-100), and the median numeric rating scale pain scores during both running and sports were 1 (IQR 0-6.5) for the unilaterally treated patients and 0 (IQR 0-4.5) and 0 (IQR 0-1) for the bilaterally treated patients, respectively. The median EQ-5D were 0.81 (IQR 0.71-1) and 1 (IQR 0.64-1), respectively. One reoperation for recurrence of symptoms was necessary. CONCLUSIONS: This study shows high patient satisfaction and good functional outcomes in patients affected by mid-portion Achilles tendinopathy who were endoscopically treated by means of release of the paratenon in combination with transection of the plantaris tendon. LEVEL OF EVIDENCE: Level IV, retrospective case series (therapeutic).

Prevalence of Os Trigonum on CT Imaging.

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

Talus bipartitus: a systematic review and report of two cases with arthroscopic treatment.

PURPOSE: The aim of this study was to provide a literature review on talus bipartitus and to introduce an arthroscopic treatment option. METHODS: A systematic review of published case reports and small case series was performed. Medline, Embase, CINAHL, Google Scholar and Web of Science databases were searched for relevant publications. In addition, three cases of talus bipartitus treated in our institute were discussed. RESULTS: Eleven articles were identified, reporting on 23 patients, of whom one patient had a bilateral talus bipartitus. Fourteen were males (61%). The median age at presentation was 15.5 years (IQR 14-24.3). In 21 of the symptomatic cases (96%), the patient experienced ankle pain, and 13 had a restricted range of motion (54%). In our institution, two patients were treated arthroscopically and had excellent short- and long-term outcomes. CONCLUSION: Talus bipartitus is a rare anatomical anomaly. Symptoms are characterized by pain and restricted subtalar motion in young patients. Surgical treatment is focused on either fixation or excision of the bony fragment. Our two cases have demonstrated that an arthroscopic approach can be a safe and effective treatment option in patients with a symptomatic talus bipartitus. LEVEL OF EVIDENCE: IV.

A rare cause of lateral ankle pain: A symptomatic talus secundarius.

The talus secundarius is one of the rarest accessory tarsal bones, being present in 0.01% of all ankles. It is located at the lateral side of the talus, distally to the tip of the fibula. Hitherto, only five cases of a symptomatic talus secundarius have been described in literature. We presented a case of bilateral symptomatic talus secundarius in a young gymnast. There was a difference in size of the two accessory bones. The large talus secundarius in the left ankle was fixated, in the right ankle the fragment was excised. Both excision and fixation in the presented patient led to satisfactory results, both in the short and long term outcome.

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

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

Current concepts review: Arthroscopic treatment of anterior ankle impingement.

Anterior ankle impingement is a common cause of chronic ankle pain, particularly in athletic populations. Morris and McMurray provided the earliest descriptions of anterior impingement, coining the condition as "athlete's ankle" or "footballer's ankle". The pathology has since been a topic of considerable investigation and has been re-termed "anterior ankle impingement syndrome". Treatment with open surgery has provided good results historically, but at the price of significant complications. Advancements in ankle arthroscopy have decreased the risk of complication drastically and evidence in the literature indicates that anterior arthroscopy is an effective approach to treating osseous and soft tissue impingement. Effective clinical diagnosis and diagnostic imaging are critical for pre-surgical planning. Preoperative detection of anterior osteophytes has been correlated with outcomes. Factors such as joint space narrowing and large osteophytes may also influence outcomes. Therefore, a comprehensive understanding of diagnosis and surgical technique can influence patient outcomes, and patient expectations can be managed around prognostic indicators such as the presence of osteoarthritis. The purpose of this review is to discuss the etiology, clinical presentation, diagnosis, surgical technique, and postoperative rehabilitation of anteromedial and anterolateral anterior ankle impingement syndrome and to evaluate the evidence-based outcomes of arthroscopic management.

Validity and reliability of a Dutch version of the Foot and Ankle Ability Measure.

PURPOSE: The aim of the study was to develop a Dutch language version of the Foot and Ankle Ability Measure (FAAM) and evaluate its measurement properties according to the consensus-based standards for the selection of health measurement instruments (COSMIN) definitions. METHODS: A forward-backward translation procedure was performed and subsequently the Dutch version of the FAAM was evaluated for its reliability and validity in 369 patients with a variety of foot and ankle complaints. The reliability was assessed by calculating the intraclass correlation coefficients (ICC, test-retest reliability), Cronbach's alpha (internal consistency), the standard error of measurement and the minimal detectable change (MDC). Additionally, this was done for athletes. The construct validity was assessed by the use of Spearman's correlation coefficient between FAAM domains and similar and contradictory domains of the Foot and Ankle Outcome Score, Short Form 36 and the Numeric Rating Scale for pain. RESULTS: The ICC of the subscales ranged from 0.62 to 0.86. Cronbach's alpha's minimum was 0.97. At individual level, the MDC ranged from 23.9 to 44.7 and at group level from 2.77 to 4.32. In the subgroup of athletes, the reliability was higher. The hypothesized correlations of the construct validity were supported by an 80% confirmation rate. CONCLUSION: The Dutch version of the FAAM met adequate measurement properties, although the reliability is not optimal. The FAAM-Sport subscale is more useful in athletes and the FAAM-Sport % seems not to contribute. In athletes with various foot and ankle symptoms, the FAAM can be used for functional assessment and follow-up at group level. For the general population, the FAAM is less appropriate. LEVEL OF EVIDENCE: Diagnostic study, Level I.

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

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

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

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

[Dutch-language patient-reported outcome measures for foot and ankle injuries; a systematic review]. / Nederlandstalige patiëntgerapporteerde uitkomstmaten voor voet- en enkelaandoeningen; Een systematisch overzicht.

OBJECTIVE: To investigate which valid and reliable patient-reported outcome measures (PROMs) are available for foot and ankle disorders in the Dutch population, and which of these is the most suitable for uniform use. DESIGN: Systematic review. METHOD: PubMed, Embase and Google Scholar were systematically searched for relevant articles; subsequently two researchers screened first the title and the abstract, and then the full article within a selection of these articles. Studies that described a validation process for foot- and ankle-PROMs in a Dutch population were included. Data on measurement characteristics and translation procedure were extracted, and methodological quality of the studies was assessed using the COSMIN checklist. ('COSMIN' stands for 'Consensus-based standards for the selection of health status measurement instruments'.) RESULTS: Two general foot- and ankle-PROMs in the Dutch language were validated: the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measurement (FAAM); two foot-PROMs: the Manchester Foot Pain and Disability Index (MFPDI) and the 5-point Foot Function Index (FFI-5pt) were also validated. There were also two disorder-specific PROMs available in Dutch: the Victorian Institute of Sports Assessment-Achilles (VISA-A) for Achilles tendinopathies and the Foot Impact Scale for Rheumatoid Arthritis (FIS-RA) for rheumatoid arthritis patients. CONCLUSION: The FAOS and the FFI-5pt showed the strongest evidence for having good measurement characteristics. Currently, we regard the FAOS as the most appropriate foot- and ankle-PROM for general foot and ankle problems. Further studies of higher methodological quality are, however, required to draw firmer conclusions.

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

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

The appearance of the pre-Achilles fat pad after endoscopic calcaneoplasty.

PURPOSE: To evaluate whether the imaging features of the retrocalcaneal recess normalize on a conventional radiograph after surgery for retrocalcaneal bursitis and evaluate whether it can be reused if complaints reoccur. METHODS: Patients who underwent an endoscopic calcaneoplasty at least 2 years before were eligible for inclusion. A lateral conventional radiograph of the surgically treated hindfoot was made to assess the retrocalcaneal recess and pre-Achilles fat pad; images were analysed, clinical complaints were registered and evaluated. Radiographs were evaluated by two experienced observers (one orthopaedic surgeon one musculoskeletal specialized radiologist), these scored the images either as "normal" (no obliteration of retrocalcaneal recess and pre-Achilles fat) or as "abnormal". RESULTS: Thirty patients (34 heels: 28 asymptomatic and 6 recurrent complaints) were included in this study. Observer one rated 12 images as "normal" (2 symptomatic heels and 10 asymptomatic), 22 "abnormal". Observer two rated 9 "normal" (1 symptomatic heels and 8 asymptomatic), 25 "abnormal". No correlation between the radiographic appearance and complaints (n.s.) was found. Cohen's kappa for interobserver agreement was low (0.11 n.s.). CONCLUSION: The appearance of the retrocalcaneal recess on a lateral radiograph cannot be used as a reliable diagnostic criterion for retrocalcaneal bursitis in patients who previously underwent endoscopic calcaneoplasty. This study clinical relevance is based upon the conclusion that a lateral radiograph cannot be used after endoscopic calcaneoplasty, whereas previous work reported the diagnostic value of a lateral radiograph for retrocalcaneal bursitis prior to surgery. LEVEL OF EVIDENCE: III.