Publications by authors named "Annechien Beumer"

34 Publications

Comparative outcomes of total wrist arthrodesis for salvage of failed total wrist arthroplasty and primary wrist arthrodesis.

J Hand Surg Eur Vol 2021 Nov 19:17531934211057389. Epub 2021 Nov 19.

Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands.

A retrospective study compared outcomes of total wrist arthrodesis as a salvage for total wrist arthroplasty versus primary total wrist arthrodesis. Seventy-one wrists were reviewed after a minimum follow-up of 12 months. Thirty-two wrists with failed total wrist arthroplasty were converted to a wrist arthrodesis and 39 wrists received a primary wrist arthrodesis. Seven converted wrist arthrodeses and five primary arthrodeses failed to fuse. Mean patient-rated wrist and hand evaluation scores and work-related questionnaire for upper extremity disorders scores were 43 and 39 for converted total wrist arthrodesis and 38 and 33 for the primary total wrist arthrodesis. Overall, there were 25 complications in 15 patients in the converted wrist arthrodesis group and 21 complications in 16 patients after a primary wrist arthrodesis. The results between the two groups were slightly in favour of patients with a primary wrist arthrodesis. Therefore, we conclude that the timing, primary or conversion, of total wrist arthrodesis could influence patient outcomes. III.
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http://dx.doi.org/10.1177/17531934211057389DOI Listing
November 2021

Ultrasound Measurements of the ECRB Tendon Shows Remarkable Variations in Patients with Lateral Epicondylitis.

Arch Bone Jt Surg 2020 Mar;8(2):168-172

Department of Orthopaedic Surgery, Upper limb unit, Amphia Hospital, Breda, the Netherlands.

Background: Lateral epicondylitis (LE) most commonly affects the Extensor Carpi Radialis Brevis (ECRB) tendon and patients are generally treated with injection therapy. For optimal positioning of the injection, as well as an estimation of the surface area and content of the ECRB tendon to determine the volume of the injectable needed, it is important to know the exact location of the ECRB in relation to the skin as well as the variation in tendon length and location. The aim of this study was to determine the variation in location and size of the ECRB tendon in patients with LE.

Methods: An observational sonographic evaluation of the ECRB tendon was performed in 40 patients with LE. The length of the ECRB tendon, distance from the cutis to the center of the ECRB tendon, the length of the osteotendinous junction at the epicondyle and the distance from cutis to middle of the osteotendinous junction were measured.

Results: The average tendon length was 1.68cm (range 1.27-1.98; SD 0.177). Compared to women, the ECRB tendon of men was on average 0.12cm longer. Overall, the average distance from cutis to the center of the ECRB was 0.75cm (range 0.50-1.46cm; SD 0.210), the average length of the junction was 0.55cm (range 0.35-0.87; SD 0.130), and the distance from cutis to middle of the osteotendinous junction was 0.73cm (range 0.40-1.25cm; SD 0.210).

Conclusion: The size and depth of the ECRB tendon in patients with LE is largely variable. While there are no studies yet suggesting sono-guided injection to be superior to that of blind injection, the anatomic variability of this study suggests that the accuracy of injection therapy for LE might be compromised when based solely on bony landmarks and therefore not fully reliable. As a result, there is value in further studies exploring the accuracy of the ultrasound guided injection techniques.
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http://dx.doi.org/10.22038/abjs.2019.37767.1999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191987PMC
March 2020

Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up.

BMC Musculoskelet Disord 2019 Jul 31;20(1):351. Epub 2019 Jul 31.

Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, P.O. Box 90158, 4800, RK, Breda, The Netherlands.

Background: In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved.

Methods/design: A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in 'Visual Analogue Scale'). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment.

Discussion: When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy.

Trial Registration: This study is registered in the Trial Register ( www.trialregister.nl ) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569.
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http://dx.doi.org/10.1186/s12891-019-2711-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668105PMC
July 2019

It's Not About The Biceps.

Arch Bone Jt Surg 2018 Nov;6(6):570-576

Research performed at Amphia Hospital, Breda, The Netherlands.

In the biomedical paradigm all symptoms and limitations are ascribed to discrete pathophysiology. However, a biopsychosocial health model that accounts for the important influence of mind-set and circumstances on illness may be preferable in the vast majority of cases. Some of the shortcomings of the biomedical model include an overreliance on tests and treatments. One major issue of the biomedical model is the raging epidemic of opioid misuse and opioid related overdose deaths as previously reported in North America. Emblematic of these issues is a 56-year-old male that had surgery for a rupture of the distal biceps in our clinic with psychosocial aspects of the illness that were underappreciated by the care team and had disastrous opioidcentric attempts at pain control leading to threats to hospital staff, and finally resulting in forcible removal by hospital security from the ward and national police from the hospital. One might argue that there is no higher priority than rejecting the biomedical model, understanding illness is its full complexity, and learning from the world's mistakes so that we don't repeat them.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310195PMC
November 2018

WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP): Factor Analysis and Internal Consistency.

Arch Phys Med Rehabil 2018 09 17;99(9):1818-1826. Epub 2018 Apr 17.

Academic Medical Center, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.

Objective: To test a 17-item questionnaire, the WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP), for dimensionality of the items (factor analysis) and internal consistency.

Design: Cross-sectional study.

Setting: Outpatient clinic.

Participants: A consecutive sample of patients (N=150) consisting of all new referral patients (either from a general physician or other hospital) who visited the orthopedic outpatient clinic because of an upper extremity musculoskeletal disorder.

Interventions: Not applicable.

Main Outcome Measures: Number and dimensionality of the factors in the WORQ-UP.

Results: Four factors with eigenvalues (EVs) >1.0 were found. The factors were named exertion, dexterity, tools & equipment, and mobility. The EVs of the factors were, respectively, 5.78, 2.38, 1.81, and 1.24. The factors together explained 65.9% of the variance. The Cronbach alpha values for these factors were, respectively, .88, .74, .87, and .66.

Conclusions: The 17 items of the WORQ-UP resemble 4 factors-exertion, dexterity, tools & equipment, and mobility-with a good internal consistency.
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http://dx.doi.org/10.1016/j.apmr.2018.03.013DOI Listing
September 2018

Development of a novel WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP).

Int Arch Occup Environ Health 2017 Nov 11;90(8):823-833. Epub 2017 Jul 11.

Academic Medical Center, Department Coronel Institute of Occupational Health, Amsterdam Public Health research institute, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Purpose: The aim of this study is to develop a patient-reported outcome measure (PROM) that identifies work-related limitations among patients with upper extremity musculoskeletal disorders in order to enhance work-directed care in daily orthopaedic practice, and to assess its content validity.

Methods: The questionnaire was developed following the evaluation of existing PROMs and consensus within the research team. The content validity was assessed in three steps: (1) one on one interviews with patients (n = 14) were held to discuss the clarity and possible adaptation of items; (2) experts from the field (physiotherapists, insurance physicians, occupational health physicians, rehabilitation physicians and orthopaedic surgeons) were approached to participate in an interview to discuss the clarity, relevance and missing items; (3) patients (n = 12) were interviewed one on one to discuss the final version.

Results: The first version of the WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP) consisted of 18 items based on the criteria: exertion, dexterity, handling tools & equipment, and mobility. According to patients (n = 14), 44% of the items were not easy enough to understand. Twenty-one experts [10 men, mean age 46 (SD = 8.5) and mean years of experience 16 (SD = 9.9)] participated in the interviews and adaptations were made. The final version of the WORQ-UP consisted of 17 items, all easy enough to understand according to patients (n = 12).

Conclusions: A PROM specific for work-related limitations in patients with upper extremity musculoskeletal disorders was developed. According to patients and experts, it has sufficient content validity. The WORQ-UP can be used to assist in enhancing communication among healthcare workers to improve work-directed care and to evaluate effects of treatment on limitations at work.
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http://dx.doi.org/10.1007/s00420-017-1246-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640741PMC
November 2017

The accuracy and precision of radiostereometric analysis in upper limb arthroplasty.

Acta Orthop 2017 Jun 2;88(3):320-325. Epub 2017 Mar 2.

b Department of Orthopaedic Surgery , Reinier de Graaf Hospital , Delft.

Background and purpose - Radiostereometric analysis (RSA) is an accurate method for measurement of early migration of implants. Since a relation has been shown between early migration and future loosening of total knee and hip prostheses, RSA plays an important role in the development and evaluation of prostheses. However, there have been few RSA studies of the upper limb, and the value of RSA of the upper limb is not yet clear. We therefore performed a systematic review to investigate the accuracy and precision of RSA of the upper limb. Patients and methods - PRISMA guidelines were followed and the protocol for this review was published online at PROSPERO under registration number CRD42016042014. A systematic search of the literature was performed in the databases Embase, Medline, Cochrane, Web of Science, Scopus, Cinahl, and Google Scholar on April 25, 2015 based on the keywords radiostereometric analysis, shoulder prosthesis, elbow prosthesis, wrist prosthesis, trapeziometacarpal joint prosthesis, humerus, ulna, radius, carpus. Articles concerning RSA for the analysis of early migration of prostheses of the upper limb were included. Quality assessment was performed using the MINORS score, Downs and Black checklist, and the ISO RSA Results - 23 studies were included. Precision values were in the 0.06-0.88 mm and 0.05-10.7° range for the shoulder, the 0.05-0.34 mm and 0.16-0.76° range for the elbow, and the 0.16-1.83 mm and 11-124° range for the TMC joint. Accuracy data from marker- and model-based RSA were not reported in the studies included. Interpretation - RSA is a highly precise method for measurement of early migration of orthopedic implants in the upper limb. However, the precision of rotation measurement is poor in some components. Challenges with RSA in the upper limb include the symmetrical shape of prostheses and the limited size of surrounding bone, leading to over-projection of the markers by the prosthesis. We recommend higher adherence to RSA guidelines and encourage investigators to publish long-term follow-up RSA studies.
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http://dx.doi.org/10.1080/17453674.2017.1291872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434603PMC
June 2017

Clinical and radiographic outcome of revision surgery of radial head prostheses: midterm results in 16 patients.

J Shoulder Elbow Surg 2017 Mar 22;26(3):394-402. Epub 2016 Nov 22.

Upper Limb Unit, Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands; Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam-Zuidoost, The Netherlands.

Background: Little is known about revision surgery of radial head arthroplasty. The aim of this study was to report on the clinical and radiographic outcome of revision arthroplasty of the elbow with a bipolar metallic radial head prosthesis.

Methods: Between 2006 and 2013, we used either a press-fit or cemented RHS bipolar radial head prosthesis for revision surgery of radial head arthroplasty in 16 patients. Patients were prospectively enrolled in the study. Differences in outcome parameters before and after revision surgery were compared.

Results: At a mean follow-up of 75 months (range, 36-116 months), none of the revised radial head prostheses needed a second revision. None of the stems showed radiographic signs of loosening. In 1 patient the head was dissociated from the prosthesis. The average flexion-extension arc was 127° (range, 105°-140°), and the average pronation-supination arc was 138° (range, 90°-160°). Stability scores improved after revision surgery, resulting in 13 stable elbows (P = .01). In 8 patients the Oxford Elbow Score was between 37 and 48 points. The percentage of patients with either good or excellent results according to the Mayo Elbow Performance Score was 63%. The mean score on the EQ-5D (EuroQol Five Dimensions) was 80 (range, 63-100), and the visual analog scale scores both for pain at rest and for pain with activity improved to 3 (range, 0-9) and 4 (range, 0-9), respectively (P < .001). All but 1 patient was satisfied with the results of the revision procedure.

Conclusion: The clinical and radiographic outcomes of revision surgery of a radial head prostheses are favorable.
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http://dx.doi.org/10.1016/j.jse.2016.09.047DOI Listing
March 2017

Development of a Prognostic Model for Patients With Shoulder Complaints in Physical Therapist Practice.

Phys Ther 2017 01;97(1):72-80

Background: Health care providers need prognostic factors to distinguish between patients who are likely to recover and those who are not likely to recover.

Objective: The aim of this study was to: (1) describe the clinical course of recovery and (2) identify prognostic factors of recovery in patients with shoulder pain at the 26-week follow-up.

Design: A prospective cohort study was carried out in the Netherlands and included 389 patients who consulted a physical therapist for a new episode of shoulder pain.

Method: Participants were followed for 26 weeks. Potential predictors of recovery were selected from the literature and, with the addition of 2 new variables (ie, use of diagnostic ultrasound and working alliance), evaluated in the multivariable regression analysis. Multiple imputation was used to handle missing data, and bootstrap methods were used for internal validation.

Results: The recovery rate was 60% for the total population and 65% for the working population after 26 weeks. Short duration of complaints, lower disability scores, having a paid job, better working alliance, and no feelings of anxiety or depression were associated with recovery. In the working population, only duration of complaints and disability remained in the final model. The area under the receiver operating characteristic curve (AUC) for the final model was 0.67 for the total population and 0.63 for the working population. After internal validation, the AUC was corrected to 0.66 and 0.63, respectively.

Limitations: External validation of the prognostic model should be done prior to its use in clinical practice.

Conclusion: The results of this study indicate that several factors can predict recovery.
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http://dx.doi.org/10.2522/ptj.20150649DOI Listing
January 2017

Radiocarpal and Midcarpal Instability in Rheumatoid Patients: A Systematic Review.

Open Orthop J 2015 31;9:246-54. Epub 2015 Jul 31.

Department of Orthopaedic Surgery, Academic Medical Center, Postbus 22660, 1100 DD Amsterdam, The Netherlands.

Background: This study was aimed at identifying the criteria for the diagnosis of Radiocarpal instability in rheumatoid arthritis RA).

Methods: The main databases were searched to identify studies describing the pathophysiology of Radiocarpal instability in patients with RA. We focussed on the epidemiology, radiographic parameters, criteria for instability and on treatment options. Results. In the search 108 articles were found, of these 12 studies were included for this review. Instability occurs in at an average of 35.2% of the rheumatoid wrists. The instability was found between 8 and 13 years after onset of rheumatoid arthritis. A strong correlation was found between instability, duration of RA and Larsen score. Several radiographic methods were described to evaluate Radiocarpal instability in RA. Several treatment options for instability in patients with RA are described. All with their own indications and limitations.

Conclusion: On a standard AP radiograph deformity can be measured using the carpal height and the ulnar translation index of Chamay. This gives an indication for instability. For describing the deterioration of the joints the Larsen score is most used. If there are more radiographs in time the Simmen classification can be used. For real assessment of instability dynamic radiographs are needed.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.2174/1874325001509010246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591907PMC
October 2015

Reconstruction of the DRUJ in a young adult after resection of a large exostosis of the distal radius.

Strategies Trauma Limb Reconstr 2015 Aug 16;10(2):123-7. Epub 2015 Apr 16.

Department of Orthopaedic Surgery, Upper Limb Unit, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands.

The prevalence of known solitary exostosis is around 1-2 % in the general population. Treatment of an exostosis may consist of resection with or without further treatment for deformity. The distal radioulnar joint (DRUJ) acts as the link between radius and ulna at the wrist and is important in the transmission of load. Its anatomic integrity should be respected in surgical procedures or ulnar-sided wrist pain because of instability, limitation of forearm rotation and potential development of grip weakness may develop. We present a case of reconstruction of the DRUJ with distraction lengthening of the ulna after resection of a large exostosis of the distal radius that had resulted in a malformed and dysplastic ulna. This treatment in a young patient resulted in a stable, functional and congruent distal radioulnar joint.
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http://dx.doi.org/10.1007/s11751-015-0224-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570885PMC
August 2015

Grip strength ratio: a grip strength measurement that correlates well with DASH score in different hand/wrist conditions.

BMC Musculoskelet Disord 2014 Oct 6;15:336. Epub 2014 Oct 6.

Upper Limb Unit of the Department of Orthopaedics, Amphia Hospital, Breda, The Netherlands.

Background: Grip strength correlates with personal factors such as gender, age and nutritional status and has a good inter-rater reliability. It reflects fairly well how much people can use their hands.The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure 3 is a 30-item, self-report, questionnaire that reflects the patients' opinion on their disability due to upper-limb disorders. We assessed if grip strength and grip strength ratio correlate with DASH score.

Methods: In 3 groups (20 healthy volunteers, 17 patients after distal radius fractures, 12 patients with different hand/wrist conditions) grip strength and DASH scores (items 1-21, 22-30 and total) were assessed. To exclude personal factors grip strengths in the injured or non-dominant hand and grip strength ratios (grip strength in the injured or non-dominant hand divided by grip strength in the non-injured or dominant hand) were assessed too. Results were analyzed groups using Pearson Correlation Coefficients and with a multivariate ANOVA.

Results: Grip strength ratio was 0.97 in healthy volunteers, 0.52 in patients after distal radius fracture and 0.74 in patients with various other hand/wrist disorders.Significant correlations were found between the grip strength ratio and DASH as well as DASH subsections in all groups and between DASH scores and grip strength in some. The correlations between the ratio of the grip strength (GSR) and DASH were much stronger than the correlation between grip strength and DASH. This emphasizes the value of the GSR. Age showed no correlation with grip strength ratio using a multivariate ANOVA.

Conclusion: Grip strength ratio correlates well with the DASH score in different hand and wrist conditions. It is a valuable tool to assess patients that speak a different language and have problems with the non-dominant hand and probably easier to follow over time than the DASH score, which is time consuming to fill in and process.
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http://dx.doi.org/10.1186/1471-2474-15-336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197251PMC
October 2014

Foreign body reaction associated with polyethylene mesh interposition used for treatment of trapeziometacarpal osteoarthritis: report of 8 cases.

J Hand Surg Am 2014 Oct 27;39(10):2016-9. Epub 2014 Aug 27.

Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands; Department of Pathology, Amphia Hospital, Breda, The Netherlands.

Purpose: To report the incidence of foreign body reactions associated with placement of a polyethylene mesh implant in patients treated with trapiezectomy for trapeziometacarpal osteoarthritis.

Methods: Between November 2008 and September 2012, 70 hands in 66 adults with stage IV trapeziometacarpal osteoarthritis had a trapiezectomy with interposition of a spacer made of polyethylene terephthalate mesh (Anchois Ligastic, Orthomed SA, St Jeannet, France). Out of these 70 implants, 8 implants (11%) in 8 patients (mean age, 60 y; range, 49-75 y) were removed because of persistent swelling, synovitis, and pain.

Results: The mean interval between primary and revision surgery was 14 (range, 5-27) months. Histological analysis in all cases showed a foreign body giant cell reaction. Two hands showed bone resorption or carpal bone cysts similar to silicone particle synovitis. The cysts resolved after implant removal and bone grafting.

Conclusions: In the light of these results and the available literature, we recommend not using this material for interposition in the treatment of osteoarthritis of the trapeziometacarpal joint.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.07.038DOI Listing
October 2014

Surgery versus conservative treatment in patients with type A distal radius fractures, a randomized controlled trial.

BMC Musculoskelet Disord 2014 Mar 19;15:90. Epub 2014 Mar 19.

Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, P,O, Box 22660, Amsterdam, DD 1100, The Netherlands.

Background: Fractures of the distal radius are common and account for an estimated 17% of all fractures diagnosed. Two-thirds of these fractures are displaced and require reduction. Although distal radius fractures, especially extra-articular fractures, are considered to be relatively harmless, inadequate treatment may result in impaired function of the wrist. Initial treatment according to Dutch guidelines consists of closed reduction and plaster immobilisation. If fracture redisplacement occurs, surgical treatment is recommended. Recently, the use of volar locking plates has become more popular. The aim of this study is to compare the functional outcome following surgical reduction and fixation with a volar locking plate with the functional outcome following closed reduction and plaster immobilisation in patients with displaced extra-articular distal radius fractures.

Design: This single blinded randomised controlled trial will randomise between open reduction and internal fixation with a volar locking plate (intervention group) and closed reduction followed by plaster immobilisation (control group). The study population will consist of all consecutive adult patients who are diagnosed with a displaced extra-articular distal radius fracture, which has been adequately reduced at the Emergency Department. The primary outcome (functional outcome) will be assessed by means of the Disability Arm Shoulder Hand Score (DASH). Secondary outcomes comprise the Patient-Rated Wrist Evaluation score (PRWE), quality of life, pain, range of motion, radiological parameters, complications and cross-overs. Since the treatment allocated involves a surgical procedure, randomisation status will not be blinded. However, the researcher assessing the outcome at one year will be unaware of the treatment allocation. In total, 90 patients will be included and this trial will require an estimated time of two years to complete and will be conducted in the Academic Medical Centre Amsterdam and its partners of the regional trauma care network.

Dicussion: Ideally, patients would be randomised before any kind of treatment has been commenced. However, we deem it not patient-friendly to approach possible participants before adequate reduction has been obtained.

Trial Registration: This study is registered at the Netherlands Trial Register (NTR3113) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on 01-10-2012.
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http://dx.doi.org/10.1186/1471-2474-15-90DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4234244PMC
March 2014

The opinion and experiences of Dutch orthopedic surgeons and radiologists about diagnostic musculoskeletal ultrasound imaging in primary care: a survey.

Man Ther 2014 Apr 3;19(2):109-13. Epub 2013 Sep 3.

Department Physical Therapy, Research Group Diagnostics, University of Applied Sciences, Breda, The Netherlands; Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

Introduction And Aim: The use of diagnostic musculoskeletal ultrasound (DMUS) in primary health care has increased in the recent years. Nevertheless, there are hardly any data concerning the reliability, accuracy and treatment consequences of DMUS used by physical therapists or general practitioners. Moreover, there are no papers published about how orthopedic surgeons or radiologists deal with the results of DMUS performed in primary care. Therefore, our aim is to evaluate the opinion, possible advantages or disadvantages and experiences of Dutch orthopedic surgeons and radiologists about DMUS in primary care.

Methods: A cross-sectional survey in which respondents completed a self-developed questionnaire to determine their opinion, experiences, advantages, disadvantages of performing DMUS in primary care.

Results: Questionnaires were sent to 838 Dutch orthopedic surgeons and radiologists of which 213 were returned (response rate 25.4%). Our respondents saw no additional value for health care for diagnostic DMUS in primary care. DMUSs were generally repeated in secondary care. They perceived more disadvantages than advantages of performing DMUS in primary care. Mentioned disadvantages were: 'false positive results' (71.4%), 'lack of experience' (70%), 'insufficient education' (69.5%), not able to relate the outcomes of DMUS with other forms of diagnostic imaging' (65.7%), and 'false negative results' (65.3%).

Conclusion: Radiologists and orthopedic surgeons sampled in the Netherlands show low trust in DMUS knowledge of physical therapists and general practitioners. The results should be interpreted with caution because of the small response rate and the lack of representativeness to other countries.
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http://dx.doi.org/10.1016/j.math.2013.08.003DOI Listing
April 2014

Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs.

BMC Musculoskelet Disord 2013 May 22;14:170. Epub 2013 May 22.

Department of Orthopaedics, Amphia Hospital, Breda, The Netherlands.

Background: Treatment of distal radius fractures in patients of a younger than osteoporotic age is complex, because they often are the result of a high-energy trauma and have intra-articular fractures and associated injuries. As yet no fracture classification exists that predicts outcome. Our aim was to find the earliest possible prognostic factor by testing which radiological parameter on the trauma radiograph would have the greatest impact on clinical outcome in a younger than osteoporotic age group.

Methods: We assessed 66 patients (34 F) with unilateral fractures of the distal radius from a non-Osteoporotic age group. The median age was 42 years, (10th -90th percentile 20-54). Pre-reduction antero-posterior and lateral wrist radiographs were obtained and fracture pattern, radiocarpal joint surface tilt, radial length, radial inclination and ulnar variance were measured. Clinical outcome was assessed with the subjective part as well as the complete modified Gartland and Werley score. Multivariate analysis of those parameters was performed to assess which radiological parameter would best predict outcome.

Results: It was found that post-traumatic ulna + (>2 mm) was the single factor that significantly correlated with a bad outcome. An intra-articular fracture pattern may also be a strong marker; however this was not statistically significant (RR 95% conf interval 0.94 - 20.59).

Conclusions: The present study showed that post-traumatic ulna + is the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too.
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http://dx.doi.org/10.1186/1471-2474-14-170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665633PMC
May 2013

Current management and prognostic factors in physiotherapy practice for patients with shoulder pain: design of a prospective cohort study.

BMC Musculoskelet Disord 2013 Feb 11;14:62. Epub 2013 Feb 11.

Faculty of Health, Research group Diagnostics, Avans University of Applied Sciences, PO Box 90,1164800, RA, Breda, The Netherlands.

Background: Shoulder pain is disabling and has a considerable socio-economic impact. Over 50% of patients presenting in primary care still have symptoms after 6 months; moreover, prognostic factors such as pain intensity, age, disability level and duration of complaints are associated with poor outcome. Most shoulder complaints in this group are categorized as non-specific. Musculoskeletal ultrasound might be a useful imaging method to detect subgroups of patients with subacromial disorders.This article describes the design of a prospective cohort study evaluating the influence of known prognostic and possible prognostic factors, such as findings from musculoskeletal ultrasound outcome and working alliance, on the recovery of shoulder pain. Also, to assess the usual physiotherapy care for shoulder pain and examine the inter-rater reliability of musculoskeletal ultrasound between radiologists and physiotherapists for patients with shoulder pain.

Methods: A prospective cohort study including an inter-rater reliability study. Patients presenting in primary care physiotherapy practice with shoulder pain are enrolled. At baseline validated questionnaires are used to measure patient characteristics, disease-specific characteristics and social factors. Physical examination is performed according to the expertise of the physiotherapists. Follow-up measurements will be performed 6, 12 and 26 weeks after inclusion. Primary outcome measure is perceived recovery, measured on a 7-point Likert scale. Logistic regression analysis will be used to evaluate the association between prognostic factors and recovery.

Discussion: The ShoCoDiP (Shoulder Complaints and using Diagnostic ultrasound in Physiotherapy practice) cohort study will provide information on current management of patients with shoulder pain in primary care, provide data to develop a prediction model for shoulder pain in primary care and to evaluate whether musculoskeletal ultrasound can improve prognosis.
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http://dx.doi.org/10.1186/1471-2474-14-62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3606323PMC
February 2013

Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic findings and results of anatomical reconstruction.

BMC Musculoskelet Disord 2011 Sep 27;12:212. Epub 2011 Sep 27.

Department of Orthopaedics, Sint Maartenskliniek, 6500GM Nijmegen, the Netherlands.

Background: The arthroscopic findings in patients with chronic anterior syndesmotic instability that need reconstructive surgery have never been described extensively.

Methods: In 12 patients the clinical suspicion of chronic instability of the syndesmosis was confirmed during arthroscopy of the ankle. All findings during the arthroscopy were scored. Anatomical reconstruction of the anterior tibiofibular syndesmosis was performed in all patients. The AOFAS score was assessed to evaluate the result of the reconstruction. At an average of 43 months after the reconstruction all patients were seen for follow-up.

Results: The syndesmosis being easily accessible for the 3 mm transverse end of probe which could be rotated around its longitudinal axis in all cases during arthroscopy of the ankle joint, confirmed the diagnosis. Cartilage damage was seen in 8 ankles, of which in 7 patients the damage was situated at the medial side of the ankle joint. The intraarticular part of anterior tibiofibular ligament was visibly damaged in 5 patients. Synovitis was seen in all but one ankle joint. After surgical reconstruction the AOFAS score improved from an average of 72 pre-operatively to 92 post-operatively.

Conclusions: To confirm the clinical suspicion, the final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle. Cartilage damage to the medial side of the tibiotalar joint is often seen and might be the result of syndesmotic instability. Good results are achieved by anatomic reconstruction of the anterior syndesmosis, and all patients in this study would undergo the surgery again if necessary.
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http://dx.doi.org/10.1186/1471-2474-12-212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191511PMC
September 2011

Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane.

Skeletal Radiol 2012 Feb 30;41(2):193-202. Epub 2011 Apr 30.

Department of Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.

Objective: To evaluate the additional value of a 45° oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture.

Materials And Methods: Prospectively, data were collected for 44 consecutive patients with an acute ankle fracture who underwent a radiograph (AP, lateral, and mortise view) as well as an MRI in both the standard three orthogonal planes and in an additional 45° oblique plane. The fractures on the radiographs were classified according to Lauge-Hansen (LH). The anterior (ATIFL) and posterior (PTIFL) distal tibiofibular ligaments, as well as the presence of a bony avulsion in both the axial and oblique planes was evaluated on MRI. MRI findings regarding syndesmotic injury in the axial and oblique planes were compared to syndesmotic injury predicted by LH. Kappa and the agreement score were calculated to determine the interobserver agreement. The Wilcoxon signed rank test and McNemar's test were used to compare the two scan planes.

Results: The interobserver agreement (κ) and agreement score [AS (%)] regarding injury of the ATIFL and PTIFL and the presence of a fibular or tibial avulsion fracture were good to excellent in both the axial and oblique image planes (κ 0.61-0.92, AS 84-95%). For both ligaments the oblique image plane indicated significantly less injury than the axial plane (p < 0.001). There was no significant difference in detection of an avulsion fracture in the axial or oblique plane, neither anteriorly (p = 0.50) nor posteriorly (p = 1.00). With syndesmotic injury as predicted by LH as comparison, the specificity in the oblique MR plane increased for both anterior (to 86% from 7%) and posterior (to 86% from 48%) syndesmotic injury when compared to the axial plane.

Conclusion: Our results show the additional value of an 45° oblique MR image plane for detection of injury of the anterior and posterior distal tibiofibular syndesmoses in acute ankle fractures. Findings of syndesmotic injury in the oblique MRI plane were closer to the diagnosis as assumed by the Lauge-Hansen classification than in the axial plane. With more accurate information, the surgeon can better decide when to stabilize syndesmotic injury in acute ankle fractures.
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http://dx.doi.org/10.1007/s00256-011-1179-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3244606PMC
February 2012

Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach.

J Anat 2010 Dec;217(6):633-45

Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands.

A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments.This definition also applies for the distal tibiofibular syndesmosis, which is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. In an estimated 1–11% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. This could be due to widening of the ankle mortise as a result of increased length of the syndesmotic ligaments after acute ankle sprain. As widening of the ankle mortise by 1 mm decreases the contact area of the tibiotalar joint by 42%, this could lead to instability and hence early osteoarthritis of the tibiotalar joint. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all of type Weber C fractures. However,in discussing syndesmotic injury, it seems the exact proximal and distal boundaries of the distal tibiofibular syndesmosis are not well defined. There is no clear statement in the Ashhurst and Bromer etiological, the Lauge-Hansen genetic or the Danis-Weber topographical fracture classification about the exact extent of the syndesmosis. This joint is also not clearly defined in anatomical textbooks, such as Lanz and Wachsmuth. Kelikian and Kelikian postulate that the distal tibiofibular joint begins at the level of origin of the tibiofibular ligaments from the tibia and ends where these ligaments insert into the fibular malleolus. As the syndesmosis of the ankle plays an important role in the stability of the talocrural joint, understanding of the exact anatomy of both the osseous and ligamentous structures is essential in interpreting plain radiographs, CT and MR images, in ankle arthroscopy and in therapeutic management. With this pictorial essay we try to fill the hiatus in anatomic knowledge and provide a detailed anatomic description of the syndesmotic bones with the incisura fibularis, the syndesmotic recess, synovial fold and tibiofibular contact zone and the four syndesmotic ligaments. Each section describes a separate syndesmotic structure, followed by its clinical relevance and discussion of remaining questions.
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http://dx.doi.org/10.1111/j.1469-7580.2010.01302.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039176PMC
December 2010

The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis.

Skeletal Radiol 2011 Jan 13;40(1):75-83. Epub 2010 Jun 13.

Department of Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.

Objective: The optimal MRI scan planes of collateral ligaments of the ankle have been described extensively, with the exception of the syndesmotic ligaments. We assessed the optimal scan plane for depicting the distal tibiofibular syndesmosis.

Materials And Methods: In order to determine the optimal oblique caudal-cranial and lateral-medial MRI scan plane, two fresh frozen cadaveric ankles were used. The angle of the scan plane that demonstrated the anterior and posterior distal tibiofibular ligament uninterrupted in their full length was determined. In a prospective study this oblique scan plane was then used in addition to the axial and coronal planes, for MRI scans of both ankles in 21 healthy volunteers. Two observers independently evaluated the anterior tibiofibular ligament (ATIFL) and posterior tibiofibular ligament (PTIFL) regarding the continuity of the individual fascicles, thickness and wavy contour of the ligaments in both the axial and the oblique plane. Kappa was calculated to determine the interobserver agreement. McNemar's test was used to statistically quantify the significance of the two scan planes.

Results: In the axial plane the ATIFL was in 31% (13/42) partly and in 69% (29/42) completely discontinuous; in the oblique plane the ATIFL was continuous in 88% (37/42) and partly discontinuous in 12% (5/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p<0.001), but not significantly less thickening (p=1.00) or less wavy contour (p=0.06) of the ATIFL. In the axial scan plane the PTIFL was continuous in 76% (32/42), partially discontinuous in 19% (8/42) and completely discontinuous in 5% (2/42); in the oblique plane the PTIFL was continuous in 100% (42/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p=0.002), but not significantly less thickening (p=1.00) or less wavy contour (p=0.50) of the PTIFL. The interobserver agreement score and kappa (κ) regarding the continuity for the ATIFL in the axial and oblique planes was 91% (κ=0.79) and 91% (κ=0.55) respectively; for the PTIFL it was 86% (κ=0.65) and 100% (κ = not defined).

Conclusion: The ATIFL and PTIFL are routinuely scanned in the orthogonal planes. The advantage of MRI scanning in an oblique image plane of about 45 degrees permits a better evaluation of the ligaments compared with the axial plane, particularly a better interpretation of ligament continuity, thickening and wavy contour. This may lead to a reduction in false-positive results, especially regarding partial or complete ligament ruptures. This can be of considerable aid in therapeutic management.
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http://dx.doi.org/10.1007/s00256-010-0938-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989003PMC
January 2011

MR-plastination-arthrography: a new technique used to study the distal tibiofibular syndesmosis.

Skeletal Radiol 2009 Jul 9;38(7):697-701. Epub 2009 Jan 9.

Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, P.O. Box 2040, 3000 CA Rotterdam, Rotterdam 3015 GD, The Netherlands.

Purpose: The purpose of this study was to describe a new technique called MR plastination arthrography to study both intra- and extra-articular anatomy.

Materials And Methods: In six human cadaveric lower legs MR arthrography was performed in either a one-step or two-step procedure. In the former a mixture of diluted Gadolinium and dyed polymer was injected. In the latter the dyed polymer was injected after arthrography wih diluted Gadolinium. Three-millimeter slices of these legs, obtained in a plane identical to that of the MR images, were plastinated according to the E12 technique of von Hagens. The plastination slices were subsequently compared with the MR images.

Results: The one-step procedure resulted in an inhomogeneous arthrogram. The two-step procedure resulted in a good correlation between the high-resolution MR images and plastination slices, as expressed by a good comparison of anatomic detail of the small syndesmotic recess.

Conclusions: Images of the distal tibiofibular syndesmosis obtained with plastination arthrography correlated well with images acquired by MR arthrography when performed in a two-step procedure.
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http://dx.doi.org/10.1007/s00256-008-0631-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7419482PMC
July 2009

A pilot study of the Video Observations Aarts and Aarts (VOAA): a new software program to measure motor behaviour in children with cerebral palsy.

Occup Ther Int 2007 ;14(2):113-22

Department of Child Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands.

A new computer software program to score video observations, Video Observations Aarts and Aarts (VOAA) was developed to evaluate paediatric occupational therapy interventions. The VOAA is an observation tool that assesses the frequency, duration and quality of arm/hand use in children, in particular those with cerebral palsy. Reliability studies show that the first module, designed to evaluate a forced-use programme, has an excellent content validity index (0.93) and good intra- and inter-observer reliability (Cohen's kappas ranging from 0.62 to 0.85 for the three activities tested). With the built-in statistical package, paediatric occupational therapy departments can conduct therapeutic evaluations with children with impairments in the upper extremities. Further research is recommended to apply the VOAA in clinical studies in paediatric occupational therapy.
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http://dx.doi.org/10.1002/oti.229DOI Listing
July 2007

Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment.

Acta Orthop 2006 Jun;77(3):531-40

Department of Orthopaedics, Erasmus University Medical Centre, Rotterdam, The Netherlands.

Background: Syndesmotic injuries of the ankle without fractures can result from external rotation, abduction and dorsiflexion injuries. Kinematic studies of these trauma mechanisms have not been performed. We attempted to describe the kinematics of the tibiofibular joint in cadaveric specimens using radiostereometry after sequential ligament sectioning, and resulting from different trauma mechanisms and axial loading, in order to put forward treatment guidelines for the different types of syndesmotic injuries.

Methods: We assessed the kinematics of the distal tibiofibular joint in fresh-frozen cadaveric specimens using radiostereometry in the intact situation, and after alternating and sequential sectioning of the distal tibiofibular and anterior deltoid ligaments. To assess which of the known trauma mechanisms would create the largest displacements at the syndesmosis, the ankle was brought into the following positions under an axial load that was comparable to body weight (750 N): neutral, dorsiflexion, external rotation, abduction, and a combination of external rotation and abduction.

Results: In the neutral position, the largest displacements of the fibula consisted of external rotation and posterior translation. Loading of the ankle with 750 N did not apparently increase or decrease the displacements of the fibula, but gave a larger variety of displacements. In every position, sectioning of a ligament resulted in some fibular displacement. Sectioning of the anterior tibiofibular ligament (ATiFL) invariably resulted in external rotation of the fibula. Additional sectioning of the anterior part of the deltoid ligament (AD) gave a larger variety of displacements. In general, sectioning of the posterior tibiofibular ligament (PTiFL) gave the smallest displacements. Combined sectioning of the ATiFL and the PTiFL resulted in a larger variety of displacements in the neutral position. Sectioning of the AD together with the ATiFL and PTiFL resulted in tibiofibular displacements in the neutral situation exceeding the maximum values found in the intact situation, the most important being fibular external rotation.

Interpretation: Sectioning of the ATiFL results in mechanical instability of the syndesmosis. Of all trauma mechanisms, external rotation of the ankle resulted in the largest and most consistent displacements of the fibula relative to the tibia found at the syndesmosis. Based on our findings and the current literature, we recommend that patients with isolated PTiFL or AD injuries should be treated functionally when no other injuries are present. Patients with acute complete ATiFL ruptures, or combined ATiFL and AD ruptures should be treated with immobilization in a plaster. Patients with combined ruptures of the ATiFL, AD and PTiFL need to be treated with a syndesmotic screw.
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http://dx.doi.org/10.1080/17453670610012557DOI Listing
June 2006

Kinematics before and after reconstruction of the anterior syndesmosis of the ankle: A prospective radiostereometric and clinical study in 5 patients.

Acta Orthop 2005 Oct;76(5):713-20

Department of Orthopaedics, Erasmus University Medical Centre, Rotterdam, the Netherlands.

Background: We have previously shown that patients with instability of the anterior syndesmosis benefit from an anatomical reconstruction. It is not known whether this is because of restored kinematics.

Methods: In a prospective study of 5 patients, we assessed clinical findings and tibiofibular kinematics, evaluated by radiostereometry, before and after reconstruction of a chronic syndesmotic injury.

Results: We found no statistically significant differences in tibiofibular kinematics before and after reconstruction. The kinematics of the fibula relative to the tibia during external rotation stress differed from that known in asymptomatic volunteers, but the differences were not typical enough to differentiate between patients and healthy subjects. Clinical examination and ankle scores, however, showed that all patients benefited from reconstruction of the anterior syndesmosis.

Interpretation: Radiostereometry is not an adequate technique to diagnose chronic syndesmotic instability or to demonstrate restoration of the kinematics of the ankle as a cause of the beneficial effect of anatomical reconstruction of the syndesmosis.
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http://dx.doi.org/10.1080/17453670510041817DOI Listing
October 2005

Surgical treatment of achilles tendon rupture: examination of strength of 3 types of suture techniques in a cadaver model.

Acta Orthop 2005 Jun;76(3):408-11

Departments of Orthopedic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.

Background: The mechanical properties of present-day percutaneous repairs of Achilles tendon ruptures are not known.

Material And Methods: Artificially-created ruptures in 24 human cadaveric Achilles tendons were repaired with an open Bunnell repair, a percutaneous calcaneal tunnel or a percutaneous bone-anchor repair. In the open technique no.1 PDS-II absorbable suture material was used, and in the percutaneous techniques either no.1 PDS-II or no.1 Panacryl absorbable suture material was used. The specimens were tested in a materials testing machine until failure occurred.

Results: The common mode of failure was suture breakage in non-anchor repairs, and anchor pullout in anchor repairs. The average strength of the repairs varied from 166 N (SD 60) to 211 N (SD 30), with no differences between the techniques (p = 0.5).

Interpretation: Taking costs into account, the percutaneous calcaneal tunnel technique and the open technique are the methods of choice.
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June 2005

Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation.

Injury 2005 Jan;36(1):60-4

Department of Orthopaedics, Erasmus University Medical Centre, Rotterdam, The Netherlands.

We assessed syndesmotic set screw strength and fixation capacity during cyclical testing in a cadaver model simulating protected weight bearing. Sixteen fresh frozen legs with artificial syndesmotic injuries and a syndesmotic set screw made of stainless steel or titanium, inserted through three or four cortices, were axially loaded with 800 N for 225,000 cycles in a materials testing machine. The 225,000 cycles equals the number of paces taken by a person walking in a below knee plaster during 9 weeks. Syndesmotic fixation failure was defined as: bone fracture, screw fatigue failure, screw pullout, and/or excessive syndesmotic widening. None of the 14 out of 16 successfully tested legs or screws failed. No difference was found in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Mean lateral displacement found after testing was 1.05 mm (S.D. = 0.42). This increase in tibiofibular width exceeds values described in literature for the intact syndesmosis loaded with body weight. Based on this laboratory study it is concluded that the syndesmotic set screw cannot prevent excessive syndesmotic widening when loaded with a load comparable with body weight. Therefore, we advise that patients with a syndesmotic set screw in situ should not bear weight.
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http://dx.doi.org/10.1016/j.injury.2004.05.024DOI Listing
January 2005

Kinematics of the distal tibiofibular syndesmosis: radiostereometry in 11 normal ankles.

Acta Orthop Scand 2003 Jun;74(3):337-43

Department of Orthopaedics, Erasmus University Medical Center Rotterdam, The Netherlands.

In 11 healthy volunteers, the normal kinematics of the tibiofibular syndesmosis of the ankle during weight bearing and external rotation stress were compared to a nonweight-bearing neutral position by radiostereometry. We found very small rotations and displacements in this "normal" group, which indicated that the fibula is closely attached to the tibia, thereby preventing larger movements at the level of the ankle. We found no common kinematic pattern during weight bearing in the neutral position. Application of a 75 Nm external rotation moment on the foot caused external rotation of the fibula between 2 and 5 degrees, medial translation between 0 and 2.5 mm and posterior displacement between 1.0 and 3.1 mm. These data can be used as normal reference values for studies of patients with suspected syndesmotic injuries.
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http://dx.doi.org/10.1080/00016470310014283DOI Listing
June 2003

External rotation stress imaging in syndesmotic injuries of the ankle: comparison of lateral radiography and radiostereometry in a cadaveric model.

Acta Orthop Scand 2003 Apr;74(2):201-5

Department of Orthopaedics, Erasmus University Medical Center, Rotterdam, The Netherlands.

We compared the value of 7.5 Nm external rotation stress in diagnosing tibiofibular syndesmotic injuries of the ankle on lateral radiographs with radiostereometric analysis (RSA) in 10 cadaveric legs. After sectioning 2 ligaments, RSA showed an increase in posterior translation and external rotation of the fibula. This increase in posterior translation was smaller than the posterior displacement of the fibula on the lateral radiograph, and RSA showed mainly an increase in external rotation of the fibula that can not be measured on conventional radiographs. We conclude that instability of the syndesmosis in cadaveric ankles can be detected with 7.5 Nm external rotation stress RSA, but that external rotation stress lateral radiography is unreliable.
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http://dx.doi.org/10.1080/00016470310013969 DOI Listing
April 2003
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