Publications by authors named "Leendert Blankevoort"

70 Publications

Adequate return to sports and sports activities after treatment of Lisfranc injury: a meta-analysis.

J ISAKOS 2021 07 10;6(4):212-219. Epub 2020 Dec 10.

Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

Importance: Although a large number of Lisfranc injuries occur during sports, data on sports outcomes, such as return to sport (RTS) rates and times as well as level of sports activities after treatment of this injury remain limited.

Objective: The aim is to assess the RTS rates, times and the sports activity levels after different treatments of Lisfranc injuries.

Evidence Review: The electronic databases PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL were searched to identify relevant articles from January 1985 to July 2020. The mean RTS rates (to any level and preinjury level of sports) and times were extracted per study, and pooled wherever methodologically possible. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies criteria (MINORS).

Findings: Fifteen studies were included in this review. Methodological quality of the studies was poor. The treatments reported in the studies were conservative treatment, surgical fixation and primary partial arthrodesis. For conservative treatment, the RTS rate regardless of sports level was 93% (95% CI 81% to 98%; n=42) and for return to preinjury level of sports was 88% (95% CI 75% to 95%; n=42). The fixation group showed a RTS percentage of 94% (95% CI 91% to 97%; n=270) to each level of sports and for return to the level before injury was 86% (95% CI 80% to 90%; n=188). In the primary partial arthrodesis group, the return to any level of sports was 94% (95% CI 85% to 98%; n=65) and for return to preinjury level was 74% (95% CI 62% to 83%; n=65). Mean time to RTS ranged from 7 to 33 weeks across all treatment groups. No data pooling was possible for this outcome measure. From the different studies, a total of 43 different sports and 440 physical activities were reported before treatment. After treatment, patients participated in 37 different sports (88%) and 391 different physical activities (89%).

Conclusions And Relevance: The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport. These sport-specific outcomes can be used to inform patients about their expected sport-specific outcomes after different treatments of Lisfranc injuries.

Level Of Evidence: Systematic review and meta-analysis.
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http://dx.doi.org/10.1136/jisakos-2020-000477DOI Listing
July 2021

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

Am J Sports Med 2021 May 28:3635465211004977. Epub 2021 May 28.

FIFA Medical Centre of Excellence Ripoll-dePrado-vanDijk SportClinic Madrid, Spain.

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.
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http://dx.doi.org/10.1177/03635465211004977DOI Listing
May 2021

Difference in orientation of the talar articular facets between healthy ankle joints and ankle joints with chronic instability.

J Orthop Res 2021 Apr 29. Epub 2021 Apr 29.

Mein Fusszentrum, Basel, University of Basel, Switzerland.

Since both the talocrural and subtalar joints can be involved in chronic ankle instability, the present study assessed the talar morphology as this bone is the key player between both joint levels. The 3D orientation and curvature of the superior and the posteroinferior facet between subjects with chronic ankle instability and healthy controls were compared. Hereto, the talus was segmented in the computed tomography images of a control group and a chronic ankle instability group, after which they were reconstructed to 3D surface models. A cylinder was fitted to the subchondral articulating surfaces. The axis of a cylinder represented the facet orientation, which was expressed by an inclination and deviation angle in a coordinate system based on the cylinder of the superior talar facet and the geometric principal axes of the subject's talus. The curvature of the surface was expressed as the radius of the cylinder. The results demonstrated no significant differences in the radius or deviation angle. However, the inclination angle of the posteroinferior talar facet was significantly more plantarly orientated (by 3.5°) in the chronic instability group (14.7 ± 3.1°) compared to the control group (11.2 ± 4.9°) (p < 0.05). In the coronal plane this corresponds to a valgus orientation of the posteroinferior talar facet relative to the talar dome. In conclusion, a more plantarly and valgus orientated posteroinferior talar facet may be associated to chronic ankle instability.
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http://dx.doi.org/10.1002/jor.25068DOI Listing
April 2021

Treatment type may influence degree of post-dislocation shoulder osteoarthritis: a systematic review and meta-analysis.

Knee Surg Sports Traumatol Arthrosc 2021 Jul 16;29(7):2312-2324. Epub 2020 Sep 16.

Department of Orthopedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Purpose: Age at primary dislocation, recurrence, and glenoid bone loss are associated with development of osteoarthritis (OA). However, an overview of OA following traumatic anterior shoulder instability is lacking and it is unclear to what degree type of surgery is associated with development of OA in comparison to non-operative treatment. The aim of this study was to determine the degree of OA at long-term follow-up after non-operative and operative treatments for patients with anterior shoulder instability. Surgery is indicated when patients experience recurrence and this is associated with OA; therefore, it was hypothesized that shoulders show a higher proportion or degree of OA following operative treatment compared to non-operative treatment.

Methods: A literature search was performed in the PubMed/Medline, EMBASE, and Cochrane databases. Articles reporting the degree of OA that was assessed with the Samilson-Prieto or Buscayret OA classification method after non-operative and operative treatment for anterior shoulder instability with a minimum of 5 years follow-up were included.

Results: Thirty-six articles met the eligibility criteria of which 1 reported the degree of OA for non-operative treatment and 35 reported the degree of OA for 9 different operative procedures. A total of 1832 patients (1854 shoulders) were included. OA proportions of non-operative and operative treatments are similar at any point of follow-up. The Latarjet procedure showed a lower degree of OA compared to non-operative treatment and the other operative procedures, except for the Bristow procedure and Rockwood capsular shift. The meta-analyses showed comparable development of OA over time among the treatment options. An increase in OA proportion was observed when comparing the injured to the contralateral shoulder. However, a difference between the operative subgroups was observed in neither analysis.

Conclusion: Non-operative and operative treatments show similar OA proportions at any point of follow-up. The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data. Operative treatment according to the Latarjet procedure results in a lower degree of OA compared to other treatments, including non-operative treatment.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-06263-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8225537PMC
July 2021

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

Foot Ankle Surg 2021 Aug 25;27(6):650-654. Epub 2020 Aug 25.

Department of Orthopaedic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands; Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.

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.
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http://dx.doi.org/10.1016/j.fas.2020.08.006DOI Listing
August 2021

Goal Attainment Scaling Rehabilitation Improves Satisfaction with Work Activities for Younger Working Patients After Knee Arthroplasty: Results from the Randomized Controlled ACTION Trial.

J Bone Joint Surg Am 2020 Aug;102(16):1445-1453

Department of Orthopaedic Surgery, Foundation for Orthopaedic Research Care and Education, Amphia Hospital, Breda, the Netherlands.

Background: Knee arthroplasty (KA) is increasingly performed in relatively young, active patients. This heterogeneous patient population often has high expectations, including work resumption and performance of knee-demanding leisure-time activities. Goal attainment scaling (GAS) may personalize rehabilitation by using patient-specific, activity-oriented rehabilitation goals. Since unmet expectations are a leading cause of dissatisfaction after KA, personalized rehabilitation may improve patient satisfaction. We hypothesized that, compared with standard rehabilitation, GAS-based rehabilitation would result in younger, active patients having higher satisfaction regarding activities after KA.

Methods: We performed a single-center randomized controlled trial. Eligible patients were <65 years of age, working outside the home, and scheduled to undergo unicompartmental or total KA. The required sample size was 120 patients. Using GAS, patients developed personal activity goals with a physiotherapist preoperatively. These goals were used to monitor patients' goal attainment and provide goal-specific feedback during postoperative outpatient rehabilitation. Standard rehabilitation consisted of regular outpatient physiotherapy visits. The primary outcome measures were visual analogue scale (VAS) scores (scale of 0 to 100) for satisfaction regarding activities of daily living and work and leisure-time activities 1 year postoperatively, which were analyzed using generalized estimating equation models.

Results: Patient satisfaction with work activities was significantly higher in the GAS group (β = 10.7 points, 98% confidence interval [CI] = 2.0 to 19.4 points) than in the control group. Patient satisfaction with activities of daily living and leisure-time activities did not differ between groups. We found no differences in VAS satisfaction scores between unicompartmental KA and total KA.

Conclusions: Personalized, goal-specific rehabilitation using GAS resulted in higher patient satisfaction with work activities, compared with standard rehabilitation, 1 year after KA.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.01471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508269PMC
August 2020

Accuracy of Currently Available Methods in Quantifying Anterior Glenoid Bone Loss: Controversy Regarding Gold Standard-A Systematic Review.

Arthroscopy 2020 08 21;36(8):2295-2313.e1. Epub 2020 Apr 21.

Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Purpose: To determine the accuracy of glenoid bone loss-measuring methods and assess the influence of the imaging modality on the accuracy of the measurement methods.

Methods: A literature search was performed in the PubMed (MEDLINE), Embase, and Cochrane databases from 1994 to June 11, 2019. The guidelines and algorithm of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used. Included for analysis were articles reporting the accuracy of glenoid bone loss-measuring methods in patients with anterior shoulder instability by comparing an index test and a reference test. Furthermore, articles were included if anterior glenoid bone loss was quantified using a ruler during arthroscopy or by measurements on plain radiograph(s), computed tomography (CT) images, or magnetic resonance images in living humans. The risk of bias was determined using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

Results: Twenty-one studies were included, showing 17 different methods. Three studies reported on the accuracy of methods performed on 3-dimensional CT. Two studies determined the accuracy of glenoid bone loss-measuring methods performed on radiography by comparing them with methods performed on 3-dimensional CT. Six studies determined the accuracy of methods performed using imaging modalities with an arthroscopic method as the reference. Eight studies reported on the influence of the imaging modality on the accuracy of the methods. There was no consensus regarding the gold standard. Because of the heterogeneity of the data, a quantitative analysis was not feasible.

Conclusions: Consensus regarding the gold standard in measuring glenoid bone loss is lacking. The use of heterogeneous data and varying methods contributes to differences in the gold standard, and accuracy therefore cannot be determined.

Level Of Evidence: Level IV, systematic review of Level II, III, and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2020.04.012DOI Listing
August 2020

Weight, BMI and stability are risk factors associated with lateral ankle sprains and chronic ankle instability: a meta-analysis.

J ISAKOS 2019 11 23;4(6):313-327. Epub 2019 Oct 23.

Orthopaedic surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.

Importance: Lateral ankle sprains (LAS) are common in the general population and may lead to chronic ankle instability (CAI). If patients at risk could be identified, they could receive adequate and on-time treatment.

Objective: The purpose of the current review was to identify all reported intrinsic factors associated with sustaining a LAS or progressing to CAI after an initial sprain.

Evidence Review: PubMed, Embase, MEDline, Cochrane and PEDro were searched for studies published until July 2019. Articles were selected if they included intrinsic factors related to LAS or CAI, subjects of at least 16 years old, and contained a minimum of 10 patients and 10 controls. Studies were excluded if they concerned reviews or case reports, included patients with previous surgical interventions, concomitant injuries or joint pathology other than ankle instability. Quality of included studies was assessed using the Quality in Prognostic Studies tool and quality of evidence was assessed using the GRADEpro tool. In case outcomes were described by at least three studies, data were pooled and assessed by performing a meta-analysis. Based on the pooled data, either a fixed-effects model or random-effects model was selected to correct for the degree of heterogeneity.

Findings: The search resulted in a total of 4154 studies. After title and abstract screening and subsequent full-text screening, 80 relevant studies were included. Results of the meta-analyses indicated that, compared with healthy controls, patients with LAS had a higher mean body mass index (BMI). In patients with CAI, a higher weight and a longer time to stabilise after performing a task (eg, jumping) were found compared with healthy controls. Other outcomes could not be compared using a meta-analysis due to heterogeneity in outcome measurement and the great number of different outcomes reported. Identification of the risk factors when patients present themselves after a LAS may help to determine which patients are at risk of recurrent sprains or developing CAI.

Conclusions And Relevance: Based on the findings in this review, a higher BMI, and a higher weight and neuromuscular stability deficits may be regarded risk factors for sustaining a LAS or developing CAI, respectively.

Level Of Evidence: III.
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http://dx.doi.org/10.1136/jisakos-2019-000305DOI Listing
November 2019

Accuracy of cup placement in total hip arthroplasty by means of a mechanical positioning device: a comprehensive cadaveric 3d analysis of 16 specimens.

Hip Int 2021 Jan 11;31(1):58-65. Epub 2019 Sep 11.

Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands.

Introduction: We tested whether a mechanical device (such as Hipsecure) to pinpoint the anterior pelvic plane (APP) as a guide can improve acetabular cup placement. To assess accuracy we asked: (1) is the APP an effective guide to position acetabular cup placement within acceptable ° of divergence from the optimal 40° inclination and 15° anteversion; (2) could a mechanical device increase the number of acetabular cup placements within Lewinnek's safe zone (i.e. inclination 30° to 50°; anteversion 5° to 25°)?

Methods: 16 cadaveric specimens were used to assess the 3D surgical success of using a mechanical device APP to guide acetabular cup placement along the APP. We used the Hipsecure mechanical device to implant acetabular cups at 40° inclination and 15° anteversion. Subequently, all cadaveric specimens with implants were scanned with a CT and 3D models were created of the pelvis and acetabular cups to assess the outcome in terms of Lewinnek's safe zones.

Results: The mean inclination of the 16 implants was 40.6° (95% CI, 37.7-43.4) and the mean anteversion angle was 13.4° (95% CI, 10.7-16.1). All 16 cup placements were within Lewinnek's safe zone for inclination (between 30° and 50°) and all but 2 were within Lewinnek's safe zone for anteversion (between 5° and 25°).

Conclusion: In cadaveric specimens, the use of a mechanical device and the APP as a guide for acetabular cup placement resulted in good positioning with respect to both of Lewinnek's safe zones.
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http://dx.doi.org/10.1177/1120700019874822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797610PMC
January 2021

Typical Shape Differences in the Subtalar Joint Bones Between Subjects with Chronic Ankle Instability and Controls.

J Orthop Res 2019 09 26;37(9):1892-1902. Epub 2019 May 26.

Department of Biomechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands.

Bone shapes, particularly those defining the subtalar joint (STJ), have not received much attention yet as a risk factor for developing chronic ankle instability (CAI) after sustaining a lateral ankle sprain (LAS). This study aimed to compare three-dimensional (3D) shape variations in the STJ bones within individuals with CAI and healthy controls. 3D statistical shape models (SSMs) of the STJ bones were built to describe the bone shape variations observed within a population consisting of 26 individuals with unilateral CAI and 26 healthy controls. Using the SSMs and analysis of covariance test, age- and gender-adjusted shape variations in the bones were compared within individuals with CAI and healthy controls. The mean age of the CAI patients (14 males and 12 females) and healthy controls (12 males and 14 females) was 29 (standard deviation [SD] = 11) and 36 years (SD = 11), respectively. Tali and calcanei did not significantly vary between ipsilateral CAI and their contralateral ankle. Two shape modes, one for the talus (p = 0.015, variations in the curvature of the talar lateral process and the inclination angle of the talar neck relative to the body) and one for the calcaneus (p = 0.003, variations in the medial and lateral tuberosities, and the contour of the anterior articular surface), described significant shape differences between the CAI patients and healthy controls. The CAI patients generally had flatter talar joint surfaces and a flattened calcaneal ground-contact surface. These findings suggest that specific bone shapes may increase the risk of developing CAI after sustaining a LAS. © 2019 The Authors. Journal of Orthopaedic Research Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:1892-1902, 2019.
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http://dx.doi.org/10.1002/jor.24336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6772087PMC
September 2019

Letter to the editor on "Return to sport following Lisfranc injuries: A systematic review and meta-analysis".

Foot Ankle Surg 2019 12 22;25(6):852-853. Epub 2019 Mar 22.

Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands; Academic Center for Evidence Based Sports Medicine (ACES), The Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center Amsterdam UMC, The Netherlands. Electronic address:

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http://dx.doi.org/10.1016/j.fas.2019.03.005DOI Listing
December 2019

Goal Setting and Achievement in Individualized Rehabilitation of Younger Total and Unicondylar Knee Arthroplasty Patients: A Cohort Study.

Arch Phys Med Rehabil 2019 08 22;100(8):1434-1441. Epub 2018 Dec 22.

Department of Orthopaedic Surgery, Foundation for Orthopedic Research, Care and Education, Amphia Hospital, Breda, The Netherlands.

Objective: To investigate activity goals, intensity and achievement of these activity goals in younger knee arthroplasty (KA) patients, and to identify the differences between total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA) patients.

Design: Prospective cohort study.

Setting: Department of orthopedic surgery and physical therapy practices.

Participants: Patients (N=48) aged 65 years or younger who underwent KA.

Intervention: Rehabilitation with goal attainment scaling (GAS).

Main Outcome Measures: GAS goals for daily life activity, work and leisure time, corresponding metabolic equivalent of task (MET) values, corrected MET values, and GAS scores at 3 and 6 months.

Results: The intensity levels of all 144 formulated activity goals were light in 16% of cases, moderate in 63%, and vigorous in 21%. Intensity levels did not differ between TKA and UKA patients. Following rehabilitation using GAS, 54% of daily life activity goals, 65% of work activity goals, and 46% of leisure time activity goals were attained after 3 months. After 6 months, 91% of daily life activity goals, 93% of work activity goals, and 89% of leisure time activity goals were attained. Goal attainment did not differ between MET intensity levels. Higher goal attainment was achieved in the UKA group (100%) compared with the TKA patients (82%) after 6 months (P<.001).

Conclusions: Younger patients aim to perform many different activities of varying metabolic intensity levels following KA. After 6 months of rehabilitation using GAS, in these patients attain 91% of their preoperatively formulated activity goals, independent of the MET intensity level. After 6 months, UKA patients attain significantly more activity goals than TKA patients. GAS might be a useful objective outcome measure in evaluating clinical outcomes of individual KA patients.
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http://dx.doi.org/10.1016/j.apmr.2018.11.019DOI Listing
August 2019

Three Out of Ten Working Patients Expect No Clinical Improvement of Their Ability to Perform Work-Related Knee-Demanding Activities After Total Knee Arthroplasty: A Multicenter Study.

J Occup Rehabil 2019 09;29(3):585-594

Department Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Purpose Three out of ten patients do not return to work after total knee arthroplasty (TKA). Patient expectations are suggested to play a key role. What are patients' expectations regarding the ability to perform work-related knee-demanding activities 6 months after TKA compared to their preoperative status? Methods A multi-center cross-sectional study was performed among 292 working patients listed for TKA. The Work Osteoarthritis or joint-Replacement Questionnaire (WORQ, range 0-100, minimal important difference 13) was used to assess the preoperatively experienced and expected ability to perform work-related knee-demanding activities 6 months postoperatively. Differences between the preoperative and expected WORQ scores were tested and the most difficult knee-demanding work-related activities were described. Results Two hundred thirty-six working patients (81%) completed the questionnaire. Patients' expected WORQ score (Median = 75, IQR 60-86) was significantly (p < 0.01) higher than their preoperative WORQ score (Median = 44, IQR 35-56). A clinical improvement in ability to perform work-related knee-demanding activities was expected by 72% of the patients, while 28% of the patients expected no clinical improvement or even worse ability to perform work-related knee-demanding activities 6 months after TKA. Of the patients, 34% expected severe difficulty in kneeling, 30% in crouching and 17% in clambering 6 months after TKA. Conclusions Most patients have high expectations, especially regarding activities involving deep knee flexion. Remarkably, three out of ten patients expect no clinical improvement or even a worse ability to perform work-related knee-demanding activities 6 months postoperatively compared to their preoperative status. Therefore, addressing patients expectations seems useful in order to assure realistic expectations regarding work activities.
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http://dx.doi.org/10.1007/s10926-018-9823-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675779PMC
September 2019

Study on the three-dimensional orientation of the posterior facet of the subtalar joint using simulated weight-bearing CT.

J Orthop Res 2019 01 29;37(1):197-204. Epub 2018 Nov 29.

Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands.

The purpose of this study was to describe the normal 3D orientation and shape of the subtalar calcaneal posterior facet. This is not adequately described in current literature. In a supine position both feet of 20 healthy subjects were imaged in a simulated weight-bearing CT. A cylinder and plane were fitted to the posterior facet of the surface model. The orientation of both shapes was expressed by two angles in (1) the CT-based coordinate system with the axis of the foot aligned with the sagittal axis and (2) a coordinate system based on the geometric principal axes of the subject's calcaneus. The subtalar vertical angle was determined in the intersection in three different coronal planes of the cylinder. The cylinder's axis oriented from supero-postero-laterally to infero-antero-medially. The plane's normal directed supero-antero-medially in the CT-based coordinate system, and supero-antero-laterally in the other coordinate system. The subtalar vertical angle was significantly different (p < 0.001) between the three defined coronal planes and increased from anterior to posterior. The mean diameter of the fitted cylinder was 42.0 ± 7.7 mm and the root mean square error was 0.5 ± 0.1 mm. The posterior facet can be modelled as a segment of a cylinder with a supero-postero-lateral to infero-antero-medial orientation. The morphometry of the posterior facet in a healthy population serves as a reference in identifying abnormal subtalar joint morphology. More generally this study shows the need to include the full 3D morphology in assessing the orientation of the subtalar posterior facet. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-8, 2018.
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http://dx.doi.org/10.1002/jor.24163DOI Listing
January 2019

A risk assessment model for chronic ankle instability: indications for early surgical treatment? An observational prospective cohort - study protocol.

BMC Musculoskelet Disord 2018 Jul 18;19(1):225. Epub 2018 Jul 18.

Orthopaedic Research Center Amsterdam, Department of Orthopedic Surgery, Amsterdam Movement Sciences, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.

Background: Chronic ankle instability (CAI) is a common result of an ankle sprain. Even though early surgical treatment yields the best results, overall only professional athletes are eligible for acute surgical stabilization. Treating all patients with early surgical stabilization leads to a high amount of unnecessary invasive interventions, as not all patients progress to CAI. If patients at risk of developing CAI can be identified, treatment policies may be applied more effectively and efficiently. The purpose of this study is to develop a risk assessment model to identify patients at risk for CAI that should receive early surgical treatment.

Methods: In this observational prospective cohort, all patients aged sixteen years and older, reporting at the emergency department of one of the participating hospitals after sustaining a lateral ankle sprain, and filled out 1 out of 3 follow-up questionnaires and the 1 year follow-up are included. A lateral and anteroposterior radiograph is made. Patients are excluded if a fracture or other pathology is present. The included patients receive four questionnaires, including questions focusing on the sprain, treatment and complaints, the Foot and Ankle Outcome Score and the Cumberland Ankle Instability Tool. A total of eleven radiographic variables are assessed for inter- and intra-observer reliability. Additionally, four factors extracted from the questionnaires, will be evaluated for correlation with CAI. Significantly correlating factors (e.a. risk factors) will be implemented in a risk assessment model. For the final model, based on sixteen variables with a minimum of 20 events per variable and a prevalence of 30-40% after an initial sprain, a sample size of 2370 patients is needed to perform both internal and external model validation.

Discussion: This study will develop the first large scale model for the risk at CAI after an ankle sprain combining radiographic and patient characteristics. With this risk assessment model, patients at risk for CAI may be identified and properly informed on the treatment options. Patients identified as being at risk, may receive more adequate follow-up and become eligible for early surgical stabilization. This prevents patients from experiencing unnecessary long-lasting complaints, increasing the success rate of conservative and surgical treatment.

Trial Registration: Retrospectively registered: NCT02955485 [Registration date: 3-11-2016]. NTR6139 [Registration date: 3-1-2017].
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http://dx.doi.org/10.1186/s12891-018-2124-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052530PMC
July 2018

The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis.

Sports Med 2018 07;48(7):1695-1726

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

Background: Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking.

Objectives: Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW.

Methods: We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle-Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics.

Results: A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks.

Conclusion: A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process.
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http://dx.doi.org/10.1007/s40279-018-0924-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999146PMC
July 2018

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability.

Foot Ankle Int 2017 Oct 26;38(10):1078-1084. Epub 2017 Jul 26.

1 Academic Medical Center, Department of Orthopedic Surgery, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.

Background: Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

Methods: This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

Results: Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

Conclusions: Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1177/1071100717718139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794102PMC
October 2017

Expectations of younger patients concerning activities after knee arthroplasty: are we asking the right questions?

Qual Life Res 2017 02 5;26(2):403-417. Epub 2016 Aug 5.

Department of Orthopaedic Surgery, Bergman Clinics, Naarden, The Netherlands.

Purpose: Indications for total and unicondylar knee arthroplasty (KA) have expanded to younger patients, in which Patient-Reported Outcome Measures (PROMs) often show ceiling effects. This might be due to higher expectations. Our aims were to explore expectations of younger patients concerning activities in daily life, work and leisure time after KA and to assess to what extent PROMs meet and evaluate these activities of importance.

Methods: Focus groups were performed among osteoarthritis (OA) patients <65 years awaiting KA, in which they indicated what activities they expected to perform better in daily life, work and leisure time after KA. Additionally, 28 activities of daily life, 17 of work and 27 of leisure time were depicted from seven PROMS, which were rated on importance, frequency and bother. A total score, representing motivation for surgery, was also calculated.

Results: Data saturation was reached after six focus groups including 37 patients. Younger OA patients expect to perform better on 16 activities after KA, including high-impact leisure time activities. From the PROMs, daily life and work activities were rated high in both importance and motivation for surgery, but for leisure time activities importance varied highly between patients. All seven PROMs score activities of importance, but no single PROM incorporates all activities rated important.

Conclusion: Younger patients expect to perform better on many activities of daily life, work and leisure time after KA, and often at demanding levels. To measure outcomes of younger patients, we suggest using PROMs that include work and leisure time activities besides daily life activities, in which preferably scored activities can be individualized.
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http://dx.doi.org/10.1007/s11136-016-1380-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288419PMC
February 2017

Which patients do not return to work after total knee arthroplasty?

Rheumatol Int 2016 Sep 24;36(9):1249-54. Epub 2016 Jun 24.

People and Work Outpatient Clinic, Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.

Total knee arthroplasty (TKA) is increasingly being performed among working patients suffering from knee osteoarthritis. Two out of ten patients do not return to work (RTW) after TKA. Little evidence is available about these patients to guide clinicians. Therefore, this study investigates patients' characteristics associated with no RTW. A multicenter retrospective cohort study was performed among working patients having undergone a primary TKA during 2005-2010. The following preoperative characteristics were assessed: age at surgery, sex, comorbidity, body mass index (BMI), preoperative sick-leave duration, patient-reported work-relatedness of knee symptoms, and physical job demands. In addition, the Knee injury and Osteoarthritis Outcome Scores (KOOS) after TKA were assessed. Backward stepwise logistic regression analyses were performed to predict no RTW. Seven hundred and sixty-four patients were approached, and 558 patients (73 %) responded. One hundred and sixty-seven met the inclusion criteria and 46 did not RTW. A preoperative sick-leave duration >2 weeks (OR 12.5, 90 % CI 5.0-31.5) was most strongly associated with no RTW. Other associations found were: female sex (OR 3.2, 90 % CI 1.3-8.2), BMI ≥ 30 (OR 2.8, 90 % CI 1.1-7.1), patient-reported work-relatedness of knee symptoms (OR 5.3, 90 % CI 2.0-14.1), and a physically knee-demanding job (OR 3.3, 90 % CI 1.2-8.9). Age and KOOS were not associated with no RTW. Especially obese female workers, with a preoperative sick-leave duration >2 weeks, who perform knee-demanding work and indicate that their knee symptoms are work-related have a high chance for no RTW after TKA. These results stress the importance of a more timely referral for work-directed care of patients at risk for no RTW after TKA.
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http://dx.doi.org/10.1007/s00296-016-3512-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4983277PMC
September 2016

Identification of the superficial peroneal nerve: Anatomical study with surgical implications.

Knee Surg Sports Traumatol Arthrosc 2016 Apr 26;24(4):1381-5. Epub 2016 Mar 26.

Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands.

Purpose: To prevent iatrogenic damage to the superficial peroneal nerve during ankle arthroscopy, it needs to be identified. The purpose of the present study was to determine which clinical test identified the superficial peroneal nerve most frequently and which determinants negatively affected the identification.

Methods: A total of 198 ankles (99 volunteers) were examined for identification of the superficial peroneal nerve. Race, gender, body mass index (BMI), shoe size and frequency of physical activity were collected.

Results: The best method to identify the superficial peroneal nerve was the maximal combined ankle plantar flexion and inversion test. In this position, the nerve was identified in 57% of the ankles by palpation. BMI was the only independently influential factor in the identification of the superficial peroneal nerve.

Conclusion: Since in nearly six out of the ten ankles the superficial peroneal nerve can be identified, it is advised to assess its anatomy prior to portal placement. A higher BMI negatively influences the identification of the superficial peroneal nerve.

Level Of Evidence: Diagnostic study, Level III.
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http://dx.doi.org/10.1007/s00167-016-4063-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823368PMC
April 2016

Does Goal Attainment Scaling improve satisfaction regarding performance of activities of younger knee arthroplasty patients? Study protocol of the randomized controlled ACTION trial.

BMC Musculoskelet Disord 2016 Mar 2;17:113. Epub 2016 Mar 2.

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

Background: Knee arthroplasty is being increasingly performed, and also more often in a younger patient population (<65 years of age). Up to 20 % of patients remain dissatisfied after knee arthroplasty, despite the apparent technical success of the operation. Recent studies suggest that the fulfilment of patients' expectations plays an important role in achieving satisfaction. Thus, addressing preoperative expectations more explicitly might improve patient satisfaction. The primary aim of the present study is to investigate the effect of a multidisciplinary, goal attained and individualized rehabilitation on satisfaction of activities of younger patients (<65 years) after knee arthroplasty.

Methods/design: A single-centre randomized controlled trial will be conducted. In total, 120 patients (<65 years of age) with knee osteoarthritis who will undergo knee arthroplasty, will be randomly allocated to either goal attainment scaling rehabilitation or usual care rehabilitation. Goal attainment scaling rehabilitation includes drafting individually set rehabilitation goals preoperatively and measuring progress of rehabilitation on a six-point scale (-3 to +2). The primary outcome is patient satisfaction concerning activities in daily life, work and leisure time, including sports. Secondary outcome measures include KOOS, OKS, SQUASH and WORQ questionnaires and activity objectively measured with the Activ8® activity monitor.

Discussion: The findings of this study will help to elucidate whether goal attainment scaling is an effective rehabilitation method for achieving higher levels of patient satisfaction, with a focus on activities, in younger patients after knee arthroplasty.

Trial Registration: This trial is since June 15(th) 2015 registered at the Dutch Trial Register: NTR5251 .
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http://dx.doi.org/10.1186/s12891-016-0965-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4776377PMC
March 2016

Histological characteristics of ligament healing after bio-enhanced repair of the transected goat ACL.

J Exp Orthop 2015 Dec 28;2(1). Epub 2015 Feb 28.

Department of Orthopedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.

Background: Recently, healing of a ruptured anterior cruciate ligament (ACL) is reconsidered. In a previous study, we have shown that the transected ACL can heal after treatment with the triple X locking suture alone or combined with small intestine submucosa (SIS). The first research question of this study was whether the healing ACLs in both groups show histological characteristics that are typical for ligament healing. Secondly, did the combined treatment with SIS lead to improved histological healing, in terms of the morphology of the fibrous synovial layer, the extracellular matrix (ECM), collagen fiber orientation, cellularity, ratio of myofibroblasts, and collagen type 3 staining. The hypothesis was that SIS enhances the healing by the scaffolding effect, endogenous growth factors, and chemoattractants.

Methods: In the Suture group, the left ACL was transected and sutured with the triple X locking suture repair technique. In the Suture-SIS group, the left ACL underwent the same procedure with the addition of SIS. The right ACL served as internal control. Standard histology and immunostaining of α-smooth muscle actin (SMA) and collagen type 3 were used.

Results: Microscopy showed that the fibrous synovial layer around the ACL was reestablished in both groups. The collagen fibers in the Suture-SIS group stained denser, were more compactly arranged, and the ECM contained fewer voids and fat vacuoles. Neovasculature running between the collagen fibers was observed in both experimental groups. Collagen type 3 stained less in the Suture-SIS group. The cellularity in the Suture group, Suture-SIS group and Control was 1265 ± 1034 per mm(2), 954 ± 378 per mm(2), 254 ± 92, respectively; 49%, 26% and 20% of the cells stain positive for α-SMA, respectively.

Conclusion: The healing ACL in both treated groups showed histological characteristics which are comparable to the spontaneously healing medial collateral ligament and showed that the ACL has a similar intrinsic healing response. Though, no definitive conclusions on the beneficial effects of the SIS scaffold on the healing process can be made.
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http://dx.doi.org/10.1186/s40634-015-0021-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4544611PMC
December 2015

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

Am J Sports Med 2016 May 22;44(5):1292-300. Epub 2016 Feb 22.

Orthopaedic Research Center Amsterdam, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands.

Background: Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage.

Hypothesis: The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively.

Results: Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results.

Conclusion: PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups.

Registration: Netherlands Trial Register NTR1636.
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http://dx.doi.org/10.1177/0363546515626544DOI Listing
May 2016

The Mechanical Functionality of the EXO-L Ankle Brace: Assessment With a 3-Dimensional Computed Tomography Stress Test.

Am J Sports Med 2016 Jan 20;44(1):171-6. Epub 2015 Nov 20.

Department of Orthopedic Surgery, Academic Medical Center, Amsterdam, the Netherlands.

Background: A new type of ankle brace (EXO-L) has recently been introduced. It is designed to limit the motion of most sprains without limiting other motions and to overcome problems such as skin irritation associated with taping or poor fit in the sports shoe.

Purpose: To evaluate the claimed functionality of the new ankle brace in limiting only the motion of combined inversion and plantar flexion.

Study Design: Controlled laboratory study.

Methods: In 12 patients who received and used the new ankle brace, the mobility of the joints was measured with a highly accurate and objective in vivo 3-dimensional computed tomography (3D CT) stress test. Primary outcomes were the ranges of motion as expressed by helical axis rotations without and with the ankle brace between the following extreme positions: dorsiflexion to plantar flexion, and combined eversion and dorsiflexion to combined inversion and plantar flexion. Rotations were acquired for both talocrural and subtalar joints. A paired Student t test was performed to test the significance of the differences between the 2 conditions (P ≤ .05).

Results: The use of the ankle brace significantly restricted the rotation of motion from combined eversion and dorsiflexion to combined inversion and plantar flexion in both the talocrural (P = .004) and subtalar joints (P < .001). No significant differences were found in both joints for the motion from dorsiflexion to plantar flexion.

Conclusion: The 3D CT stress test confirmed that under static and passive testing conditions, the new ankle brace limits the inversion-plantar flexion motion that is responsible for most ankle sprains without limiting plantar flexion or dorsiflexion.

Clinical Relevance: This test demonstrated its use in the objective evaluation of braces.
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http://dx.doi.org/10.1177/0363546515611878DOI Listing
January 2016

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BMC Musculoskelet Disord 2015 Aug 20;16:211. Epub 2015 Aug 20.

Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.

Background: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union.

Methods/design: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent.

Discussion: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures.

Trial Registration: Netherlands Trial Register (reg.nr NTR4377 ).
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http://dx.doi.org/10.1186/s12891-015-0649-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546041PMC
August 2015

Dynamic in vivo evaluation of radiocarpal contact after a 4-corner arthrodesis.

J Hand Surg Am 2015 Apr 31;40(4):759-66. Epub 2015 Jan 31.

Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands; Orthopaedic Research Center Amsterdam, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands.

Purpose: To understand the mechanisms that preserve joint integrity after 4-corner arthrodesis (FCA).

Methods: We investigated the long-term changes of the radiolunate articulation after an FCA for different motions of the wrist in a cross-sectional study that included wrists of 10 healthy participants and both operated and nonoperated wrists of 8 individuals who had undergone FCA on 1 side. The average postoperative follow-up period of the FCA group was 5.7 years. The radiolunate articulation was assessed from dynamic 3-dimensional distance maps during wrist motion. Contact surface area, centroid position of the articular area, and distance between radiolunate articular surfaces were measured and compared between healthy subjects and operated and nonoperated wrists of FCA patients.

Results: The total radiolunate articulation area was larger in patients with FCA. The average radiolunate joint space thickness was preserved in the operated FCA wrists. The centroid of the articulation area was shifted radially and dorsally in FCA wrists.

Conclusions: Changes of the motion pattern of the lunate during radioulnar deviation and flexion-extension of the wrist after FCA can explain the shift of the centroid radially and dorsally.

Type Of Study/level Of Evidence: Diagnostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.11.028DOI Listing
April 2015

The impact of ankle osteoarthritis. The difference of opinion between patient and orthopedic surgeon.

Foot Ankle Surg 2014 Dec 9;20(4):241-7. Epub 2014 Jun 9.

Orthopaedic Research Centre Amsterdam, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands.

Background: Outcome measures for ankle osteoarthritis (OA) are created by physicians with little input of the target patient group. The aim of this study was to determine the difference in opinion between patients and orthopedic surgeons concerning the importance of specific symptoms of ankle OA and its impact on daily life and function.

Methods: A modified Delphi method was applied, consisting of structured interviews with patient focus groups and experts, followed by a poll using 32 statements. The difference in opinion between patients and orthopedic surgeons was evaluated.

Results: Forty patients and forty orthopedic surgeons responded to the 32 statements. Statistically significant differences in opinion on symptoms, function and the impact of ankle OA on daily life were found.

Conclusions: This study demonstrates a significant difference in opinion between patients and orthopedic surgeons concerning specific symptoms of ankle OA. These results advocate incorporating the needs and demands of the individual patient for new outcome measures.
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http://dx.doi.org/10.1016/j.fas.2014.05.008DOI Listing
December 2014

Intrinsic healing response of the human anterior cruciate ligament: an histological study of reattached ACL remnants.

J Orthop Res 2014 Feb 5;32(2):296-301. Epub 2013 Nov 5.

A reattachment of the tibial remnant of the torn anterior cruciate ligament (ACL) to the posterior cruciate ligament is sometimes observed during surgery and apparently implies that the human ACL does have a healing response. The aim of this study was to investigate whether this reattachment tissue has similar histological characteristics of a healing response as the medial collateral ligament (MCL), which can heal spontaneously. Standard histology and immunostaining of α-smooth muscle actin and collagen type 3 was performed. The results shows that the reattached tissue has typical characteristics of a healing response: there attached ACL remnant could not be released by forceful traction; microscopy showed that the collagen fibers of the reattached tissue were disorganized with no preferred direction; increased neovascularization; the presence of lipid vacuoles; the mean number of cells within the biopsy tissue was 631±269 cells per mm2; and 68±20% was expressing α-SMA; semi-quantitative analysis of collagen type 3 expression showed that collagen type 3 had an high expression with an average score of 3. In conclusion, this study shows that the human proximal 1/3 ACL has an intrinsic healing response with typical histological characteristics similar to the MCL.
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http://dx.doi.org/10.1002/jor.22511DOI Listing
February 2014

A reliable, valid and responsive questionnaire to score the impact of knee complaints on work following total knee arthroplasty: the WORQ.

J Arthroplasty 2014 Jun 21;29(6):1169-1175.e2. Epub 2014 Jan 21.

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

The Work, Osteoarthritis or joint-Replacement Questionnaire (WORQ) was developed to assess physical difficulty experienced in work before or following total knee arthroplasty (TKA). Thirteen questions were designed. The WORQ was tested for internal consistency by factor analysis, internal reliability (Crohnbach's α), and construct validity. A test-retest reproducibility was performed for analyzing standard error of measurement (SEM agreement), reliability (ICC) and smallest detectable change (SDC) in individuals and groups. Lastly responsiveness (standardized response means [SRM]), floor and ceiling effects and interpretability (minimal important change [MIC]) were analyzed. It is shown that the WORQ is a reliable, valid and responsive questionnaire that can be used to evaluate the impact of knee complaints following TKA on patients' ability to work.
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http://dx.doi.org/10.1016/j.arth.2014.01.016DOI Listing
June 2014
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