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1.  Abbreviated Psychologic Questionnaires Are Valid in Patients With Hand Conditions 
Background
The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted.
Questions/purposes
We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires.
Methods
One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson’s correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability.
Results
There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses.
Conclusions
Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden.
Level of Evidence
Level III, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3213-2
PMCID: PMC3825874  PMID: 23913341
2.  No Effect of Hole Geometry in Microfracture for Talar Osteochondral Defects 
Background
Débridement and bone marrow stimulation is an effective treatment option for patients with talar osteochondral defects. However, whether surgical factors affect the success of microfracture treatment of talar osteochondral defects is not well characterized.
Questions/purposes
We hypothesized (1) holes that reach deeper into the bone marrow-filled trabecular bone allow for more hyaline-like repair; and (2) a larger number of holes with a smaller diameter result in more solid integration of the repair tissue, less need for new bone formation, and higher fill of the defect.
Methods
Talar osteochondral defects that were 6 mm in diameter were drilled bilaterally in 16 goats (32 samples). In eight goats, one defect was treated by drilling six 0.45-mm diameter holes in the defect 2 mm deep; in the remaining eight goats, six 0.45-mm diameter holes were punctured to a depth of 4 mm. All contralateral defects were treated with three 1.1-mm diameter holes 3 mm deep, mimicking the clinical situation, as internal controls. After 24 weeks, histologic analyses were performed using Masson-Goldner/Safranin-O sections scored using a modified O’Driscoll histologic score (scale, 0–22) and analyzed for osteoid deposition. Before histology, repair tissue quality and defect fill were assessed by calculating the mean attenuation repair/healthy cartilage ratio on Equilibrium Partitioning of an Ionic Contrast agent (EPIC) micro-CT (μCT) scans. Differences were analyzed by paired comparison and Mann-Whitney U tests.
Results
Significant differences were not present between the 2-mm and 4-mm deep hole groups for the median O’Driscoll score (p = 0.31) and the median of the μCT attenuation repair/healthy cartilage ratios (p = 0.61), nor between the 0.45-mm diameter and the 1.1-mm diameter holes in defect fill (p = 0.33), osteoid (p = 0.89), or structural integrity (p = 0.80).
Conclusions
The results indicate that the geometry of microfracture holes does not influence cartilage healing in the caprine talus.
Clinical Relevance
Bone marrow stimulation technique does not appear to be improved by changing the depth or diameter of the holes.
doi:10.1007/s11999-013-3189-y
PMCID: PMC3792274  PMID: 23893362
3.  Healing of the Goat Anterior Cruciate Ligament After a New Suture Repair Technique and Bioscaffold Treatment 
Tissue Engineering. Part A  2013;19(19-20):2292-2299.
Primary suture repair of the anterior cruciate ligament (ACL) has been used clinically in an attempt to heal the ruptured ACL. The results, however, were not satisfactory, which in retrospect can be attributed to the used suturing technique and the suboptimal healing conditions. These constraining conditions can be improved by introducing a new suturing technique and by using small intestinal submucosa (SIS) as a bioscaffold. It is hypothesized that the suturing technique keep the torn ends together and that SIS enhance and promote the healing of the ACL. The goat was used as the study model. In the Suture group, the left ACL was transected and suture repaired with a new locking suture repair technique (n=5) allowing approximation and fixation under tension. The Suture-SIS group underwent the same procedure with the addition of SIS (n=5). The right ACL served as control. After 12 weeks of healing, anterior–posterior translation and in situ force of the healing ACL were measured, followed by the measurement of the cross-sectional area and structural stiffness. Routine histology was performed on tissue samples. Gross morphology showed that the healing ACL was continuous with collagenous tissue in both groups. The cross-sectional area of the Suture and the Suture-SIS group was 35% and 50% of the intact control, respectively. The anterior–posterior translations at different flexion angles were statistically not different between the Suture group and the Suture-SIS group. Only the in situ force at 30° in the Suture-SIS group was higher than in the Suture group. Tensile tests showed that the stiffness for the Suture group was not different from the Suture-SIS group (31.1±8.1 N/mm vs. 41.9±18.0 N/mm [p>0.05]). Histology showed longitudinally aligned collagen fibers from origo to insertion. More fibroblasts were present in the healing tissue than in the control intact tissue. The study demonstrated the proof of concept of ACL repair in a goat model with a new suture technique and SIS. The mechanical outcome is not worse than previously reported for ACL reconstruction. In conclusion, the approach of using a new suture technique, with or without a bioscaffold to heal the ACL is promising.
doi:10.1089/ten.tea.2012.0535
PMCID: PMC3761389  PMID: 23725556
4.  Association between individual DASH tasks and restricted wrist flexion and extension after volar plate fixation of a fracture of the distal radius 
Hand (New York, N.Y.)  2012;7(4):407-412.
Background
Symptoms and psychosocial factors are suggested to account for more of the variation in disability than physical impairment, but perhaps less so at the level of specific tasks. This study assessed the influence of impaired wrist motion on specific tasks on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.
Methods
Sixty-three patients with an operatively treated fracture of the distal radius completed the Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale, and Center for Epidemiologic Studies Depression Scale (CES-D) just before surgery and the DASH questionnaire 3 months after surgery. Nine questions on the DASH were selected as potentially sensitive to changes in wrist motion and evaluated in bivariate and multivariable analyses.
Results
In multivariable models of factors associated with specific tasks, only “Open a tight or new jar” was affected by wrist flexion and PCS accounting for 33 % of the variation. Motion, pain, and PCS were significant predictors of the DASH score. Among the eight tasks not related to wrist motion, 33 % of the variation in disability with writing was accounted for by PCS and limb dominance; 20 % of disability preparing a meal by pain, CES-D, and PCS; 14 % of disability with making a bed by pain and CES-D; and 23 % of changing a light bulb overhead by age, pain, and fracture type.
Conclusions
After volar plate fixation of a fracture of the distal radius, upper extremity disability based on select items from the DASH questionnaire correlated minimally with impairment of wrist motion, even at the level of specific tasks.
Level of Evidence
Prognostic Level II.
doi:10.1007/s11552-012-9447-8
PMCID: PMC3508012  PMID: 24294161
Disability; Impairment; Distal radius fracture; Volar plate fixation; Psychological factors
5.  What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? 
Journal of Athletic Training  2012;47(4):435-443.
Context:
Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem.
Objective:
To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain.
Study Selection:
Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults.
Data Sources:
MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually.
Data Extraction:
We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models.
Data Synthesis:
After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest.
Conclusions:
Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.
PMCID: PMC3396304  PMID: 22889660
ankle ligament injury; cryotherapy; bandages
6.  Training Improves Interobserver Reliability for the Diagnosis of Scaphoid Fracture Displacement 
Background
The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability.
Questions/purposes
We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans.
Methods
Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel’s multirater kappa and the Z-test was used to test for significance.
Results
There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups.
Conclusions
Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.
doi:10.1007/s11999-012-2260-4
PMCID: PMC3369105  PMID: 22290132
7.  Combined Posterior and Anterior Ankle Arthroscopy 
Case Reports in Orthopedics  2012;2012:693124.
Treatment of combined anterior and posterior ankle pathology usually consists of either combined anterior and posterior arthrotomies or anterior ankle arthroscopy with an additional posterolateral portal. The first technique bears the risk of complications associated with the extensive exposure, the latter technique provides limited access to the posterior ankle joint. A case is described of combined anterior and posterior arthroscopy, with the patient lying prone and then turned supine, addressing both anterior and posterior ankle pathologies in one tempo. This minimally invasive combined approach allows quick recovery and early return to work and sports activities.
doi:10.1155/2012/693124
PMCID: PMC3504263  PMID: 23227391
8.  Endoscopic Bursectomy and Iliotibial Tract Release as a Treatment for Refractory Greater Trochanteric Pain Syndrome: A New Endoscopic Approach With Early Results 
Arthroscopy Techniques  2012;1(2):e161-e164.
Greater trochanteric pain syndrome (GTPS) is associated with excessive tension between the iliotibial band (ITB) and the greater trochanter. Several endoscopic procedures have been reported, but in most cases the endoscopic approach only consists of a bursectomy. The ITB and fascia lata act as a lateral tension band to resist tensile strains on the concave aspect of the femur and are often implicated as the source of GTPS. We therefore believe that the ITB must be addressed. We describe an endoscopic technique to release the ITB and remove the bursa and conclude that endoscopic bursectomy with cross incision of the ITB is a safe approach to treat patients with refractory GTPS.
doi:10.1016/j.eats.2012.06.001
PMCID: PMC3678627  PMID: 23766989
9.  The diagnosis and treatment of deltoid ligament lesions in supination–external rotation ankle fractures: a review 
The supination–external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.
doi:10.1007/s11751-012-0140-9
PMCID: PMC3535131  PMID: 22767333
Ankle fracture; Deltoid ligament; Stability; Diagnosis; Treatment
10.  “Web impingement” of the ankle: a case report 
This case report presents two patients with persisting anterior ankle impingement pain after an ankle distortion. A web-like intra-articular fibrous band was discovered and resected. The patients presented were, after a 1-year follow-up, pain free.
Level of evidence IV.
doi:10.1007/s00167-012-2077-4
PMCID: PMC3657074  PMID: 22688500
Ankle arthroscopy; Anterior ankle impingement; Soft-tissue impingement; Fibrous band
11.  Complications in ankle arthroscopy 
Purpose
To determine the complication rate for ankle arthroscopy.
Methods
A review of a consecutive series of patients undergoing ankle arthroscopy in our hospital between 1987 and 2006 was undertaken. Anterior ankle arthroscopy was performed by means of a 2-portal dorsiflexion method with intermittent soft tissue distraction. Posterior ankle arthroscopy was performed by means of a two-portal hindfoot approach. Complications were registered in a prospective national registration system. Apart from this complication registry, patient records, outpatient charts and operative reports were reviewed. Patients with a complication were asked to visit our hospital for clinical examination and assessment of permanent damage and persisting complaints.
Results
An overall complication rate of 3.5 % in 1,305 procedures was found. Neurological complications (1.9 %) were related to portal placement. Age was a significant risk factor for the occurrence of complications. Most complications were transient and resolved within 6 months. Complications did not lead to functional limitations. Residual complaints did not influence daily activities.
Conclusions
Our complication rate is less than half of what has been reported in literature (3.5 vs 10.3 %). The use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications. Posterior ankle arthroscopy by means of a two-portal hindfoot approach is a safe procedure with a complication rate that compares favourably to that of anterior ankle arthroscopy.
Level of evidence
Retrospective prognostic study, Level II.
doi:10.1007/s00167-012-2063-x
PMCID: PMC3402678  PMID: 22669362
Ankle arthroscopy; Non-invasive distraction; Complications
12.  Diagnosis and prognosis of acute hamstring injuries in athletes 
Purpose
Identification of the most relevant diagnostic and prognostic factors of physical examination and imaging of hamstring injuries in (elite) athletes.
Methods
A literature search was conducted in MEDLINE and EMBASE for articles between 1950 and April 2011. A survey was distributed among the members of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy, which focused on physical examination, prognosis, imaging and laboratory tests of hamstring injuries in (elite) athletes.
Results
Medical history, inspection and palpation of the muscle bellies and imaging are most valuable at the initial assessment according to the literature. Experts considered medical history, posture and gait inspection, inspection and palpation of muscle bellies, range of motion tests, manual muscle testing, referred pain tests and imaging to be most important in the initial assessment of hamstring injuries. Magnetic resonance imaging (MRI) is preferred over ultrasonography and should take place within 3 days post-trauma. Important prognostic factors are injury grade, length of the muscle tear on MR images, MRI-negative injuries and trauma mechanism.
Conclusions
Posture and gait inspection, inspection and palpation of muscle bellies, range of motion tests, manual muscle testing and referred pain tests within 2 days post-trauma were identified as the most relevant diagnostic factors.
Level of evidence
Literature review and expert opinion, Level V.
doi:10.1007/s00167-012-2055-x
PMCID: PMC3549245  PMID: 22622781
Hamstring strain injury; Sports injury; Physical examination; Imaging
14.  Weightbearing ovine osteochondral defects heal with inadequate subchondral bone plate restoration: implications regarding osteochondral autograft harvesting 
Purpose
It is unknown what causes donor site morbidity following the osteochondral autograft transfer procedure or how donor sites heal. Contact pressure and edge loading at donor sites may play a role in the healing process. It was hypothesized that an artificially created osteochondral defect in a weightbearing area of an ovine femoral condyle will cause osseous bridging of the defect from the upper edges, resulting in incomplete and irregular repair of the subchondral bone plate.
Methods
To simulate edge loading, large osteochondral defects were created in the most unfavourable weightbearing area of 24 ovine femoral condyles. After killing at 3 and 6 months, osteochondral defects were histologically and histomorphometrically evaluated with specific attention to subchondral bone healing and subchondral bone plate restoration.
Results
Osteochondral defect healing showed progressive osseous defect bridging by sclerotic circumferential bone apposition. Unfilled area decreased significantly from 3 to 6 months (P = 0.004), whereas bone content increased (n.s.). Complete but irregular subchondral bone plate restoration occurred in ten animals. In fourteen animals, an incomplete subchondral bone plate was found. Further common findings included cavitary lesion formation, degenerative cartilage changes and cartilage and subchondral bone collapse.
Conclusions
Osteochondral defect healing starts with subchondral bone plate restoration. However, after 6 months, incomplete or irregular subchondral bone plate restoration and subsequent failure of osteochondral defect closure is common. Graft harvesting in the osteochondral autograft transfer procedure must be viewed critically, as similar changes are also present in humans.
Level of evidence
Prognostic study, Level III.
doi:10.1007/s00167-011-1831-3
PMCID: PMC3445791  PMID: 22186925
Donor site morbidity; Osteochondral autograft transfer; Subchondral bone plate
15.  Biomechanical considerations in the pathogenesis of osteoarthritis of the knee 
Osteoarthritis is the most common joint disease and a major cause of disability. The knee is the large joint most affected. While chronological age is the single most important risk factor of osteoarthritis, the pathogenesis of knee osteoarthritis in the young patient is predominantly related to an unfavorable biomechanical environment at the joint. This results in mechanical demand that exceeds the ability of a joint to repair and maintain itself, predisposing the articular cartilage to premature degeneration. This review examines the available basic science, preclinical and clinical evidence regarding several such unfavorable biomechanical conditions about the knee: malalignment, loss of meniscal tissue, cartilage defects and joint instability or laxity.
Level of evidence IV.
doi:10.1007/s00167-011-1818-0
PMCID: PMC3282009  PMID: 22173730
Cartilage; Malalignment; Meniscus; Osteochondral defects; Joint instability; Pathology; Etiology
16.  Predictors of functional outcome following femoral neck fractures treated with an arthroplasty: limitations of the Harris hip score 
Introduction
To study the association between potential prognostic factors and functional outcome at 1 and 5 year follow-up in patients with femoral neck fractures treated with an arthroplasty. To analyze the reliability of the Harris hip score (HHS).
Materials and methods
A multicenter analysis which included 252 patients who sustained a femoral neck fracture treated with an arthroplasty. Functional outcome after surgery was assessed using a modified HHS and was evaluated after 1 (HHS1) and 5 (HHS5) years. Several prognostic factors were analyzed and reliability of the HHS was assessed.
Results
After 1 year the presence of co-morbidities was a significant (p = 0.002) predictor for a poor functional outcome (mean HHS1 71.8 with co-morbidities, and 80.6 without co-morbidities). After 5 years none of the potential prognostic factors had significant influence on functional outcome. Internal consistency testing of the HHS showed that when pain and function of the HHS were analyzed together, the internal consistency was poor (HHS1 0.38 and HHS5 0.20). The internal consistency of the HHS solely in function (without pain) improved to 0.68 (HHS1) and 0.46 (HHS5). Analyzing the functional aspect exclusively, age and the existence of co-morbidities could be defined as predictors for functional outcome of femoral neck fractures after 1 and 5 years.
Conclusion
After using the HHS in a modification, age and the existence of pre-operative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. The HHS, omitting pain, is a more reliable score to estimate the functional outcome, than HHS analyzing pain and function in one scoring system.
doi:10.1007/s00402-011-1424-0
PMCID: PMC3261383  PMID: 22113433
Femoral neck fracture; Arthroplasty; Functional outcome; Predictors; Harris hip score
17.  Systematic review on cadaveric studies of anatomic anterior cruciate ligament reconstruction 
Purpose
One of the templates in the development of “anatomic” anterior cruciate ligament (ACL) reconstruction has been basic science studies focusing on comparing various aspects of ACL reconstruction in order to optimize surgical technique. However, often such papers lack necessary data in the methods section to ascertain the proposed surgical technique as anatomic. The goal of this systematic review was to evaluate basic science studies on anatomic ACL reconstruction.
Methods
A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published from January 1995 to April 2009 were included. Only basic science studies on human cadavers that reported “anatomic” ACL reconstruction and written in English were included. Variation in surgical technique and reporting of surgical description were assessed.
Results
Eighteen studies were included in this systematic review. Only the fixation method, graft type and tension pattern were reported in the majority studies. Notchplasty and radiographic documentation were grossly underreported. Other surgical data were reported at best in two-thirds of the studies. There was a large variation in the reported surgical techniques among the included studies. Due to the aforementioned, it was not deemed possible to pool data of the included studies.
Conclusion
For most variables in the surgical technique description, there was sizeable underreporting resulting in an inability to pool the outcomes. To provide literature that holds up to the current high level of medical research, authors are encouraged to report their surgical technique in a thorough manner, similar to high-level clinical trials.
Level of evidence
Systematic review, Level II.
doi:10.1007/s00167-011-1544-7
PMCID: PMC3228958  PMID: 21584719
Anatomic; Anterior cruciate ligament; Surgical technique; Systematic review
18.  Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy 
Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented.
Level of evidence    V.
doi:10.1007/s00167-011-1535-8
PMCID: PMC3136709  PMID: 21567177
Achilles; Mid-portion; Painful; Cause of pain; Tendon
19.  Tertiary osteochondral defect of the talus treated by a novel contoured metal implant 
The primary treatment of most osteochondral defects of the talus is arthroscopic debridement and bone marrow stimulation. There is no optimal treatment for large lesions or for those in which primary treatment has failed. We report a 20-year-old female patient with persistent symptoms after two previous arthroscopic procedures. Computed tomography showed a cystic defect of the medial talar dome, sized 17 × 8 × 8 mm. The patient was treated with a novel contoured metal implant. At 1 and 2 years after surgery, the patient reported considerable reduction in pain and had resumed playing korfball at competitive level.
Level of evidence IV.
doi:10.1007/s00167-011-1465-5
PMCID: PMC3096766  PMID: 21409468
Osteochondral lesions; Bone cyst; Talus; Ankle; Metal implant; Treatment
20.  Factors that influence the intra-articular rupture pattern of the ACL graft following single-bundle reconstruction 
Purposes
The number of revision anterior cruciate ligament (ACL) surgeries performed annually continues to rise. The purpose of this study was to determine the most common rupture pattern in ACL revision cases after previous single-bundle reconstruction. The second aim was to determine the relationship between rupture pattern and patient-specific factors (age, gender, time between the initial ACL reconstruction and re-injury, and etiology/mechanism of failure) and surgical factors (graft type, tunnel angle).
Methods
This was a cohort study of 60 patients that underwent revision ACL surgery after previous single-bundle ACL reconstruction. Three sports medicine–trained orthopedic surgeons reviewed the arthroscopic videos and determined the rupture pattern of the grafts. The rupture pattern was then correlated to the above-mentioned factors.
Results
The inter-observer agreement had a kappa of 0.7. The most common rupture pattern after previous single-bundle ACL reconstruction is elongation of the graft. This is different from the native ACL, which displays more proximal ruptures. With the use of autograft tissue and after a longer period of time, the rupture pattern in revision surgery is more similar to that of the native ACL.
Conclusion
The most common rupture pattern after previous single-bundle reconstruction was elongation of the graft. Factors that influenced the rupture pattern were months between ACL reconstruction and re-injury and graft type.
Level of evidence
Cohort study, Level IV.
doi:10.1007/s00167-011-1427-y
PMCID: PMC3136704  PMID: 21311861
Anterior cruciate ligament; ACL; Revision surgery; Rupture pattern; Graft failure
21.  Does Perception of Usefulness of Arthroscopic Simulators Differ with Levels of Experience? 
Background
Some commercial simulators are available for training basic arthroscopic skills. However, it is unclear if these simulators allow training for their intended purposes and whether the perception of usefulness relates to level of experience.
Questions/purposes
We addressed the following questions: (1) Do commercial simulators have construct (times to perform tasks) and face validity (realism), and (2) is the perception of usefulness (educational value and user-friendliness) related to level of experience?
Methods
We evaluated two commercially available virtual reality simulators (Simulators A and B) and recruited 11 and nine novices (no arthroscopies), four and four intermediates (one to 59 arthroscopies), and seven and nine experts (> 60 arthroscopies) to test the devices. To assess construct validity, we recorded the median time per experience group for each of five repetitions of one identical navigation task. To assess face validity, we used a questionnaire to judge up to three simulator characteristic tasks; the questionnaire asked about the realism, perception of educational value, and perception of user-friendliness.
Results
We observed partial construct validity for Simulators A and B and considered face validity satisfactory for both simulators for simulating the outer appearance and human joint, but barely satisfactory for the instruments. Simulators A and B had equal educational value according to the participants. User-friendliness was judged better for Simulator B although both were graded satisfactory. The perception of usefulness did not differ with level of experience.
Conclusions
Our observations suggest training on either simulator is reasonable preparation for real-life arthroscopy, although there is room for improvement for both simulators.
Clinical Relevance
These simulators provide training in surgical skills without compromising patient safety.
doi:10.1007/s11999-011-1797-y
PMCID: PMC3094627  PMID: 21290203
22.  Does Perception of Usefulness of Arthroscopic Simulators Differ with Levels of Experience? 
Background
Some commercial simulators are available for training basic arthroscopic skills. However, it is unclear if these simulators allow training for their intended purposes and whether the perception of usefulness relates to level of experience.
Questions/purposes
We addressed the following questions: (1) Do commercial simulators have construct (times to perform tasks) and face validity (realism), and (2) is the perception of usefulness (educational value and user-friendliness) related to level of experience?
Methods
We evaluated two commercially available virtual reality simulators (Simulators A and B) and recruited 11 and nine novices (no arthroscopies), four and four intermediates (one to 59 arthroscopies), and seven and nine experts (> 60 arthroscopies) to test the devices. To assess construct validity, we recorded the median time per experience group for each of five repetitions of one identical navigation task. To assess face validity, we used a questionnaire to judge up to three simulator characteristic tasks; the questionnaire asked about the realism, perception of educational value, and perception of user-friendliness.
Results
We observed partial construct validity for Simulators A and B and considered face validity satisfactory for both simulators for simulating the outer appearance and human joint, but barely satisfactory for the instruments. Simulators A and B had equal educational value according to the participants. User-friendliness was judged better for Simulator B although both were graded satisfactory. The perception of usefulness did not differ with level of experience.
Conclusions
Our observations suggest training on either simulator is reasonable preparation for real-life arthroscopy, although there is room for improvement for both simulators.
Clinical Relevance
These simulators provide training in surgical skills without compromising patient safety.
doi:10.1007/s11999-011-1797-y
PMCID: PMC3094627  PMID: 21290203
23.  Proximal tibiofibular synostosis as a possible cause of a pseudoradicular syndrome: a case report 
This paper presents a case report of persistent low back pain and suspected lumbar radiculopathy. A synostosis at the level of the proximal tibiofibular joint was diagnosed. After successful resection of the synostosis, the low back symptoms resolved completely. This is the first report of a proximal tibiofibular synostosis as a possible cause of referred pain proximally.
doi:10.1007/s00167-010-1379-7
PMCID: PMC3217150  PMID: 21222100
Proximal tibiofibular joint; Synostosis; Pseudoradicular syndrome
24.  Direction of the oblique medial malleolar osteotomy for exposure of the talus 
Introduction
A medial malleolar osteotomy is often indicated for operative exposure of posteromedial osteochondral defects and fractures of the talus. To obtain a congruent joint surface after refixation, the oblique osteotomy should be directed perpendicularly to the articular surface of the tibia at the intersection between the tibial plafond and medial malleolus. The purpose of this study was to determine this perpendicular direction in relation to the longitudinal tibial axis for use during surgery.
Materials and methods
Using anteroposterior mortise radiographs and coronal computed tomography (CT) scans of 46 ankles (45 patients) with an osteochondral lesion of the talus, two observers independently measured the intersection angle between the tibial plafond and medial malleolus. The bisector of this angle indicated the osteotomy perpendicular to the tibial articular surface. This osteotomy was measured relative to the longitudinal tibial axis on radiographs. Intraclass correlation coefficients (ICC) were calculated to assess reliability.
Results
The mean osteotomy was 57.2 ± 3.2° relative to the tibial plafond on radiographs and 56.5 ± 2.8 on CT scans. This osteotomy corresponded to 30.4 ± 3.7° relative to the longitudinal tibial axis. The intraobserver (ICC, 0.90–0.93) and interobserver (ICC, 0.65–0.91) reliability of these measurements were good to excellent.
Conclusion
A medial malleolar osteotomy directed at a mean 30° relative to the tibial axis enters the joint perpendicularly to the tibial cartilage, and will likely result in a congruent joint surface after reduction.
doi:10.1007/s00402-010-1227-8
PMCID: PMC3117279  PMID: 21165631
Medial malleolus; Osteotomy; Ankle; Radiography; Preoperative planning; Surgical approach
25.  ACL graft re-rupture after double-bundle reconstruction: factors that influence the intra-articular pattern of injury 
Purpose
To determine the most common rupture patterns of previously reconstructed DB-ACL cases, seen at the time of revision surgery, and to determine the influence of age, gender, time between the initial ACL reconstruction and re-injury, tunnel angle and etiology of failure.
Methods
Forty patients who presented for revision surgery after previous double-bundle ACL reconstruction were enrolled. Three orthopedic surgeons independently reviewed the arthroscopic videos and determined the rupture pattern of both the anteromedial and posterolateral grafts. The graft rupture pattern was then correlated with the previously mentioned factors.
Results
The most common injury pattern seen at the time of revision ACL surgery was mid-substance AM and PL bundle rupture. Factors that influenced the rupture pattern (proximal vs. mid-substance and distal rupture vs. elongated, but in continuity) were months between ACL reconstruction and re-injury (P = 0.002), the etiology of failure (traumatic vs. atraumatic) (P = 0.025) and the measured graft tunnel angle (P = 0.048).
Conclusions
The most common pattern of graft re-rupture was mid-substance AM and mid-substance PL. As the length of time from the initial DB-ACL reconstruction to revision surgery increased, the pattern of injury more closely resembled that of the native ACL. Evaluation of patients who have undergone double-bundle ACL reconstruction, with a particular focus on graft maturity, mechanism of injury and femoral tunnel angles, and graft rupture pattern assists in preoperative planning for revision surgery.
doi:10.1007/s00167-010-1297-8
PMCID: PMC3038235  PMID: 21085932
Anterior cruciate ligament; Double-bundle ACL; Revision surgery; Rupture pattern; Graft failure

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