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Diagnostic guidelines for chronic ankle pain. From loose bodies to joint venture

Verhagen, R.A.W.

Publication date2004

Link to publication

Citation for published version (APA):Verhagen, R. A. W. (2004). Diagnostic guidelines for chronic ankle pain. From loose bodies tojoint venture.

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Chapter r

I n t r o d u c t i on n a nd d

A i mm of t h is thes is

Chapterr 1

Introductio n n Chronicc ankle pain Inversionn sprains of the ankle and ankle fractures are common injuries. In 2002, in The

Netherlands,, 78,000 patients presented at hospital emergency departments with ankle injuries,

59%% of which were treated for an inversion sprain.1 In more than 40% of cases the injuries

weree sports-related. Most patients with sprains of the lateral ligaments are young working

adults.11 These patients place a large demand on the healthcare system and are often temporarily

disabledd due to the ankle injury. This leads to higher healthcare costs and loss of productivity.

Althoughh most patients go on to an uncomplicated recovery, those who continue to have

painn in the ankle and hindfoot can present a diagnostic problem.2 This is known as chronic

anklee pain.

Causess of chronic ankle pain Thee causes of chronic ankle pain can be divided into three main groups: intra-articular, extra-

articular,, and peri-articular (Table). Nowadays most intra-articular conditions can be treated

byy means of an arthroscopic procedure. In the past extra-articular and peri-articular causes

weree not an indication for arthroscopy, however currently tendonitis, os trigonum syndrome,

andd subtalar pathology can all be treated by soft tissue endoscopy.3"10

Tablee Causes of chronic ankle pain

Intra-articularr Bony impingement Softt tissue impingement Osteochondrall lesion Loosee bodies Osteoarthritis s Infection n Neoplasm m Rheumaticc diseases

rheumatoidd arthritis pigmentedd villonodular synovitis synoviall chondromatosis hemophilia a otherr inflammatory arthritides (gout, chondrocalcinosis, Crohn disease)

Extra-articularr Subtalar pathology Vascularr / neurological problems Neoplasm m

Peri-articularr Chronic instability Syndesmoticc injury Oss trigonum syndrome Tendonitiss TA/TP/FHL/Per * Recurrentt peroneal tendon (sub-) luxation Tarsall tunnel syndrome

** TA = Tibialis Anterior tendon TPP = Tibialis Posterior tendon FHLL = Flexor Hallucis Longus tendon Perr = Peroneal tendon

11 1

Introductionn and Aim of this thesis

Impingement t

Thee most important cause of residual ankle pain is impingement. This can be divided into

bonyy or soft tissue impingement.

Bonyy impingement

Anteriorr impingement spurs in the ankle were first described by Morris in 1943, and later by

McMurrayy and O'Donoghue.11 Anterior bony impingement is a common cause of chronic pain

inn the ankle, especially in athletes. It is a clinical diagnosis, caused by anteriorly located bony

impediments.12"188 It is characterized by anterior pain, aggravated by repetitive movements, and

restrictedd dorsiflexion.19 Physical examination reveals pain on palpation over the anterior aspect

off the ankle joint with recognition of the pain. The differentiation between anterolateral and

anteromediall impingement is generally accepted.19-20 Standard AP and lateral radiographs are

usedd to detect the presence or absence of osteophytes.11 In patients with anterior talar and/or

tibiall spurs, these spurs are regarded as the cause of the anterior bony impingement

syndrome.14"16,211 Due to their location they can lead to the "kissing" phenomenon and

concomitantt pinching of hypertrophic synovial tissue. This results in a limited dorsiflexion

withh associated symptoms of impingement.12

Althoughh it is a recognized clinical diagnosis, some authors state that additional diagnostic

evaluationn is necessary to differentiate between symptomatic and asymptomatic lesions.22

Bonee scans may show increased uptake in the area of impingement in symptomatic lesions,

whilee computed tomography (CT) can be helpful to determine the precise anatomical location

andd medial and lateral extent of the osteophyte preoperatively.

Inn ankles with no severe osteoarthritic changes, arthroscopic treatment of the anterior

impingementt syndrome has produced good results.11"14,16,19,23"27

Softt tissue impingement

Thee clinical diagnosis of soft tissue impingement is one of exclusion. In patients with clinical

signss of an anterior ankle impingement syndrome and no visible osteophytes on radiography,

thee diagnosis of anterior soft tissue impingement syndrome is made. Similar symptoms can

occurr in chronic ankle instability, peroneal tendon tears or subluxations, sinus tarsi syndrome,

stresss fractures, loose bodies, osteochondral lesions, bony impingement, and degenerative

jointt disease.28 Patients with the soft tissue impingement syndrome present with anterolateral

anklee pain and tenderness after sprains, fractures, or surgery.24,28 Other clinical signs include

exacerbationn of the pain on dorsiflexion and an effusion.24 28,29

Ann magnetic resonance imaging (MRI) finding of an abnormal soft tissue structure within the

anterolaterall ankle gutter, as distinct from the anterior tibiofibular ligament and chondromalacia

off the talus, suggests the diagnosis of anterolateral soft tissue impingement.14,20,28

Thee predictive outcome in treating synovial impingement may be compromised when

12 2

Chapterr 1

documentedd ankle instability is present. Therefore, it is recommended that patients with

associatedd chronic ankle instability should have ankle ligament reconstruction as their initial

treatment.26 6

Iff in patients with clinical signs of an anteromedial ankle impingement syndrome, routine

radiographss show no abnormalities, a soft tissue impediment can be expected. However, it

hass been demonstrated that in the majority of these patients an anteromedially located

osteophytee can be present.30 The reason being that in the standard lateral projection

anteromediall osteophytes remain undetected due to superposition or overprojection of the

moree prominent anterolateral border of the distal tibia.19

Severall authors have stated that surgical distinction between normal variant bony and soft

tissuee and pathological conditions is difficult, due to subtle variations in joint anatomy.31,32

Anteromediall bony spurs are often poorly visualized at arthroscopy and can be easily missed

particularlyy in patients with accompanying secondary synovial reflections overlying the

concealedd osteophytes.33 As radiographic classification of the spur formation has proven to be

correlatedd with the outcome of surgery, detection of these osteophytes is important for a precise

diagnosis,, defining a treatment plan, the peroperative procedure and the final outcome.1119'34,35

Osteochondrall lesion Anotherr important cause of residual pain after an ankle sprain is osteochondral lesion of the

taluss (OLT). It is defined as the separation of a fragment of articular cartilage, with or without

subchondrall bone.36"38 The incidence of OLT after an ankle sprain is probably underestimated

becausee these lesions often remain undetected. The incidence has been reported to be as high

ass 6.5% after ankle sprains.39,40 OLTs most frequently occur in young adults with a nearly

equall distribution between the sexes. In the acute situation, symptoms depend on the amount

off damage to the peri-articular tissues and the involvement of afferent pain fibres in the

subchondrall bone.

Figuree Arthroscopic view of 42-year old man with persistent ankle pain after ankle sprain. A.. Posterolateral osteochondral lesion of talar dome with loose fragment B.. Same lesion after removal of loose fragment, curettage and drilling

13 3

Introductionn and Aim of this thesis

Usually,, the lesion is located in the anterolateral or posteromedial aspect of the talar dome.

Histologicallyy the medial and lateral lesions are identical, but morphologically they differ.

Thee lateral lesions are shallow and more wafer shaped, indicating a shear mechanism of

injury.. In contrast, medial lesions are generally deep, cup shaped, and located posteriorly,

indicatingg a mechanism of torsional impact.36,41 From the aetiological point of view, trauma is

thee most common cause of OLT, but idiopathic osteonecrosis may often be the underlying

pathologicall process. In the literature the latter has been associated with alcohol abuse, use

off steroids, endocrine disorders and some hereditary conditions.40,42"47

Althoughh initial symptoms may be absent, in chronic cases most patients present with

intermittentt pain located deep in the ankle joint which increases on weight bearing. On physical

examinationn signs are often lacking. A discrete limitation of range of motion with some synovitis

mayy be present. Local tenderness on palpation with recognition is absent in most cases.

Sincee there are no specific pathognomonic signs or symptoms, it is of key importance that the

examiningg physician and radiologist are aware that an osteochondral lesion could be present.

Thee frequent absence of radiographic changes on conventional radiography has led to the

usee of more sensitive methods for detection.48,49

Radionuclidee bone scanning,50 CT,51"53 MRI,43,54^7 and diagnostic arthroscopy58 have been used

too assess the ankle joint for osteochondral lesions.

Theree have been no reports on the accuracy of CT arthrography for detection of osteochondral

lesionss in the ankle. However, case reports suggest that CT arthrography may be a useful tool

forr assessing the stability of osteochondral lesion.59

Neverthelesss prospective studies that compare the efficacy of these modalities in the evaluation

off osteochondral lesions are still absent.60

Loosee bodies

Chondrall and osteochondral loose bodies of the ankle joint are often caused by trauma (ankle

sprainss and fractures of the ankle and talus), degenerative and posttraumatic osteoarthritis,

osteochondrall lesion of the talus, and synovial chondromatosis. Loose bodies are not as common

inn the ankle as in the knee and elbow.61

Loosee bodies may cause locking, catching, swelling, pain, and decreased range of motion as

theyy float freely within the joint. These symptoms can be intermittent because the loose

bodiess may become fixed to the synovium and are therefore asymptomatic, only to recur

whenn the chondral or osteochondral fragments come loose. Physical examination is usually

unremarkable.. Rarely is there any specific area of tenderness or a palpable loose body.

Nowadays,, radiographs are still the modality of choice when a loose body is suspected on

clinicall grounds. However, the false positive rate is quite high. Lesions that appear to be loose

bodiess on standard radiographs may actually be intracapsular, or extra-articular in location,

particularlyy in the posterior ankle joint compartment.32

14 4

Chapterr 1

Iff additional imaging is requested CT is the modality of choice. CT arthrography can help

detectt intra-articular loose bodies.62 On MRI loose bodies are sometimes difficult to identify,

butt in MR arthrography the detection of intra-articular loose bodies is improved due to the

highh contrast and joint distension.63

Osteoarthr i t is s

AA noteworthy characteristic of the ankle is its resistance to osteoarthritis. This observation is

reinforcedd when the incidence of osteoarthritis in the ankle is compared with that of the hip

orr the knee, but ankle osteoarthritis is still a fairly common sequela of traumatic injuries.64

Diagnosiss is by definition made by standard AP and lateral weight-bearing radiographs. The

severityy of the osteoarthritic changes of the ankle can be classified.16

Operativee arthroscopy for osteoarthritis of the ankle has not been successful.1265 Arthroscopic

debridementt does not offer a cure for all forms of degenerative joint disease of the ankle.

However,, it does alleviate symptoms in many patients and seems to resolve symptoms

permanentlyy in some cases of degenerative arthritis.66

Diagnosticc modalities in chronic ankle pain Theree are multiple imaging options for the assessment of chronic ankle pain, including stress

radiography,, radionuclide bone scanning, ultrasound, CT, MRI, and injection procedures.

Injectionn procedures for assessment include arthrography, CT arthrography, MR arthrography,

andd diagnostic injection with anaesthetics.

Thee first and most important steps in the preoperative diagnostic process are history taking,

physicall examination, combined with standard AP and lateral weight bearing radiographs.67

Mostt research on additional diagnostic imaging for chronic ankle pain has focused on the

accuracyy of one imaging method for specific conditions. Only a few studies have compared

imagingg methods for a specific condition.68 There have been no studies comparing imaging

methodss for the assessment of chronic ankle pain of uncertain aetiology. For example there

havee been no studies specifically addressing the value of plain films in the assessment of

chronicc ankle pain.68 However, plain films are routinely obtained as the first option to exclude

arthritis,, infection, fracture, or neoplasm. Because there are many different tests available for

usee in diagnosing ankle and foot problems, they must be used judiciously. Therefore, a keen

understandingg of the indications and limitations of each diagnostic test is mandatory. At

presentt no single test clearly stands out as superior for foot and ankle problems.

Thee diagnostic modality of choice depends not only on effectiveness, but also on availability

andd costs. Generally in medical practice there is a growing awareness of the need for practice

guideliness for diagnosis and treatment of disease. This is also true of orthopaedic surgery. To

addresss this need for practice guidelines a prospective study was designed at the Academic

Medicall Center in Amsterdam, The Netherlands.

15 5

Introductionn and Aim of this thesis

Questionss that remain

Reviewingg the literature reveals that most studies concerning chronic ankle pain are

retrospectivee and non-comparable. Nor have there been studies in which different diagnostic

modalitiess are prospectively compared with particular reference to their accuracy. Healthcare

financess play an important role and the diagnostic modality used depends not only on

effectivenesss (accuracy), but also on costs of that modality. This has led to evidence based

algorithmss ('evidence based medicine').68

Althoughh there are existing orthopaedic and radiological guidelines for chronic ankle pain,68"70

improvementss in CT and MR imaging and an ever-expanding armoury of therapeutic options

requiree that these guidelines be continuously updated.

Aimm of this thesis Thee aim of this thesis is to develop evidence based guidelines for diagnosis of patients with

chronicc ankle pain, especially osteochondral lesions of the talus.

Inn Chapter 2 the prevalence and incidence of ankle sprains leading to residual complaints in

thee long term is presented and discussed. The incidence of residual complaints after lateral

anklee ligament rupture is compared with the data from the literature.

Inn Chapter 3 a prospective study concerning the need for a preoperative diagnosis in the

treatmentt of chronic ankle pain is presented. Does the outcome of an arthroscopic procedure

dependd on having a preoperative diagnosis or not? If it does then preoperative diagnostic

modalitiess have to be evaluated for their accuracy in patients with chronic ankle pain.

Consideringg the conclusion of chapter 3 the accuracy of existing and new diagnostic modalities

forr patients with chronic ankle pain has to be evaluated.

Inn Chapter 4 a new type of radiograph for detecting anteromedial bony impingement of the

anklee joint is evaluated.

Forr detection of osteochondral lesions of the talar dome and tibia plafond, ankle distraction

cann be used. In Chapter 5 a new resterilizable non-invasive distraction device is presented

andd discussed. By using joint distraction in ankle arthroscopy more posterior localized

osteochondrall lesions can be detected and treated.

Variouss diagnostic modalities for identifying osteochondral lesions in the ankle are described

inn Chapter 6. It concentrates on single diagnostic strategies in a prospective cohort study. In

Chapterr 7 the same cohort of patients is used to find the best combination of diagnostic strategies

forr detection or exclusion of osteochondral lesions in a study based on decision modelling.

Inn Chapter 8 the results of a systematic review are presented considering the treatment options

off osteochondral lesions of the talar dome.

16 6

Chapterr 1

Inn Chapter 9 an overview of the results of the studies presented is given and the conclusions

aree discussed. Potential new developments and areas for future research are described.

Introductionn and Aim of this thesis

References s 1.. Consumer Safety Institute. [The Dutch

Injuryy Surveillance System: Ankle injuries]. PersonalPersonal Communication, 2004.

2.. Verhagen RA, de Keizer G, van Dijk CN: Long-termm follow-up of inversion trauma of thee ankle. Arch Orthop Trauma Surg 1995;114:92-6. 1995;114:92-6.

3.. van Dijk CN, Kort N: Tendoscopy of the peroneall tendons. Arthroscopy 1998;14:471-8.

4.. van Dijk CN, Scholten PE, Kort NP: Tendoscopyy (tendon sheath endoscopy) for overusee tendon injuries. Operative TechniquesTechniques in Sports Medicine 1997;5:170-8.

5.. van Dijk CN: Hindfoot endoscopy. Sports MedicineMedicine and Arthroscopy Review 2000;8:365-71. .

6.. van Dijk CN, van Dyk GE, Scholten PE, Kort NP:: Endoscopic calcaneoplasty. Am J Sports MedMed 2001;29:185-9.

7.. van Dijk CN, Kort N, Scholten PE: Tendoscopyy of the posterior tibial tendon. ArthroscopyArthroscopy 1997;13:692-8.

8.. van Dijk CN, Scholten PE, Krip s R: A 2-portall endoscopic approach for diagnosis and treatmentt of posterior ankle pathology. ArthroscopyArthroscopy 2000;16:871-6.

9.. Zimmer TJ, Ferkel RD: Future developments: Endoscopicc procedures for the retrocalcaneal bursa,, plantar fascia, and achilles tendon. In: Whipplee TL ed. Arthroscopic surgery: The footfoot and the ankle. Philadelphia, USA: Lippincott-Ravenn Publishers, 1996:31-324.

10.. Frey C, Feder KS, DiGiovanni C: Arthroscopicc evaluation of the subtalar joint: doess sinus tarsi syndrome exist? Foot Ankle IntInt 1999;20:185-91.

11.. Scranton PE, Jr., McDermott JE: Anterior tibiotalarr spurs: a comparison of open versus arthroscopicc debridement. Foot Ankle 1992;13:125-9. .

12.. Biedert R: Anterior ankle pain in sports medicine:: aetiology and indications for arthroscopy.. Arch Orthop Trauma Surg 1991;110:293-7. .

13.. Ferkel RD, Scranton PE, Jr.: Arthroscopy of thee ankle and foot. J Bone Joint Surg [Am] 1993;75-A:: 1233-42.

14.. Ogilvie-Harri s DJ, Mahomed N, Demazière A:: Anterior impingement of the ankle treated byy arthroscopic removal of bony spurs, f Bone JointJoint Surg [BrJ 1993;75-B:437-40.

15.. Ogilvie-Harri s DJ, Gilbar t MK, Chorney K: Chronicc pain following ankle sprains in athletes:: the role of arthroscopic surgery. ArthroscopyArthroscopy 1997;13:564-74.

16.. van Dijk CN, Verhagen RA, Tol JL: Arthroscopyy for problems after ankle fracture. JJ Bone Joint Surg [BrJ 1997;79-B:280-4.

17.. Bal BS, Jones L, Jr.: Arthroscopic resection of aa chondroblastoma in the knee. Arthroscopy 1995;11:216-9. .

18.. van Dijk CN, Fiévez AW, Heijboer MP, et al.:: Arthroscopy of the ankle. Acta Orthop 5caW1993;64:9(S253). .

19.. van Dijk CN, Tol JL, Verheyen CC: A prospectivee study of prognostic factors concerningg the outcome of arthroscopic surgeryy for anterior ankle impingement. Am J SportsSports Med 1997;25:737-45.

20.. Ferkel RD, Karzel RP, Del Pizzo W, Friedmann MJ, Fischer SP: Arthroscopic treatmentt of anterolateral impingement of the ankle.. Am J Sports Med 1991;19:440-6.

21.. van Dijk CN, Bossuyt PM, Mart i RK: Medial anklee pain after lateral ligament rupture. / BoneBone Joint Surg [Br] 1996;78-B:562-7.

22.. Ferkel RD, Ruland CM: Operative arthroscopyy of the ankle. In: Andrews JR, Timmermann LA eds. Diagnostic and operative arthroscopy.arthroscopy. Philadelphia, USA: W.B. Saunderss Company, 1998:431-47.

23.. Ferkel RD, Fischer SP: Progress in ankle arthroscopy.. Clin Orthop 1989;240:210-20.

24.. Liu SH, Raskin A, Osti L, Baker C, Jacobson K,, Finerman G: Arthroscopic treatment of anterolaterall ankle impingement. ArthroscopyArthroscopy 1994;10:215-8.

25.. Marti n DF, Baker CL, Curl WW, Andrews JR,, Robie DB, Haas AF: Operative ankle arthroscopy.. Long-term follow-up. Am J SportsSports Med 1989;17:16-23.

26.. Meislin RJ, Rose DJ, Parisien JS, Springer S: Arthroscopicc treatment of synovial impingementt of the ankle. Am J Sports Med 1993;21:186-9. .

27.. Tol JL, Verheyen CP, van Dijk CN: Arthroscopicc treatment of anterior impingementt in the ankle. J Bone Joint Surg /J'r/2001;83-B:9-13. .

28.. Rubin DA, Tishkoff NW, Britto n CA, Conti SF,, Towers JD: Anterolateral soft tissue impingementt in the ankle: diagnosis using MR imaging.. ^/n/ieoeiif^e/7o71997;169:829-35.

18 8

Chapterr 1

29.. Bassett FH, Gates HS, Billys JB, Morri s HB, Nikolaouu PK: Talar impingement by the anteroinferiorr tibiofibular ligament. A cause of chronicc pain in the ankle after inversion sprain.. J Bone Joint Surg [Am] 1990,72-A.55-9.

30.. Seil R, Rupp S, Pape D, Dienst M, Kohn D: [Approachh to open treatment of osteochondral lesionss of the talm]. Orthopade 2001;30:47-52.

31.. Vogler HW, Stienstra JJ> Montgomery F, Kippp L: Anterior ankle impingement arthropathy.. The role of anterolateral arthrotomyy and arthroscopy. Clin Podiatr MedMed Surg 1994; 11:425-47.

32.. Ferkel RD: Articvdar surface defects, loose bodies,, and osteophytes. In: Whipple TL ed. ArthroscopicArthroscopic surgery: The foot and the ankle. Philadelphia,, USA: Lippincott-Raven Publishers,, 1996:145-84.

33.. Ray RG, Gusman DN, Christensen JC: Anatomicall variation of the tibial plafond: the anteromediall tibial notch, f Foot Ankle Surg 1994;33:419-26. .

34.. van Dijk CN, Wessel RN, Tol JL, Maas M: Obliquee radiograph for the detection of bone spurss in anterior ankle impingement. Skeletal RadiolRadiol7002:31:214-21. 7002:31:214-21.

35.. Ferkel RD, Fasulo GJ: Arthroscopic treatment off ankle injuries. Orthop Clin North Am 1994;25:17-32. .

36.. Berndt AL, Harty M: Transchondral Fracturess (Osteochondritis Dissecans) of the talus,, f Bone Joint Surg [Am] 1959;41 -A:988-1020. .

37.. Alexander AH, Lichtman DM: Surgical treatmentt of transchondral talar-dome fracturess (osteochondritis dissecans). Long-termm follow-up. J Bone Joint Surg [Am] 1980;62-A:646-52. .

38.. König F: Ueber freie Körper in den Gelenken. DeutschDeutsch Z Chir 1888;27:90-109.

39.. Bosien WR, Staples OS, Russell SW: Residual disabilityy following acute ankle sprains. / BoneBone Joint Surg [Am] 1955;37-A:1237-43.

40.. Flick AB, Gould N: Osteochondritis dissecans off the talus (transchondral fractures of the talus):: review of the literature and new surgical approachh for medial dome lesions. Foot Ankle 1985;5:165-85. .

41.. Davis AW, Alexander I J: Problematic fracturess and dislocations in the foot and anklee of athletes. Clin Sports Med 1990;9:163-81. .

42.. Goldstone RA, Pisani AJ: Osteochondritis dissecanss of the talus. A^ YState J Med 1965;65:2487-94. .

43.. DeSmet AA, Fisher DR, Bumstein MI , Graf BK,, Lange RH: Value of MR imaging in stagingg osteochondral lesions of the talus (osteochondritiss dissecans): results in 14 patients.. Am J Roentgenol 1990;154:555-8.

44.. Rynn M, Fazekas EA, Hecker RL: Osteochondrall lesions of the talus. J Foot Surg 1983;22:155-8. .

45.. Wells D, Oloff-Solomon J: Radiographic evaluationn of transchondral dome fractures of thee talus. J Foot Surg 1987;26:186-93.

46.. Naumetz VA, Schweigel JF: Osteocartilagenouss lesions of the talar dome, ƒ TraumaTrauma 1980;20:924-7.

47.. Hanley WB, McKusick VA, Barranco FT: Osteochondritiss dissecans with associated malformationn in two brothers. J Bone Joint SurgSurg [Am] 1967;49-A:925-37.

48.. Kabbani YM, Mayer DP: Magnetic resonance imagingg of osteochondral lesions of the talar dome.. J Am Podiatr Med Assoc 1994;84:192-5.

49.. McCullough RW, Gandsman EJ, litchman HE,, Schatz SL: Dynamic bone scintigraphy in osteochondritiss dissecans. Int Orthop 1988;12:317-22. .

50.. Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooneyy T: Osteochondral lesions of the talus. AmAm J Sports Med 1993;21:13-9.

51.. Meyer JM, Hoffmeyer P, Savoy X: High resolutionn computed tomography in the chronicallyy painful ankle sprain. Foot Ankle 1988;8:291-6. .

52.. Zinman C, Wolfson N, Reis ND: Osteochondritiss dissecans of the dome of the talus.. Computed tomography scanning in diagnosiss and follow-up. J Bone Joint Surg [Am][Am] 1988;70-A:1017-9.

53.. Kelberine F, Frank A: Arthroscopic treatmentt of osteochondral lesions of the talar dome:: a retrospective study of 48 cases. ArthroscopyArthroscopy 1999;15:77-84.

54.. Yulish BS, Mulopulos GP, Goodfellow DB, Bryann PJ, Modic MT, Dollinger BM: MR imagingg of osteochondral lesions of talus. / ComputComput Assist Tomogr 1987; 11:296-301.

55.. Anderson IF, Crichton KJ, Grattan-Smith T, Cooperr RA, Brazier D: Osteochondral fracturess of the dome of the talus. J Bone Joint SurgSurg [Am] 1989;71-A:1143-52.

56.. Bohndorf K: Osteochondritis (osteochondrosis)) dissecans - a review and neww MRI classification. Eur Radiol 1998;8:103-12. .

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57.. Aerts P, Disier DG: Abnormalities of the foot andd ankle: MR imaging findings. Am J RoentgenolRoentgenol 1995;165:119-24.

58.. Helgason JW, Chandnani VP: Magnetic resonancee imaging arthrography of the ankle. TopTop Magn Reson Imaging 1998;9:286-94.

59.. Heare MM , Gillespy T, III , Bittar ES: Direct coronall computed tomography arthrography off osteochondritis dissecans of the talus. SkeletalSkeletal Radiol 1988; 17:187-9.

60.. Stroud CC, Mark s RM: Imaging of osteochondrall lesions of the talus. Foot Ankle ClinClin 2000;5:119-33.

61.. Baker CL, Graham JM, Jr.: Current concepts inn ankle arthroscopy. Orthopedics 1993;16:1027-35. .

62.. Tehranzadeh J, Gabriele OF: Intra-articular calcifiedd bodies: detection by computed arthrotomography.. South Med f 1984;77:703-10. .

63.. Trattni g S, Rand T, Breitenseher M, Ba-Ssalamahh A, Schick S, Imhof H: [MRI arthrographyy of the ankle joint]. Radiologe 1999;39:47-51. .

64.. Hansen ST, Jr.: Posttraumatic and degenerativee problems in the joints. FunctionalFunctional reconstruction of the foot and ankle.ankle. Philadelphia, USA: Lippincott Williams && Wilkins, 2000:145-86.

65.. Demazière A, Ogilvie-Harri s DJ: [Operative arthroscopyy of the ankle. 107 cases]. Rev RhumRhum Mai Osteoartic 1991;58:93-7.

66.. Cheng JC, Ferkel RD: The role of arthroscopyy in ankle and subtalar degenerativee joint disease. Clin Orthop 1998;349:65-72. .

67.. van Dijk , C. N. [Beweegredenen. De patiënt alss bron van inspiratie]. Inaugural lecture. Amsterdam,, The Netherlands, Vossiuspers UvA,, 2002.

68.. DeSmet AA, Dalinka MK , Alazraki N, Berquistt TH, Daffher RH, el Khoury GY, Goergenn TG, Keats TE, Manaster BJ, Newbergg A, Pavlov H, Schweitzer ME, Haralsonn RH, III , McCabe JB: Chronic ankle pain.. American College of Radiology. ACR Appropriatenesss Criteria. Radiology 2OQ0;2\5 Suppl:321-32. .

69.. Ferkel RD: Soft tissue lesions of the ankle. In: Whipplee TL ed. Arthroscopic surgery: The footfoot and ankle. Philadelphia, USA: Lippincott-Ravenn Publishers, 1996:121-43.

70.. Traughber PD: Imaging of the foot and ankle. In:: Mann RA, Coughlin MJ eds. Surgery of thethe foot and ankle. 6 ed. St. Louis, USA: Mosby,, 1997:61-139.