Sports Injuries of the Ankle and Ankle Arthritis. Mr Amit Amin Consultant Foot and Ankle Surgeon Parkside Hospital

Transcription

1 Sports Injuries of the Ankle and Ankle Arthritis Mr Amit Amin Consultant Foot and Ankle Surgeon Parkside Hospital

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3 Impingement Painful mechanical limitation of full ankle movement secondary to osseous / soft tissue abnormality

4 Anatomical Classification Anterolateral Anterior Posterior Posteromedial Anteromedial

5 Clinical features Anterolateral swelling and Tenderness Pain on single leg squatting Molloy! et al JBJS 2003 Synovial impingement test

6 Imaging features MRI Adds to diagnosis? Rules out other pathology MRI arthrogram better CLINICAL DIAGNOSIS

7 Management Physio / NSAIDs / activity modification Injection LA / Steroid little published! Arthroscopic assessment + debridement

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9 Imaging features Plain radiography Full dorsiflexion view MRI additional soft tissue disruption

10 Anteromedial Impingement Uncommon poorly defined Rarely isolated Anatomy Anterior tibio-talar ligament (deep deltoid)

11 Posterior Impingement Acute injury Inversion injury posterior pain 4-6 weeks Repetitive hyperplantar flexion Common in dancers and footballers

12 Clinical features Posterolateral ankle pain with activity Particularly hyperplantar flexion Local posterolateral tenderness Positive hyperplantar flexion test

13 Imaging features

14 Management Image guided LA and steroid injections Surgical decompression: Arthroscopic 2 portal posterior approach with patient prone

15 Os trigonum Posterior Impingement: Surgery

16 Instability

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18 Currently considered the standard 2 Types: Anatomic Reconstruction 1. Direct Repair Brostrum-Gould 2. Anatomic Ligament Reconstruction Augmentation of ATFL & CFL with tendon graft

19 BROSTRUM-GOULD

20 Internal bracing

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23 CONTROVERSIAL Rehabilitation 2 weeks cast Aircast Boot from 2 weeks for 2 weeks Weight-bearing from 2 weeks and ROM DF/PF No inversion/eversion for 2 weeks! Use bike, eliptical from 4 weeks

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25 Ankle sprain not settling!

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30 High Ankle Sprain Syndesmosis injury Diagnosis INDEX OF SUSPICION EVERSION MECHANISM MRI

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32 DYNAMIC ULTRASOUND DORSIFLEXION / EVERSION MANOUEVRE OR STRESS VIEW? SCOPE?

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35 Peroneal tendon disorders Peroneus brevis and Peroneus longus

36 Retromalleolar course & ridge

37 Pathology Tenosynovitis Tears Subluxation All usually due to trauma

38 Clinical features History trauma dorsiflexion / inversion Retrofibular pain Swelling Snapping subluxation / tear Ankle instability

39 Functional Anatomy

40 Longitudinal split tear

41 Surgical Repair tubularisation vs excision

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43 Subluxation

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48 SHALLOW GROOVE - CONGENITAL

49 Low Peroneus Brevis Muscle Belly

50 Groove-deepening procedures Incision over posterior border of fibula Tendon sheath and SPR divided Groove deepened SPR reefed

51 AVN Ankle Arthritis

52 Anatomy and Biomechanics Ankle bears up to 5 times body weight with normal walking Small surface contact area of 350mm 2 Highest load per surface area of any joint in the body

53 Ankle Arthritis Fusion or Replacement

54 50 year old lady

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57 Arthroscopic ankle arthrodesis

58 Ankle fusion

59 Results of Ankle Arthrodesis Gait efficiency decreased by 10% Oxygen consumption increased by 3% Stability maintained Patient satisfaction is high

60 Disadvantages of ankle fusion Movement is life Function gait analysis Non-union risk (1-10%) Adjacent segment arthritis subtalar, talonavicular

61 WHY NOT ANKLE ARTHROPLASTY? Because the ankle is a difficult joint to replace Forces 2-3 times greater than at the knee or hip Limited bone stock Complex anatomy - including gutters Patients with ankle arthrodesis do OK!

62 Ideal patient <50 Fusion grey area informed decision >65 good candidate for replacement But Consider: Patient Deformity Surgeon 75% 10 year survival

63 Ankle Replacement

64 Ankle Replacement Prevalence increasing 850 ankle replacements Concentrate surgery to specialist centres

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66 Rheumatoid varus ankle

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69 78 year old very fit/active lady

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72 48 year old post pilon too young??

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75 Questions?