V E R I TAS MGH 1811 MGH 1811 V E R I TAS. *Gerber JP. Persistent disability with ankle sprains. Foot Ankle Int 19: , 1998.

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MGH 1811 Management of Ankle Instability Richard J. de Asla, M.D.

V E R I TAS It s just a sprain Lateral Ankle Sprains Most common

day 90% involve lateral ankle ligaments 32% may be associated with chronic

1 MGH 1811 Management of Ankle Instability Richard J. de Asla, M.D. V E R I TAS MGH 1811 I have no potential conflicts with this presentation. V E R I TAS It s just a sprain Lateral Ankle Sprains Most common musculoskeletal injury seen in medical practice More than 25,000 sprains per day 90% involve lateral ankle ligaments 32% may be associated with chronic symptoms * *Gerber JP. Persistent disability with ankle sprains. Foot Ankle Int 19: ,

2 Lateral Ankle Sprains Most common injury in sports 20% of all sports related injuries 45% basketball 31% soccer* *Ekstrand J, Tropp H: The incidence of ankle sprains in soccer. Foot Ankle 11:41-44, Sandelin J: Acute sports injuries. Helsinki, University of Helsinki, 1988, pp Lateral Ankle Sprains May include injury to subtalar joint ligaments Cll Collectively l known as the lateral l ligamentous complex Anatomy Ankle Joint: Three major ligaments Anterior Talofibular (ATFL) Calcaneofibular (CFL) Posterior Talofibular (PTFL) 2

Thickening of anterolateral capsule Lowest load to failure but highest strain Parallel to axis of foot in

3 Anatomy Subtalar Joint: Five Structures Calcaneofibular ligament (CFL) Inferior extensor retinaculum Lateral talocalcaneal ligament Cervical ligament Interosseous talocalcaneal ligament Biomechanics ATFL Thickening of anterolateral capsule Lowest load to failure but highest strain Parallel to axis of foot in neutral Foot in plantar flexion - parallel to leg (collateral ligament) Most sprains: plantar flexion and inversion 3

4 Biomechanics CFL Extra-capsular, cordlike Load to failure 2 to 3.5 times ATFL Spans ankle and subtalar joint Most important subtalar lateral stabilizer PTFL Strongest, horizontal orientation Rarely torn Under tension in dorsiflexion 4

Pathology Inversion injuries Plantarflexion Internal

common ATFL always injured first Midsubstance ruptures most

instability) Neuromuscular deficits Reduced proprioceptive

5 Pathology Inversion injuries Plantarflexion Internal Rotation ATLF most common by far ATFL and CFL 2 nd most common ATFL always injured first Midsubstance ruptures most common Pathology Injury can result in Laxity (mechanical instability) Neuromuscular deficits Reduced proprioceptive sense Delayed peroneal muscle response Strength deficits Functional Instability 5

$Associated injuries Anterolateral impingement Sinus tarsi syndrome Peroneal tendons Osteochondral lesions of the talus Syndesmosis injuries Missed fractures Neuritis Diagnosis My ankle rolls on me$

6 Associated injuries Anterolateral impingement Sinus tarsi syndrome Peroneal tendons Osteochondral lesions of the talus Syndesmosis injuries Missed fractures Neuritis Diagnosis My ankle rolls on me History of prior or recurrent sprains Uneven surfaces more difficult May be associated with pain Physical Exam Predisposing factors: Peroneal weakness Varus hindfoot Tarsal coalition Hypermobility? e and a pressor e this picture. 6

Physical Exam Usually pain over ATFL Drawer exam Strength and

Used to assess ligament integrity Comparison views controversial MRI Bone

t Jigs available >15 likely positive * Wide variability *Rubin G, Witten

7 Physical Exam Usually pain over ATFL Drawer exam Strength and Proprioception Imaging 3-view ankle (AP, lateral, mortise) Stress views Used to assess ligament integrity Comparison views controversial MRI Bone Scan: chronic pain with equivocal exam Imaging Talar tilt Manual lt test t Jigs available >15 likely positive * Wide variability *Rubin G, Witten M: The talar-tilt angle and the fibular collateral ligaments. JBJS Am 42: ,

8 QuickTime and a decompressor are needed to see this picture. Imaging Anterior Drawer Test Evaluates ATFL > 5 mm for positive exam > 3 mm difference QuickTime and a decompressor are needed to see this picture. Subtalar Instability History is identical to ankle instability May have more sinus tarsi pain May coexist with ankle instability Increased inversion and internal rotation on exam (extremely difficult to appreciate) Treatment is similar Subtalar Instability Traditional AP stress Increase exposure > 3mm positive test Other methods described 8

9 Conservative Treatment Correct deficits: Proprioception Strength Flexibility Bracing vs. taping Lateral heel wedge Lower heels Indications for surgery Failed conservative measures Documented mechanical instability Contraindications Lateral pain without instability Other causes of instability (e.g. Neuromuscular disease) Noncompliant patient Arthroscopy: To scope or not to scope Not helpful in addressing instability per se Reported high rates of associated intra- articular pathology * Should be performed if any doubt No randomized studies *Kibler WB: Arthroscopic findings in ankle ligament reconstruction. Clin Sports Med 15: , 1996 *Hintermann B. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30: ,

Surgical Treatment Secondary ligament repair/imbrication Ligament reconstruction Free tendon grafts Tendon transfers Multitude of methods

Modified by Gould * to include IER Advantage - excellent ROM, no tendon harvesting Disadvantage - strength may be a problem in heavy

10 Surgical Treatment Secondary ligament repair/imbrication Ligament reconstruction Free tendon grafts Tendon transfers Multitude of methods described Over 50 procedures described Most report success >80% Bröstrom Most popular anatomic technique Anatomical repair of ATFL and CFL Modified by Gould * to include IER Advantage - excellent ROM, no tendon harvesting Disadvantage - strength may be a problem in heavy patients, requires good tissue *Gould N, Seligson D, Gassman J: Early and late repair of lateral ligament of the ankle. Foot Ankle 1:84-89,

procedure Utilizes anterior 1/3 to 1/2 of P.B.

11 Modified Bröstrom- Post op Immobilized 6 weeks P.T. started at 6 weeks Return to sports at 4 months Bracing for 6 months after surgery Split Evans procedure Utilizes anterior 1/3 to 1/2 of P.B. tendon Nonanatomic Functions as a vector sum of ATFL and CFL Girard P, et al: Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle 20: ,

12 Chrisman-Snook * ATFL and CFL reconstruction Modification of Elmslie Locked subtalar joint a pitfall QuickTime and a decompressor are needed to see this picture. *Chrisman OD, Snook GA: Reconstruction of lateral ligament tears of the ankle. J Bone Joint Surg Am 51: , 1969 Modified Bröstom vs. Chrisman Snook (Hennritius et al 1984) Prospective, randomized trial Both provided d excellent stability CS more complications 6 wounds 7 sural nerve injuries Current trend is toward anatomic reconstruction Biomechanical data suggests better motion * Mt Meta-analysisanalysis (Baumhauer) Modified Bröstrom vs. nonanatomic procedures Fewer complications Faster return of function Recommended tendon transfer in laxity and salvage *Bahr R, Pena F, Shine J, et al: Biomechanics of ankle ligament reconstruction. Am J Sports Med 25: , 1997 Baumhauer JF: Surgical considerations in the treatment of ankle instability. J Athl Train 37: ,

13 Krips * : Multicenter retrospective study Modified Bröstrom vs. tenodesis Minimum 15 yr follow up Tenodesis resulted in: Poorer results More positive drawer signs Higher mean talar tilt More medial ankle OA *Krips R, van Dijk N, Halasi T, et al. Foot Ankle 22: , 2001 Other techniques Anatomic reconstructions ti Hamstring grafts Allograft Bröstrom usually first choice QuickTime and a decompressor are needed to see this picture. Coughlin MJ, Schenck RC Jr, Grebing BR, et al. Foot Ankle Int 25: , 2004 The Varus Heel When to correct varus alignment? No data Coleman block test QuickTime and a decompressor are needed to see this picture. Coleman Block Test 13

14 Treatment Lateral heel or sole wedging, bracing Dwyer closing wedge osteotomy Lateralizing osteotomy 1st met. dorsiflexion osteotomy Combination Do not transfer entire P.B.! Thank You! MGH

Management of Chronic Lateral Ligament Instability

Management of Chronic Lateral Ligament Instability Bony Anatomy Curved trochlear surface of talus produces a cone-shaped articulation whose apex is directed medially; thus the fan-shaped deltoid is all