Ligament lesions of the ankle. Marc C. Attinger

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1 Ligament lesions of the ankle Marc C. Attinger

2 Anatomy

Mechanism of injury Each lig with its function during ROM

plantarflexion/ir CFL slack, ATFL tight Acute ankle

50-75%, PTFL 10% involved Strength: CFL 2-2.

3 Mechanism of injury Each lig with its function during ROM in dorsiflexion/er ATFL slack, CFL tight in plantarflexion/ir CFL slack, ATFL tight Acute ankle sprain: excessive inversion and IR -> ATFL 100%, CFL 50-75%, PTFL 10% involved Strength: CFL times stronger than ATFL (345 vs 140 N) Rare: isolated CFL, isolated PTFL, combination CFL and PTFL

4 Biomechanics Anterior drawer +100% Internal Rotation of the talus +12 Inversion Test (talar tilt) +20 Kjaersgard 1986, Cass 1994

5 Biomechanics Anterior drawer +100% Internal Rotation of the talus +12 Inversion Test (talar tilt) +20 Kjaersgard 1986, Cass 1994

6 Biomechanics Anterior drawer +100% Internal Rotation of the talus +12 Inversion Test (talar tilt) +20 Kjaersgard 1986, Cass 1994

$Medial instability Abduction/eversion force Forced external rotation, in combination with malleolar fracture (SER/PER) Isolated medial ligament injury is rare (5%)$

7 Medial instability Abduction/eversion force Forced external rotation, in combination with malleolar fracture (SER/PER) Isolated medial ligament injury is rare (5%) Most often in combination with lateral instability (40%) Secondary rotational instability Chronic lateral Instability -> overload medial Rasmussen 1985, Valderrabano 2005

8 Biomechanics: medial instability Abduktion Rotation IR + 8 AR + 5 Dorsiflexion + 17 Rasmussen 1985

9 Biomechanics: medial instability Abduktion Rotation IR + 8 ER + 5 Dorsiflexion + 17 Rasmussen 1985

10 Biomechanics: medial instability Abduktion Rotation IR + 8 AR + 5 Dorsiflexion + 17 Rasmussen 1985

11 Secondary rotational instability IR +150% ER +100% Rasmussen 1985

12 Acute vs. chronic instability Acute instability Chronic instability 14% 43% 10% 5% 85% 43% lateral Syndesmose medial lateral kombiniert medial Gerber 1998, Schneideberger /Hintermann 2005, Thermann 1997

Hindfoot varus deformity Joint reaction force medial of subtalar -> torsional moment (inversion) Lever arm for peronei reduced Higher incidence of hindfoot varus in

13 Hindfoot varus deformity Joint reaction force medial of subtalar -> torsional moment (inversion) Lever arm for peronei reduced Higher incidence of hindfoot varus in chronic instability (8%) Higher failure rate of ligament reconstruction in varus deformity (up to 35%) Tropp 2002, Strauss/Lippert 2007, van Bergeyk 2001, Vienne 2007,

14 Impact of chronic lateral instability Increases risk of ankle arthritis 20% of chronic instability develop OA 2/3 of arthritic ankle due to lateral ankle instability had hindfoot varus Valderrabano 2006, Krause 2012

$out fractures, no stress$

15 Acute ankle sprain Pain, swelling, hematoma, limited ROM Xray: rule out fractures, no stress views

functional rehabilitation: ROM exercise,

16 Acute ankle sprain Management: Grade I/II: Rest, Ice, Compression, Elevation (RICE) Grade III: immobilization with brace/ softcast boot for 2-6 wks Early functional rehabilitation: ROM exercise, strengthening, proprioception, activity-specifc training

17 Chronic lateral instability Functional insufficiency: impaired proprioception, postural/neuromuscular control Mechanical insufficiency: pathological laxity Combination leads to chronic instability (20% of acute ankle sprains) Persistent pain anterolateral ankle, recurrent sprains, giving way on uneven ground

18 Clinical tests Tenderness over ATLF/CFL Anterior drawer sign Sulcus sign Inversion stress test (dorsiflexion)

19 Diagnostics Ultrasound: examiner-dependend Radiographic: assessment of hindfoot axis MRI: 1. quality of lateral ligaments, 2. rule out other lesions Cardinal signs: ligament swelling, discontinuity, wavy ligament or non-visulaization

20 Other reasons for lateral ankle pain after acute ankle sprain Osteochondral lesions, bone bruising, loose bodies Neuropathic: stretching N. peroneus superficialis, N. Suralis Tendon tears: Peronei: Elongation or Sub/Luxation, Tib Post tendon Osteoarthritis Other ligament injuries: syndesmotic, bifurcate, sinus tarsi Impingement: anterior tibial osteophyt

21 Management Indication for surgery: failure of non-surgical treatment Conservative: Functional rehabilitation: proprioception, strengthening of peronei, ROM ankle Ortho-technical: insoles with more hindfoot valgus, braces functional instability more likely to benefit than mechanical instability Try at least 2-4 months

22 Surgery Should begin with ankle arthroscopy

Surgical technique Over 60 techniques have been described Non-anatomic Tenodesis Reconstruction Local tendon grafts, persistent instability,

23 Surgical technique Over 60 techniques have been described Non-anatomic Tenodesis Reconstruction Local tendon grafts, persistent instability, altered kinematics Anatomic repair Restore normal anatomy and biomechanics Anatomic reconstruction Replace attenuated ligaments, restore normal anatomy

24 Anatomic repair Broström 1966: gold standard, imbrication of ATFL and CFL Modified by Gould: augmentation of repair with mobilized lateral portion of extensor retinaculum, attached to fibula

25 Aftercare and outcome > Aftercare: > 6 weeks cast, initial 3 weeks in slight eversion > Physiotherapy > Outcome: > 91% good or excellent functional results > Superior to non-anatomic reconstructions > Rel CI: failed previous repair, generalized laxity syndrom, long-standing instability >10y

26 Anatomic reconstruction Replace attenuated ligament: Periostal flaps, autografts or allografts Fixation with interference screws

27 Anatomic reconstruction Hintermann 2006: Plantaris graft

28 Anatomic reconstruction Coughlin 2004: Gracilis graft, Paterson 2000: Semitendinosus

29 Anatomic reconstruction

30 Lateral-sliding calcaneal osteotomy Indication: Hindfoot varus deformity With hyperactivity of peroneus longus Consider peroneus longus-to-brevis transfer

31 Lateral-sliding calcaneal osteotomy

32 Conclusion 20% of acute lateral sprains develop chronic lateral ankle instability, 20% of which may develop osteoarthritis of the ankle, assess medial rotational instability Multiple surgical techniques, mod. Broström-Gould Goldstandard, anatomic reconstruction in attenuated ligaments, general laxity, long-standing insufficiency and failed previous repair Respect hindfoot varus deformity->lateralizing calcaneal osteotomy With correct indication excellent results in 90%

33 Thanks for attention!

Ankle Pain After a Sprain.

Ankle Pain After a Sprain. Ankle Pain After a Sprain www.fisiokinesiterapia.biz Anterior Drawer Stress Test Talar Tilt Talar Tilt (CFL) Difficult to isolate from subtalar ROM Slight plantar flexion (dorsi = relative subtalar isolation)