Sports Injuries of the Ankle and Ankle Arthritis Mr Amit Amin Consultant Foot and Ankle Surgeon Parkside Hospital
Impingement Painful mechanical limitation of full ankle movement secondary to osseous / soft tissue abnormality
Anatomical Classification Anterolateral Anterior Posterior Posteromedial Anteromedial
Clinical features Anterolateral swelling and Tenderness Pain on single leg squatting Molloy! et al JBJS 2003 Synovial impingement test
Imaging features MRI Adds to diagnosis? Rules out other pathology MRI arthrogram better CLINICAL DIAGNOSIS
Management Physio / NSAIDs / activity modification Injection LA / Steroid little published! Arthroscopic assessment + debridement
Imaging features Plain radiography Full dorsiflexion view MRI additional soft tissue disruption
Anteromedial Impingement Uncommon poorly defined Rarely isolated Anatomy Anterior tibio-talar ligament (deep deltoid)
Posterior Impingement Acute injury Inversion injury posterior pain 4-6 weeks Repetitive hyperplantar flexion Common in dancers and footballers
Clinical features Posterolateral ankle pain with activity Particularly hyperplantar flexion Local posterolateral tenderness Positive hyperplantar flexion test
Imaging features
Management Image guided LA and steroid injections Surgical decompression: Arthroscopic 2 portal posterior approach with patient prone
Os trigonum Posterior Impingement: Surgery
Instability
Currently considered the standard 2 Types: Anatomic Reconstruction 1. Direct Repair Brostrum-Gould 2. Anatomic Ligament Reconstruction Augmentation of ATFL & CFL with tendon graft
BROSTRUM-GOULD
Internal bracing
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
Ankle sprain not settling!
High Ankle Sprain Syndesmosis injury Diagnosis INDEX OF SUSPICION EVERSION MECHANISM MRI
DYNAMIC ULTRASOUND DORSIFLEXION / EVERSION MANOUEVRE OR STRESS VIEW? SCOPE?
Peroneal tendon disorders Peroneus brevis and Peroneus longus
Retromalleolar course & ridge
Pathology Tenosynovitis Tears Subluxation All usually due to trauma
Clinical features History trauma dorsiflexion / inversion Retrofibular pain Swelling Snapping subluxation / tear Ankle instability
Functional Anatomy
Longitudinal split tear
Surgical Repair tubularisation vs excision
Subluxation
SHALLOW GROOVE - CONGENITAL
Low Peroneus Brevis Muscle Belly
Groove-deepening procedures Incision over posterior border of fibula Tendon sheath and SPR divided Groove deepened SPR reefed
AVN Ankle Arthritis
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
Ankle Arthritis Fusion or Replacement
50 year old lady
Arthroscopic ankle arthrodesis
Ankle fusion
Results of Ankle Arthrodesis Gait efficiency decreased by 10% Oxygen consumption increased by 3% Stability maintained Patient satisfaction is high
Disadvantages of ankle fusion Movement is life Function gait analysis Non-union risk (1-10%) Adjacent segment arthritis subtalar, talonavicular
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!
Ideal patient <50 Fusion 50-65 grey area informed decision >65 good candidate for replacement But Consider: Patient Deformity Surgeon 75% 10 year survival
Ankle Replacement
Ankle Replacement Prevalence increasing 850 ankle replacements Concentrate surgery to specialist centres
Rheumatoid varus ankle
78 year old very fit/active lady
48 year old post pilon too young??
Questions? amit.amin@sportsortho.co.uk laura@sportsortho.co.uk