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- 1. Epidemiology • Each day about one inversion injury of the ankle occurs for every 10,000 people. • Seven to ten percent of all admissions to hospital emergency departments are attributed to ankle sprains. • 20% of acute ankle sprains will develop into chronic ankle instability.
- 2. Syndesmosis Testing in High ankle sprains • Syndesmosis tenderness • Hopkins squeeze test (Hopkin's) • External rotation stress test • Cotton stress test • Fibular translation test
- 5. CT and MRI for syndesmotic injuries • CT: • Post-operatively to assess reduction of syndesmosis after fixation • More sensitive than radiographs for detecting minor degrees of syndesmotic injury • MRI • Normal radiographs with clinical suspicion of syndesmotic injury • Lambda sign described as being highly sensitive and specific for detecting syndesmotic injury
- 6. Ankle Sprain Nonoperative Treatment • RICE in Grade I, II, and III injuries • Grade I and II : 1 week of weight-bearing immobilization in a walking boot, aircast or walking cast • Grade III :10 days of casting and NWB • High ankle sprain: NWB cast for 2 to 3 weeks • Early movement and rehabilitation should begin with motion exercises and progresses to strengthening of peroneal muscles, proprioception when pain and welling subsides. • In high ankle sprain physical therapy program using a brace that limits external rotation.
- 7. Syndesmotic Injury Surgical Management • Syndesmosis fixation with screw or suture button • Syndesmotic ankle sprain with instability on stress radiographs • Syndesmotic injury refractory to conservative treatment • Syndesmotic injury with associated fracture that remains unstable after fixation of fracture • Screw often requires removal after 6 weeks • Fiberwire suture with two buttons tensioned around the syndesmosis and does not require removal • Some studies show earlier return to activity when compared to screw fixation
- 8. Chronic ankle instability Mechanical instability due to ligament and/or bone trauma Functional instability due to postural or proprioceptive defect
- 9. Functional Instability risk factors : • Functional Instability risk factors : • Congenital hindfootvarus • Proprioceptive deficit • Laxity-related osteochondral talar dome lesions • Peroneal tendon dislocation and/or fissure • Anterior or posterior impingement • All should be treated at the same time as lateral laxity
- 10. Patient History • Frequent episodes of giving way, rolling the ankle, or tripping • Sensation of instability • Pain that is present between episodes of instability suggests possible additional pathology.
- 11. Talar Tilt
- 13. Radiology • MRI is important to evaluate the patient for concomitant injuries because some reports demonstrate that up to 96.9%of patients with ankle instability have additional pathologies
- 14. Surgical Techniques • Anatomic repair or reconstruction • Direct repair of the injured ligament and anatomical reconstruction with use of a graft • Indicated for patients with sufficient ligament remnants amendable to sutures, whereas reconstruction is indicated for those with insufficient or attenuated ligament remnants. • Non-anatomic reconstructions with tenodesis effect
- 15. Anatomic Repair or Reconstruction Non anatomic reconstruction Brostrom Watson Jones Brostrom Gould Chrisman-Snook Roy Camille Colville Blanchet Evans Dequennoy Karlsson
- 16. • Direct repair using the native ligament remnant with or without reinforcement of local tissue is generally considered to be the first- line operative treatment of ATFL • Contraindications: • Longstanding ankle instability with insufficient ligamentous tissue. • Previous failed stabilization procedures. • High body mass index. • Generalized ligamentous laxity.
- 17. Positioning and approach • Supine, with a support holding the limb in internal rotation. • The approach is centered with respect to the lateral malleolus, curving forward then upward .
- 21. Gould Modification • This procedure was reinforced to reinforce Broström reinsertion. • The superior distal extensor retinaculum bundle is fixed transosseously or by anchors to the anterior par tof the fibular malleolus, thereby reinforcing the anterior capsule and anterior tibiofibular ligament. • The technique can be performed arthroscopically (arthroscopic Broström-Gould procedure)
- 23. Blanchet Technique • Ligamentous tension restoration. • The scar tissue of the LTFA is exposed and excised, simultaneously creating an anterior joint opening in front of the malleolus. • The resection is carried out until reaching the "healthy ligament" near the talus, while preserving a few millimeters of tissue, even scar tissue, for suturing. • Exploration to identify any associated lesions and to check for any incarceration of residual ATFL. • The ligament can then be sutured to the remaining stump on the lateral edge of the talus, with the foot positioned in dorsal flexion and valgus • Often it is necessary to reinforce this suture using a portion of the fibular tendon sheath. • If needed, a final reinforcement with the frondiform ligament is described in the initial technique.
- 24. Duquennoy Technique • Removal as a single unit, the anterior periosteum, the LTFA attached to it, and the joint capsule, simultaneously performing a pre-malleolar arthrotomy. • This approach allows for the exploration of cartilage, particularly in the search for osteochondral lesions of the talar dome. • Healthy ligament tissue is identified on the deep side of the disinserted tissue, and U-shaped sutures are passed through this healthy tissue. The reinsertion is supported by four to five transosseous sutures previously drilled by a Kirschner wire from the lateral face of the malleolus to its anterior edge, near the articular cartilage. • The U-shaped sutures are passed through the bone tunnels before being tightened, with the foot at a right angle, enabling visualization of the anterior ligament tension. • Currently, reinsertion has been facilitated by using anchors placed at the level of the lateral malleolus instead of transosseous tunnels.
- 30. Evans Procedure
- 31. Ankle Arthroscopy • Several intra-articular conditions are associated with chronic ankle instability, including osteochondral lesions of the talus, impingement, loose bodies, painful ossicles, adhesions, chondromalacia, and osteophytes. These conditions in themselves may produce ankle pain; left untreated, they may lead to less than favorable results after ligamentous stabilization. • They found that 93% of patients had associated lesions requiring intervention but reported 96% good to excellent results.
- 32. Take off messages • Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligamentreconstruction are the two recommended options. • Non-anatomic reconstructions using the peroneus brevis should be abandoned. • Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available.
- 33. Suture Anchors vs Direct Repair • Biomechanical studies have similarly revealed no significant differences in tensile strength and stiffness between direct repair techniques and suture anchor stabilization
- 34. Suture Tape Augmentation • Attempts to improve the strength of the construct were sought, and the concept of a suture tape augmentation was initiated. • Could possibly lead to overconstraint. • Several authors have found no significant difference in suture anchor lateral ligament repair with and without suture tape augmentation. • Still no clear evidence.
Editor's Notes
- #3: Hopkins squeeze test (Hopkin's) compression of tibia and fibula at midcalf level causes pain at syndesmosis External rotation stress test pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees Cotton widening of the syndesmosis with lateral pull on the fibula fibular translation anterior and posterior drawer force to the fibula with the tibia stabilized causes increased translation of the fibula and pain
- #5: Radiographic views to obtain (weight bearing) AP Lateral ATFL injury suggested with anterior talar translation Mortise AP, lateral of entire tibia may show fracture of proximal fibula
- #8: no difference between 3 or 4 cortices number of screws fixation with two screws is preferable position of foot during fixation a recent study challenges the principle of holding the ankle in maximal dorsiflexion to avoid overtightening postoperative typically non-weight-bearing for 6-12 weeks may prolong if screw breakage is a concern
- #12: Anterior drawer test tests for excessive anterior displacement of talus relative to tibia ATFL best tested in plantarflexion, CFL in dorsiflexion Talar tilt test excessive ankle inversion (> 15 degrees) compared to contralateral side indicated injury to ATFL and CFL Some aspects of the physical examination may be limited at the time of initial presentation because of pain and swelling. Therefore, a repeat physical examination is recommended approximately 4 to 7 days postinjury
- #13: Plain weight-bearing x-rays are essential in the evaluation of patients with CAl to exclude any bony lesions and malalignment. Stress radiographs comparing the affected side to the unaffected sign are the gold standard for mechanical stability. Dynamic radiographs can be performed manually, intraoperatively, or using a Telos stress device to demonstrate the anterior drawer test, the talar inversion test The value of stress radiographs is questionable because of oedema, muscle spasms and the patient’s reactions to pain that can affect the radiographic technique
- #14: Gadolinium-enhanced MRI is more effective thans imple MRI. MRI arthrography allows easier interpretation of ligament tear and is more effective than gadolinium-enhanced MRI for cartilage analysis but less effective for ligament distension or synovial impingement. The future may belong to dynamic MRI, but for the moment this remains a purely research tool
- #19: The associated risks are: Cutaneous, which is why extensive subcutaneous release is to be avoided and the inframalleolar fat pad should be conserved Neurologic: superficial sural cutaneous (or lateral dorsal cutaneous) terminal sensory branch and superficial peroneal nerve lesions
- #20: ligament is sutured end-to-end Two variations in addition to the usual observation of a simple rupture: rearrangement of the two ligament stumps, which do not allow for direct suturing. In this case, a flap of the lateral talocalcaneal ligament is suggested by transferring a portion of its talar insertion to the anterior edge of the lateral malleolus
- #23: The whole fibroperiosteal covering of the lateral malleolus (8–10 cm long) is harvested, conserving the distal fibular attachment. The flap insertion base is reinforced by non-absorbable sutures to avoid avulsion during tensioning. An anterior talar tunnel and a posterior calcaneal tunnel (requiring further skin incision) are needed for fixation. The capsule-ligament structure is sutured as cover at end of surgery. The fibular malleolar periosteum, however, is not always veryresistant, and in some cases does not even exist.This reconstruction may be associated to reconstruction byextensor retinaculum. The sutures are tied, with the foot in neutral position (90◦flexion without varus or valgus). The periosteal flap is repositionedon the lateral side of the fibular malleolus, reinforcing the recon-struction. Further sutures, lying on the extensor digitorum brevismuscle, completely close the sinus tarsi entry.
- #26: suture en « paletot » The technique described by Karlsson also aims to tighten the ATFL and CFL, not through elevation but after transection of the ATFL and CFL, followed by transosseous reinsertion The ATFL and CFL are transected 3 to 5mm from their malleolar insertion to enable suturing at the end of the procedure. The bony area between these insertions and the articular cartilage of the malleolus is prepared to promote osseous-tendon healing, and tunnels are drilled to prepare for the transosseous reinsertion of the ligaments. Three tunnels are dedicated to the ATFL, and two to the CFL. Their entry points are located on the prepared area, near the cartilage, and they exit a few millimeters upstream from the insertion of each ligament. U-shaped sutures are placed on the distal stumps of the ligaments, and the threads are passed through the bone tunnels (or now using anchors). Tightening, performed with the foot in eversion, serves to secure the ligaments against the prepared area.
- #28: Peroneus brevis is routed through the fibula from posterior to anterior, then into talus. This is a reconstruction of the ATFL but does not address the CFL. Late deterioration, including worsening function and pain, have been described with this technique.79-82 Limits anterior translation and inversion. Has same fibular angle as the Evans procedure; therefore, it severely limits inversion.
- #29: tendon transfer to reconstruct the two lateral ankle ligaments individually. Chrisman-Snook procedure—Uses split peroneus brevis tendon routed through talus, through the fibula from anterior to posterior, then to the calcaneus. This technique is the only nonanatomic technique to address the ATFL and CFL. It is more technically demanding than the Evans and Watson-Jones procedures. It is associated with the disadvantage of partially sacrificing the peroneus brevis tendon
- #30: The fibularis brevis is longitudinally divided into two equal parts, and it is the posterior portion that is detached from the muscular body. The tendon is passed through a first bony tunnel drilled in the calcaneus in such a way that the distal opening aligns perfectly with the insertion of the CFL. The tendon is then pulled through a second tunnel, a lateral transmalleolar tunnel, whose path is posterior-anterior, and the distal opening is located as close as possible to the insertions of the ATFL and CFL. Finally, a last vertical tunnel is created at the talus neck. The tendon is passed through it and sutured to itself under tension.
- #31: Simple tenodesis of the peroneal brevis to the fibula. It limits inversion but does not restrict anterior translation; therefore, it is seldom used. It does not reconstruct the ATFL or CFL because the tenodesis is in a plane between these two ligaments. Long-term follow-up studies have shown considerable functional deterioration (as much as 50%) Hintermann and Regli describe anatomical reconstruction using the plantaris tendon without weakening the peroneal muscles.