A. Amendola, MD

January 8, 2004

SM Conference 

Acute Ankle Instability

Treatment of Acute Sprains

•      Non –operative functional treatment for all sprains

Acute Ankle Instability

Kannus et al. JBJS, 1991

•      Critical review 12 studies (prospective, randomized)

•      Rx of choice:  early functional over Sx + cast or cast alone     

Chronic Ankle Instability

Epidemiology:

•      50% basketball players have residual symptoms following ankle sprains

•      15% decreased function

                         Smith et al, Am J Sports Med, 1986

Chronic Ankle Instability

Incidence Chronic Pain / Dysfunction after Sprains:

( literature review, Petrik, J., 1991 )

•      Cast                              21 - 78%

•      Functional                    17 - 78%

(early ROM/ WB)

•      Operative                     7 - 58%

Chronic Ankle Instability

The most common cause

of chronic pain following

an ankle sprain is a missed

or associated injury

Chronic Ankle Pain

Extra-articular

• Bone

• Soft tissue

• Neural

• Venous stasis

Intra-articular

• OLT / tibia

• Impingement

• OA / chondromalacia

• Synovitis

Acute Ankle Instability

Acute Ankle Arthroscopy:

van Djik (1994)

•      66% medial talar chondral lesion

Babowitz and Schweitzer

Occult osseous injuries after ankle sprains:

Incidence, Location, Pattern and Age

•      Retrospective

•      108 ankle sprains

•      MRI bone bruises in 39%

Ankle Ankle Instability

OCL Talus:

Bosien             6.7%

Lippert             7%

OLT: Diagnosis

•      Diagnosis commonly missed,       delayed

•      Chronic pain, swelling,

    giving way

•      ± associated instability

OCL Talus

–  location

–  size

–  cartilage surface

–  joint condition

OCL Talus

Classification

Type I        cartilage intact

Type II      partially detached

Type III     complete separation in crater

Type IV     completely displaced in joint

                                                          Canale et al., 1980

OCL Talus

Classification

OCL Talus

Treatment

(i)  Acute - usually excision

                  - indications for repair?

(ii) Chronic

         Type I,II    - drilling vs. excision

        Type III,IV - usually excision, curretage

                             - indications for repair?

OLT:  Treatment

Results of excision:

•      literature review : 60 - 90 % good - excellent results

OLT:  Treatment

Access to very posterior lesions:

•      medial malleollar osteotomy

•      posteromedial open approach

•      posterior arthroscopy

OLT:  Treatment

OLT:  Treatment

Access to very posterior lesions:

OLT:  Treatment

Indications for repair:

•      cartilage surface intact

•      large lesion > 35 % talar dome

OLT:  Treatment

Loomer type 5 ( cartilage surface intact with subchondral cyst):

OLT:  Treatment

OLT:  Treatment

Indications for mosaicplasty:

•      very large lesions ( > 1.5 cm)

•      failed excision

OLT:  Treatment

Chronic Ankle Instability:  Issues

Problem:  OCL talus (symptomatic)                       and instability

Approach:

®scope to deal with OCL talus

®if pain is primary deal with OCL talus only

®if instability is also significant add modified Brostrum

Chronic Ankle Instability:  Issues

Problem:  OCL talus (asymptomatic)

                        and instability

Approach:

®scope to assess the OCL talus

®modified Brostrum

OLT

Continuing pain after excision

•      Rule out other causes

•      Treat associated lesions,              ie impingement

•      Treat instability 

•      Assess joint overload at area of lesion

Chronic Ankle Pain

Etiology:

Soft tissue lesions

•     Anterolateral impingement

•     Syndesmosis injury

•     Peroneal tendinitis/subluxation

•     Sinus tarsi/ subtalar joint injury

•     Peroneal nerve injury

Chronic Ankle Pain

Etiology:

Soft tissue lesions

•     Anterolateral impingement

•     Syndesmosis injury

•     Peroneal tendinitis/subluxation

•     Sinus tarsi/ subtalar joint injury

•     Peroneal nerve injury

Chronic Ankle Instability

May Present with:

•      Pain

•      Pain and instability

•      True instability

Chronic Ankle Instability

Investigation:

routine radiographs

stress x-rays?

CT/ MRI

bone scan

Chronic Ankle Instability

Ankle Instability

•      Functional

•      Mechanical

•      Subtalar

Chronic Ankle Instability

Ankle: Functional Instability

Rehabilitation

•      Reduce swelling / pain

•      Muscle strengthening

•      Proprioceptive training (multi-axial platform)

•      Balance training (stabilometry)

•      Bracing

Ankle Rehabilitation

Prevention of  Inversion Sprains

•      Taping

•      Bracing

•      High top shoes

Have all been shown to reduce

incidence of ankle injuries

Chronic Ankle Instability

•      Functional

•      Mechanical

-     Failure of static components

-     Failure of dynamic mechanisms to compensate

•      Subtalar

Chronic Ankle Instability

Approach to Mechanical Instability:

•      Diagnosis

•      Rehabilitation program

•      Surgical stabilization

Chronic Ankle Instability

Stress Radiography:

Is it Useful?

•      Talar tilt

•      Anterior drawer

Chronic Ankle Instability

Stress X-rays for Acute Sprains (7 papers):

( Frost, Amendola, CJSM, 1999 )

•      6 of 7 authors concluded that AD or TT stress x-rays inadequate in assessing degree of instability

Chronic Ankle Instability

Stress X-rays for Chronic Instability:

•      talar tilt : large normal variation

•      stress x-rays (TT + AD) not useful in assessing degree of instability

            Lofvenberg (1989), Chandrani (1994),

            Kristiansen (1991), Harper (1992)

•      AD may be useful :  AD >= 10 mm

                                                Karlsson (1991)

Ankle Functional Instabilty

Stabilometry

•      127 soccer players

•      57% injury rate with impaired postural stability

•      higher injury rate with history of previous sprains

                   Tropp et al., 1984

Ankle Rehabilitation

Sheth et al., AmJ Sports Med. ’97

“Ankle Dish Training Influences

  Reaction Times of Selected

  Muscles in Simulated  Ankle Sprain”

•      “Trap door” inversion

•      Improved peroneus longus function

Chronic Ankle Instability

• 35 ankles / 33 patients

• 19 / 34 excellent

• 11 good

• 3 fair

• 1 poor

•  14 / 34 restricted inversion /

    eversion

•  32 34 calf atrophy

•  18% complcations

 - 2  spn

 - 1 sn

 - 2 infection

 - 1 fracture

Chronic Ankle Instability

Evans Repair:

(Rosenbaum et al, Foot & Ankle, ’97

•   19 patients. 10 year FU                        

•   15 excellent/good

•    4 fair

Chronic Ankle Instability

Evans Repair:  (Rosenbaum et al, Foot & Ankle, 1997)

19 patients:

•     53% (10)   - persistent falling and giving way

•     47% (9)     - pain with prolonged WB

•     12              - inversion deficit 20-60%

•     3                - eversion 20%

Chronic Ankle Instability

Evans Repair:  (Rosenbaum et al, Foot & Ankle, 1997)

Functional assessment

•     ¯ peroneal reaction time

•     ­ lateral foot loading

Chronic Ankle Instability

Surgical Options:

•      Anatomic     - Brostrum (and modifications)

•      Non-anatomic      - Evans

                - Watson-Jones

                - Chrisman-Snook

                - others

Chronic Ankle Instability

Authors Approach:

Anatomic        - Brostrum repair

            - direct repair to bone

            - Gould (extensor retinaculum)

Chronic Ankle Instability

Summary:

•      “Giving way” ¹mechanical instability

•      A.nkle dysfunction following sprains is common, often due to a missed or associated injury

•      Aggressive rehab program essential prior to surgical intervention

Post-operative Rehabilitation

•      0 –4 weeks immobilization

•      4 – 8 weeks

–     ROM

–     strength

–     WBAT  

•      8 – 12 weeks

–      brace

–      functional exercises                 

Chronic Ankle Instability: Issues

Problem: Peroneal tendon symptoms and              instability

Approach:

•      Modify approach to expose peroneals

•      Repair peroneal tendon/retinaculum modified Brostrum type repair

Chronic Ankle Instability: Issues

Peroneal tendon symptoms and instability

Karlsson et al., Med Sc in Sports ’98

• 10 ankles

•  Repair tednon

• Repair superior peroneal tendon

    retinaculum  /  Brostrum type repair

• 9 / 10 good to excellent

Chronic Ankle Instability

Authors Approach:

•      If failed Brostrum

    (ie. revision):   half of peroneus brevis in “anatomic” repair

    (ie. modified as by Colville)

THE END

Introduction

Etiology of Residual Dysfunction Following an Ankle Sprain:

proprioceptive deficit

peroneal weakness

mechanical laxity

                                                          Freeman, JBJS, 1965

Chronic Ankle Instability

Etiology:

Soft tissue lesions

•     anterolateral impingement

•     syndesmosis injury

•     peroneal tendinitis/subluxation

•     sinus tarsi/ subtalar joint injury

•     peroneal nerve injury

Chronic Ankle Instability

Etiology:

soft tissue lesions

•     anterolateral impingement

•     syndesmosis injury

•     peroneal tendinitis/subluxation

•     sinus tarsi/ subtalar joint injury

•     peroneal nerve injury

Chronic Ankle Instability

Etiology:

soft tissue lesions

•     anterolateral impingement

•     syndesmosis injury

•     peroneal tendinitis/subluxation

•     sinus tarsi/ subtalar joint injury

•     peroneal nerve injury

Chronic Ankle Instability

True Mechanical Instability:

pain and swelling results from the sprain, and is not present between giving way episodes

Chronic Ankle Instability

Mechanical Instability:  Evaluation:

clinical exam

x-ray stress views

special investigations

Chronic Ankle Instability

Radiographic Exam:

stress x-rays:  useful?

anterior drawer > 10 mm vs. normal side

Subtalar Instability

Stability:

inferior extensor retinaculum

CF ligament

fibulotalocalcaneal

cervical

interosseous ligament

anterior capsular TC joint

Chronic Ankle Instability

functional

mechanical

subtalar

Chronic Ankle Instability

Predisposing Factors:

history of previous inversion sprains

pes cavovarus (CMT)

idiopathic forefoot valgus (dropped 1st ray)

Chronic Ankle Instability

Eversion/External Rotation Injury:

deltoid

syndesmotic ligaments

Chronic Ankle Instability

Mechanical Instabilty:  Surgical Indications:

symptomatic true instability

failure of non-operative treatment

Chronic Ankle Instability

Goal of Surgery:

to prevent recurrent giving way episodes

little evidence that instability predisposes to arthrosis

Chronic Ankle Instability

20 Year Follow-up Study, Non-operative

Treatment:

37 patients                    22/ 37 still unstable

FU 20.3 years                6 (13%) OA changes

          (18-23)    

sex/age matched

          control group

                                                                                                Lofvenberg et al, 1994

Chronic Ankle Instability:  Issues

Problem:  Recurrent instability post

                   repair or reconstruction

Approach:

1.     Failed tenodesis ie. Evans

                - release tenodesis

                - Brostrum repair (modified)

Chronic Ankle Instability:  Issues

2.     Failed Brostrum

                - anatomic repair ie. Colville,

                  Chrisman-Snook

3.     Tenodesis is “too tight”:   subtalar                                                       motion/pain

        - release tenodesis (extra capsular)

Chronic Ankle Instability:  Issues

Problem:          Peroneal tendon symptoms

                        and instability

Approach:

®modify incision to expose peroneals

®repair peroneal tendon/retinaculum

®modified Brostrum type repair

Chronic Ankle Instability:  Issues

Problem:  OCL talus (symptomatic)                       and instability

Approach:

®scope to deal with OCL talus

®if pain is primary deal with OCL talus only

®if instability is also significant add modified Brostrum

Chronic Ankle Instability:  Issues

Problem:  OCL talus (asymptomatic)

                        and instability

Approach:

®scope to assess the OCL talus

®modified Brostrum

Chronic Ankle Instability:  Issues

Problem:  Chronic pain from treated OCL talus

Approach:

®assess lesion - repeat MRI

®assess alignment varus/valgus for mechanical overload

®if malalignment present       osteotomy

®if limb well aligned - consider osteochondral grafting

Chronic Ankle Instability

Long Term Results:

Watson Jones Tenodesis:  10-18 yr FU

35 ankles/33 patients

19/34       excellent

11            good

3      fair

1      poor                 Sugimoto, Takakura                                                        et al,JBJS 1998

Chronic Ankle Instability

14/34               restricted inversion/                                eversion

32/34               calf atrophy

18%         complications

        - 2 spn             - 2 infection

        - 1 sn               - 1 fracture

Chronic Ankle Instability

Peroneal tendon tears and ankle

instability                  Karlsson, J. et al

                                                            SJMedSc in Sports, Feb 1998

10 ankles

•     repair of tendon

•     repair of superior per retinaculum

•     Brostrum type repair

Good or Excellent 9/10

Chronic Ankle Instability

Revision of failed lateral ankle

reconstruction: Sammarco et al, Foot & Ankle, 1995

10 pts            

Primary sx :     Brostrum-Gould - 5                                         Watson Jones - 2

                Evans - 1

                modified Elmslie - 2

Chronic Ankle Instability

Revision

•       split PB modified(Elmslie)      4

•       accessory tendons (Elmslie)   3

•       Brostrum-Gould                      3

9/10 - good/excellent results

10            - all stable ankles

                        Sammarco et al, Foot & Ankle, 1995

Chronic Ankle Instability

223 pts.      1981-85

102 anatomic reconstruction, 87 Evans, 34 Chrisman-Snook

outcome, stability similar in all groups

anatomic reconstruction - no loss of motion

•     Evans                     7.5° loss inversion

•     Chrisman-Snook   7.2° loss of inversion

Chronic Ankle Instability

Anatomic vs. Gould Modification:

                                Karlsson et al, AJSM, 1997

Prospective, randomized, 60 pts:

functional score, stress x-rays

no difference in stability or functional scores

Chronic Ankle Instability:  Issues

Prospective Randomized Comparison

Chrisman-Snook & Modified Gould (40 pts):

excellent/good in 80% in both groups

complications

          CS                                                     Mod B

5 wound problems                 2 superficial PN

8 sural N loss                                   2 felt ankle “too

6 felt ankle “too tight”             tight”

 (1 revised)                              Hennrikus et al, AJSM, 1996