Steadman Hawkins Clinic of the Carolinas The Athletes’ Ankle Thomas Alexander, MD Special Thanks to Douglas J. Wyland, MD for assistance with talk and slides Steadman Hawkins Clinic of the Carolinas
Problems Fractures Chondral lesions Chronic Instability & Pain Tendinopathies Posterior Tibialis, and Peroneal Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Routine Ankle Fracture? Post injury / fixation problems Loss of motion ARTHROFIBROSIS Catching /swelling and pain LOOSE BODIES, CHONDRAL DEFECT Anterolateral pain IMPINGEMENT, SYNOVITIS Post-traumatic DJD
Ankle Fracture Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Routine Ankle Fracture? Traumatic Articular Surface Injuries (TASL’s) VERY COMMON 61% TASL’s > 5mm (scope) 75% if Syndesmosis disrupted 46 acute ankle fractures. Loren and Ferkel. Arthroscopy, 2002 79% in 288 scoped ankle Fx Hintermann, et al. JBJS-B, 2000 73% in 84 scoped ankle Fx Leontaritis, et al. JBJS-A, 2009 Greater risk with higher energy Fx (SER IV and PER) 70% in 40 ankle Fx (scope and MRI) Chu, et al. AOFAS 2002 20% Ono, A et al: Arthroscopy, 2004
Routine Ankle Fracture? Indications for arthroscopy Closed, easily reducible fractures No significant neurovascular injury Minimal to mild swelling Contraindications Open fractures and/or gross instability Significant swelling Neurovascular injury
Post-traumatic Arthrosis Spurs and loose bodies SCAR Limit range of motion and pain
Case Anterior Pain, Stiffness with running
Loss of Motion -Especially dorsiflexion, limits walking -10 deg. DF required for smooth gait Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Arthroscopic excision of tibial spur Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Tight / Scarred Posterior Capsule Anterior Tibial Spur
Osteochondral Lesions (OCL) Often subtle presentation – High index of suspicion Need to rule out – Ankle sprain that doesn’t get better
Osteochondral Lesions (OCL) Often subtle presentation – High index of suspicion Need to rule out- Ankle sprain that doesn’t get better Identify early – treat aggressively Non Weight-bear and watch closely (I-IIa) or surgical treatment (IIb-V)
Osteochondral Lesions (OCL) Often subtle presentation – High index of suspicion Need to rule out- Ankle sprain that doesn’t get better Identify early – treat aggressively Non Weight-bear and watch closely (stable) or surgical treatment (unstable) Must treat other underlying problems – Eg. Instability and/or varus malalignment
Acute – anterolateral talar dome Chronic – posteromedial talar dome Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
CT Scan Osteochondral lesion of Talus
MRI
OCL Surgical Treatment Shallow lesion, Healthy Bone Microfracture /Drilling Juvenile Cartilage graft Deeper /cystic lesion OATS autograft (ipsi knee) Large Cystic Lesion Debride, Osteochondral Allograft Transplant, Fusion, TAA
Curretage and Microfracture Stem cells Fibro-cartilage Fills and seals Protect the bone Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Retrograde decompression/drilling and bone grafting Can perform if chondral surface intact Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Osteochondral Lesions Surgical Outcomes Meta-Analysis electronic database 1996-98 Excision alone: 38% Good or Excellent (G/E) Excision and curretage: 78% G/E Excision and drilling: 85% G/E Nonoperative: 45% G/E Tol, JL, et al. Foot Ankle Int. 21. 2000
Osteochondral Lesions Surgical Outcomes Microfracture 26 pts—High demand sports 96% G/E results Pre-op AOFAS=54.6 Post-op AOFAS 94.4 Saxena A and Eakin C:Am J Sp Med. 2007. 35(10):1680-7
MicroFracture: Age and outcomes? Ankle - 29 pts 83% G/E results at 2 years, Age > 50 NOT a factor in outcome Becher, C, et al:Foot Ankle Int. 2005. 26(8):583-9 - 105 consecutive pts OCL <15 mm—No failures— Smaller the better OCL > 15mm—only 1 success Negative correlation to outcome between increasing lesion size, age, BMI, history of trauma and presence of osteophytes Chuckpaiwong B, et al. Arthroscopy. 2008; 24(1):106-12
Juvenile Cartilage Graft Particulated Juvenile Cartilage Minced donor tissue < 12 yo donors 24 ankles Talus lesions – avg f/up 16 months 78% Good /Excellent Outcomes – all lesions 92% G / E results if lesion less than 15mm Promising option – more to come Coetzee JC, et al. FAI. Sep 2013.
Cystic Osteochondral Lesions Open OATS JT
Medial Talus OC Lesion JT
Open Osteochondral Grafting Malleolar Osteotomy Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Harvest Osteochondral Graft --Knee JT
Massive OCD Bulk Allograft Older patients??
Osteochondral Allograft
Osteochondral allograft Outcomes Main problem graft degradation Those that last (60-70%) do pretty well, with longevity (up to 19 years)
Chronic Instability / Pain Co-existing problems -Anterolateral impingement -OCL -Loose debris -Peroneal tear / dysfunction Must treat Chronic lateral instability Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Stress Inversion UNSTABLE STABLE Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Stress Anterior Drawer Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996. STABLE UNSTABLE
Chronic Instability / Pain Anterolateral Impingement Tenderness over anterolateral corner of ankle “lateral gutter” Pain caused by scar tissue, synovitis MRI useful in diagnosis Treatment with arthroscopic debridement usually successful- 84% G/ E at 3 years Ferkel, et al. AJSM, 19(5).1991 Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Modified Brostrom: Anatomic Repair of ATFL and CFL plus Gould Extensor Retinaculum augmentation + Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Chronic Instability / Pain OUTCOMES: Combining Stabilization (mod. Brostrom) and Scope Debridement 95% patients had intra-articular pathology 100% Good to Excellent outcomes (?) Ferkel RD, et al: Foot and Ankle Int. 2007 Jan;28(1):24-31 Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Tendinopathies Posterior Tibialis Peroneals
Posterior Tibial Tendon disorders Hindfoot inversion weakness and pain “Too many toes” sign Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Posterior Tibial Tendon Stages
Posterior Tibialis Treatment Stage 1, 2 and 3 Stage 1 tenosynovitis aggressive rest Boot and arch support Early tenosynovectomy if rest fails Stage 2 – 3Reconstruction / osteotomy or Fusions Sammarco, GJ, et al. Foot Ank. Inter. 2001 22(4) 305-12.
Peroneal Tendon Peroneal tears, tenosynovitis, subluxation or dislocation Weakness, pain, tender, ± chronic lateral instability Treat Rest Boot, lat heel post orthotic Surgical: 50% rule >50% torn Tenodesis to other peroneal <50% torn Excise damaged area and Tubularize Repair Heckman, DS, et al. JBJS A. Feb 2008.
Peroneal tendon tears and dislocation Surgical options -Fibular groove deepening and superior peroneal retinaculum (ligament) repair -Peroneal Tenodesis or Repair Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
Bonus! STRESS FRACTURES When in doubt MRI
Summary More to fractures than meet the eye Chondral Lesions not shown on injury X-Ray Arthroscopy for many pathologies Impingement/synovitis to OsteoChondral Lesions Tendinopathies are common Most do not need surgery—but aggressive rest then rehab Stress Fractures Don’t overlook
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