1. 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

2. 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.

3. 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

4. Ankle Fracture
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

5. 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, 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

6. 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

7. Post-traumatic Arthrosis
Spurs and loose bodies
SCAR
Limit range of motion and pain

8. Case
Anterior Pain, Stiffness with running

9. 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.

10. Arthroscopic excision of tibial spur
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

11. Tight / Scarred Posterior Capsule
Anterior Tibial Spur

12. Osteochondral Lesions (OCL)
Often subtle presentation – High index of suspicion
Need to rule out – Ankle sprain that doesn’t get better

13. 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)

14. 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

15. Acute – anterolateral talar dome
Chronic – posteromedial talar dome
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

16. CT Scan
Osteochondral
lesion of Talus

17. MRI

18. 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

19. 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.

20. 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.

21. Osteochondral Lesions Surgical Outcomes
Meta-Analysis electronic database
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

22. 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 (10):1680-7

23. 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 (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

24. 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.

25. Cystic Osteochondral Lesions
Open OATS JT

26. Medial Talus OC Lesion JT

27. Open Osteochondral Grafting
Malleolar Osteotomy
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

28. Harvest Osteochondral Graft --KneeJT

29. Massive OCD
Bulk Allograft
Older patients??

30. Osteochondral Allograft

31. Osteochondral allograft
Outcomes
Main problem graft degradation
Those that last (60-70%) do pretty well, with longevity (up to 19 years)

32. 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.

33. Stress Inversion UNSTABLE STABLE
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

34. Stress Anterior Drawer
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.
STABLE
UNSTABLE

35. 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.

36. 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.

37. 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 Jan;28(1):24-31
Arthro Surg. - The Foot and Ankle. Ferkel, FD and Whipple, TL. Lippincott-Raven, Philadelphia, 1996.

38. Tendinopathies
Posterior Tibialis
Peroneals

39. 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.

40. Posterior Tibial Tendon Stages

41. Posterior Tibialis Treatment
Stage 1, 2 and 3
Stage 1 tenosynovitis aggressive rest
Boot and arch support
Early tenosynovectomy if rest fails
Stage 2 – 3Reconstruction / osteotomy or Fusions
Sammarco, GJ, et al. Foot Ank. Inter (4)

42. 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.

43. 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.

44. Bonus!
STRESS FRACTURES
When in doubt  MRI

45. 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

46. Steadman Hawkins Clinic of the Carolinas
Thank You
Steadman Hawkins Clinic of the Carolinas