High Ankle Research Articles

Leg Pain in a 23 Year Old Football Player

HISTORY: A 23 year old male reported getting kicked in the leg during a collegiate football game. He noted immediate pain in his lateral calf after attempting a tackle. He did not feel or hear a pop. He had a noticeable limp walking off the field. There was no pain in the ankle or foot, but he noted pain with ankle movement. He had pain with weight-bearing but denied any numbness or tingling. The next day, he developed worsening pain that was unbearable with any change of position or movement. The pain was greatest along the mid-lateral leg but extended along the entire leg anterior and laterally. He had limited ability to move his toes and foot which was a new symptom. PHYSICAL EXAMINATION General: Alert and oriented in mild distress at rest. Left leg Edema: Anterior and lateral leg without pitting. Compartments: Diffusely tender but not tense. Tenderness: Diffuse, anterior and lateral compartments more than fibula and posterolateral. Range of motion: DF 0 degrees, PF 30 degrees. Pain was worse with initiation. He tolerated gradual passive stretch of the anterior, more than the lateral. Pain with inversion and eversion . Strength: 1/5 anterior tibialis, EHL, EDL, Peroneals with pain, 2/5 GS/PT with pain. Neurovascular: Intact, 2+ PT/DP pulses, cap refill < 2 sec. DIFFERENTIAL DIAGNOSIS 1. Gastrocnemius Strain 2. Compartment Syndrome 3. Popliteus Strain 4. Fibular Fracture 5. High Ankle Sprain TESTS AND RESULTS XRays 1. Fluoroscopic imaging of the tib-fib and ankle were negative. 2. Tib-fib and Ankle xrays were negative for fracture and stress view demonstrated stable joint. Compartment Testing Diastolic pressure: 74 Left lower leg anterior compartment: 20 Left lower leg lateral compartment: 28 Left lower leg posterior superficial compartment: 27 Left lower leg posterior deep compartment: 26 MRI 1. Nondisplaced fracture of the middle third of the fibula. 2. Acute grade 1 muscular injury of the peroneal muscles of the lateral compartment. FINAL WORKING DIAGNOSIS Midshaft fibular stress fracture TREATMENT AND OUTCOMES 1. Patient was admitted to the hospital for observation for one night. 2. Patient was discharged and allowed to weight bear as tolerated in the tall CAM boot for two weeks. 3. At two weeks, he was weaned out of the boot and allowed to progress into activities. 4. At six weeks, he was participating in football without any limitations.

Influence of shoe drop on running kinematics and kinetics in female runners

This study investigated the effects of shoe drop on lower limb kinematics and kinetics in female runners.Fifteen healthy female runners ran on a 15-m runway at their preferred speed with three different shoe-drop conditions: 0 (D0), 6 (D6) and 10 (D10) mm. Three-dimensional marker positions and ground reaction forces were recorded to analyse kinetic and kinematic parameters using zero- (0D) and one-dimensional (1D) metrics (statistical parametric mapping, SPM). Regarding 0D parameters, significantly higher loading rates and transient peaks were found in D0 compared to D6 and D10 conditions (both p < .01). For 1D analysis, significantly higher ankle dorsiflexion moments were found in D0 compared to D6 and D10 during the braking phase (p < .01). Lower knee extension moments between 52% and 55% and 61% and 65% of contact time (p < .05) were also found. No difference was found between D6 and D10 conditions (p > .05). As previously shown in men, this study demonstrates that shoe drop influences running kinematic and kinetic patterns. Using SPM analysis in conjunction with classical analysis, the study adds new understanding on the influence of shoes on joint moment during contact time.

A Comparison of Cyst Formation and Management in Mobile-Bearing and Fixed-Bearing Total Ankle Arthroplasty

Category:Ankle ArthritisIntroduction/Purpose:The Scandinavian Total Ankle Replacement(STAR) system and Salto Talaris(ST) total ankle system are two of the more commonly studied total ankle implants. As the STAR is one of the oldest total ankle arthroplasty (TAA) implants still in use today, most studies focus on longevity and survivorship. Reported rates of cyst formation for these two prosthesis in most series vary from 11-22% but no large study has focused on surgical management of these cysts or included patient reported outcomes after surgery. In this series, we aimed to investigate rates of cyst formation between mobile(MB) and fixed-bearing(FB) TAA and examine clinical and patient reported outcomes of bone grafting or cementing of large cysts surrounding the STAR and ST implants.Methods:A prospectively collected database at a high volume total ankle replacement center was retrospectively reviewed to identify patients who underwent TAA with either the STAR or the ST total ankle system between 2007 and 2015. Cysts were identified and measured on standard weight bearing radiographs and confirmed on computed tomography(CT) when available. Visual analog scale (VAS) score, Short Form-36 (SF-36) physical and mental component scores, Short Musculoskeletal Function Assessment(SMFA), and AOFAS hindfoot scores were collected from all patients preoperatively and then at 6 months, 1 year and annually postoperatively. Patients with a minimum 2 years follow-up who underwent revision TAA secondary to catastrophic bone cysts or who were managed with either curettage and bone grafting or curettage and cementing of bone cysts surrounding the TAA prosthesis were included in the patient reported outcomes (PRO) analysisResults:Excluding 53 patients for inadequate follow-up, 232 patients (29% female, 71% male; follow-up 6.7 years) who underwent STAR-TAA and 147 patients (26.6% female, 73.5% male; follow-up 7 years) who underwent ST-TAA were identified. Cysts <20 mm diameter occurred more often in the MB TAAs, and more often in the tibia than talus (table). Cysts >10 mm were identified in 95/232 (41%) STAR and 24/147 (16%) ST ankles. In the STAR group, 24 patients underwent cyst bone grafting (13), cementing (6) or both (8) at a mean 4.8 years. In the ST group, 14 patients underwent cyst bone grafting (6), cementing (4), or both (4) at a mean of 2.7 years. PRO data improved significantly for both the STAR and ST group in all questionnaires (p<0.05 for all).Conclusion:Mobile-bearing total ankle arthroplasty in this cohort had a higher rate of cyst formation greater than 10 mm (95/232 patients, 41%) when compared to a fixed-bearing TAA (24/147, 16.3%). Only 24/95 (25%) of STAR patients and 14/24 (58%) of ST patients required surgical intervention for cyst management. Patient reported outcomes after cyst surgery improved significantly when compared to pre-cyst management surgery and did not differ between MB and FB cohorts (p=0.424). Successful surgical management of large cyst surrounding either mobile-bearing or fixed-bearing total ankle systems can be expected based on the results of this study.Mobile-Bearing TAAFixed-Bearing TAA Total patients (n) 232147 Total Patients with Cysts >10mm95(41%)24 (16%) Patients Requiring Cyst Surgery24/95 (25%)14/24 (58%) Age (years) 61.863.3 Sex Male165(71%)107(73%) Female67(29%)40(27%) Time Until Cysts Visible (years) 1.821.63 Cysts <20mm Diameter Tibia89 patients10 patients Talus51 patients4 patients Both Tibia and Talus29 patients1 patients Cysts >20mm Diameter Tibia28 patients4 patients Talus4 patients2 patients Both0 Patients2 patients Reoperation for Cyst n=24n=14 Management mean 4.8 years post-opmean 2.7 years post-op Bone Grafting136 Cementing64 Both84 SF-36 Before Cyst Surgery Physical Function23.819.9 Mental Health75.177.9 SF-36 After Cyst Surgery Physical Function68.367.6 Mental Health89.488.8 VAS Before Cyst Surgery 62.759.4 VAS After Cyst Surgery 4.13.7

High Ankle Block Versus Regional Block for Acute Pain Control After Ankle Surgery

High Ankle Block Versus Regional Block for Acute Pain Control After Ankle Surgery

Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis

The aim of this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury. Systematic review and narrative synthesis. The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018. Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury. No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search. There are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

Selective effect of static stretching, concentric contractions, and a balance task on ankle force sense.

Proper ankle motor control is critical for balance in the human body during functional activities such as standing, walking, and running. Different exercise modalities are often performed during the same training session where earlier activities may influence later ones. The purpose of the current study was to determine the acute effects of different exercise modalities on ankle force sense. Seventeen subjects performed four different intervention protocols (static stretching, balance task, concentric contractions, and control) in random order. Each session comprised measurements before and after the intervention protocol of the force sense of the ankle plantar flexors (PF) and dorsal flexors (DF) at 10% and 30% of maximal voluntary isometric contraction (MVC). Absolute errors (AE) were calculated separately for each force level and muscle group. An overall PF error (PF-SUM = PF at 10%MVC + PF at 30%MVC), DF error (DF-SUM = DF at 10%MVC + DF at 30%MVC) and ankle error (PF-DF-SUM = PF-SUM + DF-SUM) were also calculated. The main effect of time generally revealed that ankle force sense was significantly reduced after static stretching (PF-DF-SUM: Pre: 6.11±2.17 Nm, Post: 8.03±3.28 Nm; p < 0.05), but no significant differences were observed for the concentric contractions (PF-DF-SUM: Pre: 6.01±1.97 Nm, Post: 6.50±2.28 Nm) and the balance task (PF-DF-SUM: Pre: 5.25±1.97 Nm, Post: 5.50±1.26 Nm). The only significant interaction was observed for the PF-DF-SUM (F = 4.48, p = 0.008) due to greater error scores after stretching (+31.4%) compared to the concentric (+8.2%), balance (+4.8%), and control (-3.5%) conditions. Based on these results, static stretching should not be performed before activities that require a high ankle force sense such as balance, coordination, and precision tasks.

Ultrasound of the midfoot ligaments, syndesmosis and bands of the deltoid

This presentation will predominantly bring together methods for scanning all regions of the ankle and midfoot to result in a thorough front-line approach to ligament injury in the acute setting. While alternative diagnostic techniques exist, each offering varying degrees of accuracy, expense and time, it is posited that ultrasound is an accurate, cost-effective, and efficient modality for front-line assessment in acute and subacute ankle sprains. Ultrasound examination is often confined to the lateral ligament complex due to operator inexperience or the ingrained perception that its use in other regions of the ankle is limited. However, if the scope of an ultrasound examination is not extended to include the midfoot, syndesmosis and medial ankle, more time-critical injuries may be missed leading to poor patient management and recovery. The following demonstrations will be given in support of this posit: 1. Correct probe positioning to find important midfoot ligaments 2.Correct dynamic stress-ultrasound for detection of tibiofibular diastasis in the setting of AITFL ligament disruption (high ankle sprain) 3. Correct patient positioning to optimally visualise the components of the medial ankle deltoid ligament. It will be seen that such ultrasound techniques can be used to obtain comparative views; allow for accurate appraisals of the tibiofibular syndesmosis, midfoot and deltoid ligaments (along with routine lateral ligament complex assessment). Dynamic positioning of the ankle or stress-ultrasound during assessment can assist with triage and ensure that best patient management is provided.

Hypertension and high ankle brachial index: the overlooked combination.

Assessment of asymptomatic organ damage in the management of hypertension includes low (<0.9) ankle brachial index (ABI) values. No recommendations are given for patients with high ABI (≥1.3), despite evidence of an association with increased risk. We aimed to study the association of high ABI with all-cause mortality and cardiovascular outcomes in a hypertensive population. In anonymized clinical records from the Catalan Primary Care (SIDIAP) database, we designed a large cohort of hypertensive patients aged 35-85 years at the start date. Participants were excluded if they had previous heart failure, coronary heart disease, stroke, diabetes mellitus, or chronic kidney disease. The study population was categorized according to ABI values. Cox proportional hazards models were used to assess all-cause mortality, heart failure, acute myocardial infarction, and stroke. From 2006 through 2015, SIDIAP records included 44 657 hypertensive patients with an ABI measurement 9126 of whom met inclusion criteria. The median follow-up (first to third quartiles) was 6.0 years (4.7-7.6). High ABI (≥ 1.3) was associated with an increase in mortality risk, hazard ratio, and 95% confidence interval: 1.44 (1.10-1.88), similar to the group with ABI at least 0.9 and less than 1.1, hazard ratio 1.36 (1.12-1.65), and lower than all groups with ABI less than 0.9. High ABI values tended to associate with heart failure, hazard ratio 1.34 (0.95-1.91), but the relation of high ABI with acute myocardial infarction and stroke was nonsignificant, hazard ratios 1.30 (0.72-2.35) and 0.97 (0.65-1.42), respectively. Patients with high ABI values and hypertension presented an increased all-cause mortality risk that could be considered when advising such patients.

On the measurement of ski boot viscoelasticity

ObjectivesSince the polymeric materials commonly used for ski boots feature viscoelastic properties, the results of ski boot flexion tests are expected to be influenced by flexion velocity. Devices testing at all skiing specific ankle angular velocities are currently not available. Therefore, the aims of this study were to (i) develop a system allowing the testing of ski boots at high ankle angular velocities, (ii) quantify the effect of ankle angular velocity on viscoelasticity and (iii) determine the repeatability of the system. Design and MethodA test bench and a lower limb prosthesis were developed to determine tibia angle and applied torque. To assess the effect of angular velocity, two pairs of ski boots were tested at 5°/s, 50°/s, 75°/s and 100°/s. To assess stiffness variation and measurement repeatability, ten different used ski boots of different manufacturers were tested twice. ResultsFour ski boot flexion stiffness parameters and two energy dissipation factors were reported. The repeatability of the stiffness and the energy dissipation parameters was better than 4% and 3%, respectively. Stiffnesses and dissipation factors increased with increasing angular velocity. ConclusionIn the present study a reliable system facilitating the testing of ski boots at velocities of up to 100°/s was developed. To comprehensively characterise the viscoelastic properties of ski boots, we propose to report four ski boot stiffness parameters and two energy dissipation factors. An ankle angular velocity above 50°/s was recommended to perform mechanical tests of ski boots if employed in slalom-like skiing.

10-Year Epidemiology of Ankle Injuries in Men's and Women's Collegiate Basketball.

Background:Ankle injury is the most common injury in men’s and women’s basketball, regardless of the level of competition.Purpose:To use the National Collegiate Athletic Association (NCAA) Injury Surveillance Program/System (ISP/ISS) to review the 10-year epidemiology of ankle injuries in men’s and women’s collegiate basketball players.Study Design:Descriptive epidemiology study.Methods:The NCAA ISP was queried for men’s and women’s collegiate basketball ankle injury data from the 2004 through 2014 academic years. Ankle injury rates were calculated based on injuries per athlete-exposure (AE). Injury proportion ratios (IPRs) were determined by comparing variables between sexes. Activity and position of injury were also studied.Results:Over the 10-year study period, most ankle injuries in collegiate basketball occurred in the preseason (female, 1.45/1000 AEs; male, 2.00/1000 AEs), were contact related (female, 50.4%; male, 57.6%), were treated conservatively (female, 98.5%; male, 99.3%), and were new injuries (female, 78.0%; male, 78.9%), resulting in a time loss of less than 7 days (female, 62.7%; male, 65.2%). The most common injury types were lateral ligament complex tears (female, 83.5%; male, 80.0%), deltoid ligament tears (female, 5.6%; male, 7.2%), and high ankle sprains (female, 7.1%; male, 7.0%). Guards experienced the highest rate of ankle injuries in competition (female, 50.1%; male, 43.3%), and rebounding was found to be the most common activity during an injury (female, 30.3%; male, 34.4%). The rate of ankle injuries was significantly lower in women than in men (IPR, 0.81 [95% CI, 0.75-0.88]).Conclusion:This study found that most ankle injuries in collegiate basketball occurred during the preseason, were contact related, were treated conservatively, and were new injuries that resulted in a time loss of less than 7 days.

Quantifying joint stiffness in clubfoot patients

BackgroundIn clinical practice, clubfeet feel stiffer compared to healthy feet. Furthermore, the clinical impression is that stiffer clubfeet have a higher tendency to relapse. Until now, no objective measure has been available to determine the stiffness of clubfeet. The goal of the current project was to objectively quantify ankle and subtalar joint stiffness in clubfeet patients and to compare this stiffness between clubfeet patients and healthy controls using a newly developed measurement device. MethodsThe newly developed Torque-Displacement-Handpiece in combination with an adjusted Abduction Dorsiflexion Mechanism clubfoot-brace, made it possible to move a foot over two rotational axis, while continuously capturing the applied torque and the achieved angulation. Based on this information, stiffness of the ankle and subtalar joint were assessed for 11 clubfoot patients with 17 clubfeet and 11 healthy subjects with 22 healthy feet. FindingsWith the Torque-Displacement-Handpiece measuring device it was possible to measure torque, angulation and stiffness in a reliable and precise manner. Clubfoot patients showed less angulation and a higher stiffness for measurements over the ADM subtalar axis compared to controls. After adjusting for shoe size, the stiffness for measurements over the ADM tibiotalar axis was also significantly higher in clubfeet than controls. InterpretationOverall, these results indicate that clubfoot patients have a higher ankle and subtalar joint stiffness in the affected joint compared to healthy controls. In the future, the Torque-Displacement-Handpiece could be used to monitor stiffness of clubfeet during treatment, and as such, play a potential role in the early detection of relapsing clubfeet.

Current Clinical Recommendations for Use of Platelet-Rich Plasma.

This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications. Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.

Foot and Ankle Injuries in Soccer.

The ankle is one of the most commonly injured joints in soccer and represents a significant cost to the healthcare system. The ligaments that stabilize the ankle joint determine its biomechanics-alterations of which result from various soccer-related injuries. Acute sprains are among the most common injury in soccer players and are generally treated conservatively, with emphasis placed on secondary prevention to reduce the risk for future sprains and progression to chronic ankle instability. Repetitive ankle injuries in soccer players may cause chronic ankle instability, which includes both mechanical ligamentous laxity and functional changes. Chronic ankle pathology often requires surgery to repair ligamentous damage and remove soft-tissue or osseous impingement. Proper initial treatment, rehabilitation, and secondary prevention of ankle injuries can limit the amount of time lost from play and avoid negative long-term sequelae (eg, osteochondral lesions, arthritis). On the other hand, high ankle sprains portend a poorer prognosis and a longer recovery. These injuries will typically require surgical stabilization. Impingement-like syndromes of the ankle can undergo an initial trial of conservative treatment; when this fails, however, soccer players respond favorably to arthroscopic debridement of the lesions causing impingement. Finally, other pathologies (eg, stress fractures) are highly encouraged to be treated with surgical stabilization in elite soccer players.

Templating of Syndesmotic Ankle Lesions by Use of 3D Analysis in Weightbearing and Nonweightbearing CT.

Diagnosis and operative treatment of syndesmotic ankle injuries remain challenging due to the limitations of 2-dimensional imaging. The aim of this study was therefore to develop a reproducible method to quantify the displacement of a syndesmotic lesion based on 3-dimensional computed imaging techniques. Eighteen patients with a unilateral syndesmotic lesion were included. Bilateral imaging was performed with weightbearing cone-beam computed tomography (CT) in case of a high ankle sprain (n = 12) and by nonweightbearing CT in case of a fracture-associated syndesmotic lesion (n = 6). The healthy ankle was used as a template after being mirrored and superimposed on the contralateral ankle. The following anatomical landmarks of the distal fibula were computed: the most lateral aspect of the lateral malleolus and the anterior and posterior tubercle. The change in position of these landmarks relative to the stationary, healthy fibula was used to quantify the syndesmotic lesion. A control group of 7 studies was used. The main clinical relevant findings demonstrated a statistically significant difference between the mean mediolateral diastasis of both the sprained (mean [SD], 1.6 [1.0] mm) and the fracture group (mean [SD], 1.7 [0.6] mm) compared to the control group ( P < .001). The mean external rotation was statistically different when comparing the sprained (mean [SD], 4.7 [2.7] degrees) and the fracture group (mean [SD], 7.0 [7.1] degrees) to the control group ( P < .05). This study evaluated an effective method for quantifying a unilateral syndesmotic lesion of the ankle. Applications in clinical practice could improve diagnostic accuracy and potentially aid in preoperative planning by determining which correction needs to be achieved to have the fibula correctly reduced in the syndesmosis. Level III, retrospective comparative study.

Evaluation and Management of Lateral Ankle Pain Following Injury.

* Ankle sprains are the most common disorder in patients with lateral ankle pain; however, other pathologies can present similarly and can require different treatments.* In the acute setting, it is important to evaluate for subtle fractures that may mimic an ankle sprain, including fractures of the lateral process of the talus, anterior process of the calcaneus, or base of the fifth metatarsal. In addition, ankle sprains may also involve further injury to the syndesmosis (high ankle sprains), articular cartilage (osteochondral lesions), or peroneal tendons.* Proper diagnosis through physical examination and appropriate imaging can help to ensure proper treatment.* It is important to consider that multiple causes of lateral ankle pain can coexist, particularly in cases of chronic lateral ankle pain.

Templating of Syndesmotic Ankle Lesions by Use of 3D Analysis in Weightbearing and Classical CT

Category: Ankle Introduction/Purpose: Syndesmotic lesions of the ankle have shown to be challenging injuries towards diagnosis and surgical treatment. This could be mainly attributed to the limitations of 2D imaging, which make it difficult to accurately determine the extent of the lesion and to verify if peroperatively an anatomical reduction is achieved of the distal tibiofibular congruence. The aim of this study is therefore to develop a reproducible method to quantify the displacement in a syndesmotic ankle lesion in all six degrees of freedom based on 3D imaging. Methods: Eighteen patients were retrospectively included having a unilateral syndesmotic lesion. N=12 sustained a high ankle sprain and a bilateral weightbearing conebeam CT was obtained because of positive clinical syndesmotic tests. N=6 presented with a fracture associated syndesmotic lesion and were imaged by a bilateral non-weightbearing CT. The non-affected ankle was used as a template after being mirrored and matched on the contralateral ankle containing a syndesmotic lesion (Fig 1A-B). The distal fibula was marked by computer calculation of the most outer point of the anterior tubercle, posterior tubercle and apex malleolis lateralis. The change of these points towards the unaffected fibular position was used to quantify the syndesmotic lesion (Fig 1C). A control group of seven patients (N=7) was used to analyse if these changes differed from the normal variation in tibio-fibular congruency (Fig 1D). Results: The main findings consisted of a statistical significant difference in the mean mediolateral diastasis of both the sprained group (M = 1.60 mm, SD=1.02) and the fracture group (M = 1.69 mm, SD=0.62) compared to the control group (P&lt;.001). The mean external rotation was statistically different when comparing the sprained group (M = 4.68°, SD=2.74) and the fracture group (M = 6.97°, SD=3.02) towards the control group (P&lt;.05). The mean antero-posterior translation was only significantly different when comparing the fracture group (M = -4.73 mm, SD=4.53) towards the sprained group (M = -0.91 mm, SD=1.26) and the control group (M = -0.26 mm, SD=1.53) (P&lt;.05). Conclusion: This study demonstrates an effective method to quantify a unilateral syndesmotic lesion of the ankle. The pathological measurements differed from the normal distal tibio-fibular configuration in the syndesmotic complex. This sequential analysis is of use for an accurate diagnosis and a pre-operative planning to know in advance which correction needs to be achieved to have the fibula at proper length correctly rotated, and reduced into the syndesmosis with no anterior, posterior or lateral displacement.

Midterm Clinical and Radiological Outcome After Autologous Matrix-induced Chondrogenesis (AMIC) for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Autologous matrix-induced chondrogenesis (AMIC) has recently become an interesting treatment option for osteochondral lesions of the talus since it combines safety and efficacy with overcoming several drawbacks of other surgical techniques. With AMIC, donor side morbidity of osteochondral autografts is eliminated, two-step procedures like matrix-induced autologous chondrocyte implantation are minimized to a more cost-effective single step and restrictions due to limited availability of osteochondral allografts are resolved. The purpose of this study was to evaluate the therapeutic efficacy of AMIC by analyzing AMIC-repaired osteochondral talar lesions in consecutively treated patients after a minimum follow-up of 2 years. Methods: All patients with an osteochondral lesion of the talus treated with the AMIC technique completing a minimum follow-up of 2 years were enrolled in the study for clinical and radiological follow-up. Patients with additional procedures such as lateral ligament reconstruction or corrective calcaneal osteotomy were excluded. 31 of the 47 eligible patients (28 males, 13 females; mean age at surgery 35.7 (range, 13-75) years); body mass index 27.1+-4.7 kg/m2) could be retrospectively evaluated after a mean follow-up of 4.6 (range, 2.3-7.9) years. The preoperative defect size was 0.9+-0.5 (range 0.4-2.3) cm2. Only two osteochondral lesions were localized laterally. Data analysis included general demographics, the visual analogue scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle function, the Tegner Score for sports activity, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system for radiological evaluation. Results: The VAS improved significantly from 6.5+-2.0 preoperatively to 1.5+-2.2 at follow-up (p&lt;0.001). The mean AOFAS score was 93.0+-8.2 (range, 74-100) points. The sports activity level improved significantly from 3.5+-1.8 points preoperatively to 4.9+-1.8 points at follow-up (p&lt;0.001), but 29% did not reach their pre-injury level of activity. The MOCART score averaged 61.5+-21.2 (range, 0-95) points. Complete filling of the defect was seen in 41%, hypertrophy of the cartilage layer in 53%. Normal or nearly normal signal intensity was detected in 67%. All patients showed subchondral bone edema or cysts. The MRI findings did not correlate with the clinical outcome. 91% were satisfied with the outcome and would undergo the same procedure again. Conclusion: AMIC is a reliable procedure to treat osteochondral lesions of the talus. Significant pain reduction and high ankle function were observed after a mean midterm follow-up of 4.5 years. MRI findings did not reflect the good clinical results and therefore should only be performed to rule out other pathologies that might cause persistent symptoms.

Talar Motion is Constrained by Tricortical Screw Fixation of the Syndesmosis: A Cadaveric Robotic Study

Objectives:High ankle sprains are a common injury that occur in up to 11% of ankle sprains. Injury to the structures of the syndesmosis, the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM), has been shown to be predictive of residual symptoms after ankle injury. When the syndesmosis is unstable, it is typically treated surgically with cortical screw fixation or suture button fixation. Studies have shown that a 1 mm lateral shift of the talus relative to the tibia significantly decreases the tibiotalar contact area by 42%. Thus, restoring the tibiotalar kinematics to those of the intact ankle with appropriate fixation is important to avoid accelerated tibiotalar arthritis. The objective of this study was to quantify tibiotalar joint motion after syndesmotic screw and suture button fixation compared to the intact ankle.Methods:Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system. The subtalar joint was fused and the tibia and calcaneus were rigidly fixed to a robotic manipulator, while fibular length was maintained and fibular motion was unconstrained. Talar motion with respect to the tibia was measured using the robotic testing system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied independently to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included talar medial-lateral (ML) translation, anterior-posterior (AP) translation, and internal/external rotation relative to the tibia in the following syndesmosis states: 1) intact, 2) AITFL transected, 3) AITFL, PITFL, and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, and 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis. Statistical significance was set at p < 0.05.Results:There were significant differences in ML translation of the talus relative to the tibia between the tricortical screw fixation and the intact ankle. These significant changes were only present during states with no loads applied. Tricotical screw fixation resulted in a significant decrease in medial translation of the talus compared to the intact ankle at 30° plantarflexion and increased lateral translation at 0° flexion (p < 0.05) (Figure 1). The talus moved 1.1 mm less medially at 30° plantarflexion and 0.4 mm more laterally at 0° flexion in the tricortical screw fixation state compared to the intact ankle. The total medial translation of the talus relative to the tibia during plantarflexion decreased from 1.1 mm to only 0.4 mm. No significant difference in AP translation or external rotation of the talus existed between the tricortical screw fixation and the intact ankle. No significant differences existed in translation or rotation of the talus between the suture button fixation and intact ankle at any ankle positions.Conclusion:Suture button fixation restored tibiotalar motion in all planes, with no significant differences compared to the intact ankle. Tricortical screw fixation significantly increased lateral shift of the talus in a neutral ankle position and constrained motion during plantarflexion compared to the intact ankle, which can lead to accelerated tibiotalar arthritis. Thus, physicians should consider hardware removal after tricortical screw fixation for syndesmotic repair to avoid post-traumatic arthritis.Figure 1.Medial-lateral translation of the talus relative to the tibia with no loads applied. (Mean ± Standard Deviation), *p < 0.05

High-Speed Video Analysis of Syndesmosis Injuries in Soccer—Can It Predict Injury Mechanism and Return to Play? A Pilot Study

Background: Ankle syndesmosis injuries in professional soccer may lead to an unpredictable and prolonged recovery. This injury has been investigated in anatomical and radiologic studies but the precise mechanism leading to syndesmosis injury is not well understood and remains debated. The 2 goals of this study were to (1) evaluate the relationship between the mechanism of syndesmosis injury as determined by high-speed video analysis and the injured structures identified by clinical and radiologic examination and to (2) investigate the relationship between mechanism of injury and time of return to play. Methods: This pilot study prospectively reviewed high-speed video analysis of 12 professional soccer players who sustained syndesmosis injuries. The mechanism of injury was compared with the clinical and MRI evaluation and the time taken to return to play. Results: Higher-grade syndesmosis injuries occurred during ankle external rotation with dorsiflexion. Supination-inversion injuries with a standard lateral ankle sprain (rupture of the anterior talofibular ligament) may extend proximally, causing a lower-grade syndesmosis injury. These may present with signs of a high ankle sprain but have a quicker return to sport than those following a dorsiflexion-external rotation injury (mean 26 days vs 91 days). Conclusions: Video analysis confirmed that at least 2 mechanisms may result in injury to the ankle syndesmosis. Those “simple” ankle sprains with signs of syndesmosis injury had a quicker return to play. This new finding may be used by club medical teams during their initial assessment and help predict the expected time away from soccer in players with suspected high ankle sprains. Level of Evidence: Level IV, retrospective cohort study.

Syndesmosis injuries at the ankle

Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options. The aim of this review is to summarize the current knowledge on syndesmotic instability and to present some recommendations for the clinical practice for acute an chronic injuries. Analysis of the current literature concerning the anatomy, etiology, diagnostics and treatment of syndesmosis injuries. Purely ligamentous injuries (high ankle sprains) are not associated with alatent or frank tibiofibular diastasis and can be treated with an extended protocol of physiotherapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments and requires surgical stabilization. Syndesmotic disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. The proposed means of fixation are one or more tibiofibular screws or suture button implants. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. The most frequent complication is syndesmotic malreduction and can be minimized with direct visualization and intraoperative 3D scanning. Other complications include hardware failure, adhesions, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.