Functional Versus Mechanical Instability: Keys to Diagnosis, - PowerPoint PPT Presentation

Dalhosie University Halifax Nova Scotia Mark Glazebrook MSc., PhD, MD, FRCS(C), Dip Sports Med Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia Foot and Ankle 1:52 PM Functional Versus Mechanical Instability: Keys to Diagnosis, Physical Examination and Radiological Evaluation Mark Glazebrook MD PhD

Mark Glazebrook Disclosure Statement Mark Glazebrook has received something of value in the past 1 year ( ≥ $500.00) or served as a Journal review er from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below. a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee f = Journal review er NAME: DISCLOSURE: COMPANY/SOURCE: 1. Glazebrook e Stryker Wright Inc. 2. Glazebrook a,e Ferring Inc. 3. Glazebrook a,e Cartiva Inc 4. Glazebrook ae Smith & Nephew 5. Glazebrook f Foot & Ankle International 6. Glazebrook f JBJS(A) 7. Glazebrook f The Bone & Joint Journal 8. Glazebrook f CORR 9. Glazebrook Past BOD Member AOFAS 10. Glazebrook President Elect/BOD Canadian Orthopedics Association (COA)

Acute Ankle Sprains Inversion injury Lateral 90% Anterior talofibular ligament (ATFL 70%) Calcaneofibular ligament (CFL 20%) Syndesmotic (High sprain) injuries 10% PTFL and deltoid (w ithout #) - Rare

Classification Grade Ligament Injured Severity & Presentation Grade 1 ATFL Mild : O tear or change in length, no swelling. Point tenderness Mild functional loss Grade 2 ATFL & CFL Moderate : Partial ligament tear, with elongation. Pain, localized swelling, tenderness. Moderate functional loss Grade 3 ATFL, CFL & PTFL Severe: Complete ligamentous rupture, Marked pain, swelling, tenderness, Marked loss of Function ----  Instability

Injury to Ligaments Grade 3 Severe : • Complete disruption • Obvious Laxity on exam and paradoxically less tender • Signal and structural changes on MRI w ith torn ends visible and fluid filled gap

Injury to Ligaments Grade 3 Severe : • Complete disruption • Obvious Laxity on Chronic Ankle Instability exam and (CAI) paradoxically less tender • Signal and structural changes on MRI w ith torn ends visible and fluid filled gap

Ankle Instability Mechanical Vs Functional Mechanical (Abnormal movement talus in Mortise) Pathological ligament laxity Synovial changes Degenerative conditions Hind foot stiffness Functional (Complaint of Giving w ay) Impairments to proprioception Neuromuscular Strength deficits around the ankle Postural control deficits Deformity(Hindfoot Varus) Intraarticular Pathology (OCL & Impingement)

Ankle Instability Associated Conditions Lateral Stress Hindfoot Varus Peroneal Tears Peroneal Instability Plantar Lateral Pain Anterolateral Impingement OCL

Ankle Instability Clinical Presentation History: Persistent pain Recurrent giving w ay Difficulties on uneven ground Improved w ith ankle stabilizing orthosis (ASO) Physical Exam: COMPARE TO CONTRALATERAL! Anterolateral sw elling & /or tenderness Difficulty w ith SLS & Toe w alking Anterior Draw er Testing: ATFL  Dorsiflexion CFL  Plantarflexion (or Neutral to resist eversion)

Imaging • Stress views Talar tilt angle 5 degrees greater than Anterior translation 5 mm greater than that on the uninvolved side or an absolute on the uninvolved side or an absolute value value of 10 degrees is indicative of of 9 mm is indicative of instability. pathologic laxity

Ankle Instability • Ultrasound Griffith and Brockw ell F& A Clinics 2006 Ultrasound show ing ( A ) complete tear (discontinuity) of anterior talofibular ligament ( arrow s ) w ith ( B ) normal side ( arrow s ) for comparison. ( C ) Compete tear (no visualization) ( arrow s ) of calcaneofibular ligament w ith ( D ) normal side ( arrow s ) for comparison. F, fibula; T, talus; C, calcaneum In experienced hands, the accuracy of ultrasonography for acute tears : Anterior Talofibular Ligament (ATFL) ~ 95% CalcaneoFibular Ligament (CFL) ~ 90% Anterior Tibiofibular Ligament ~ 85%

Ankle Instability Imaging Studies Griffith and Brockw ell F& A Clinics 2006 MRI demonstrate associated causes of ankle pain: chondral injuries bone bruising stress fractures associated tendon tears chronically disrupted ligament thickened, lax, w avy, discontinuous or completely non-visualized

Ankle Instability TREATMENT

Ankle Instability TREATMENT Non Operative RICE from Injury Functional Rehabilitation Peroneal Strengthening Achilles Stretching Proprioception Bracing or High Top Shoe w ear Lateral Wedge Orthotic Taping (Ineffective after ~10 min exercise)

Ankle Instability TREATMENT Operative Open (Traditional) Vs Minimally Invasive (MIS) Anatomic Repair Non Anatomic Repair Anatomic Reconstruction Non Anatomic Reconstruction

CAI: Open Operative Procedures Anatomic Repair +/- augmentation w adjacent Extensor retinaculum Brostrom-Gould

CAI: Open Operative Procedures Anatomic Repair Ligament +/- augmentation w Reconstruction adjacent Extensor Partial or complete ligament retinaculum reconstruction Brostrom-Gould Watson Jones Evans Chrisman-Snook

CAI: O PEN Stabilization Outcomes Level Level Level Level Level Grade of Procedure Total 1 2 3 4 5 Recommendation Open Anatomic Repair 0 6 4 7 4 21 B Open Non-anatomic Repair 0 0 1 0 0 1 I Open Anatomic Reconstruction 1 0 3 12 2 18 A Open Non-anatomic Reconstruction 0 1 4 23 1 29 B Internal Brace 0 0 1 1 0 2 I Total 1 7 13 43 7 71 Conclusion: OPEN ankle stabilization surgery provides good to excellent results

Less is Better!!

Current Literature Available on MIS stabilization Techniques Current Evidence for Treatment of Ankle Instability with MIS?? Minimally Invasive Surgical Treatment of Chronic Ankle Instability: A Systematic Comprehensive Evidence Based Review of Current Literature Kentaro Matsui, Bernard Burgesson, Masato Takao, James Stone, Stephane Guillo, ESSKA AFAS Ankle Instability Group, and Mark Glazebrook

Current Evidence MIS Approaches to Ankle Stabilization . Surgical Total Level Level Level Level Level Grade of For or Technique Papers I II III IV V Recommendation Against MIS Non A 0 0 0 0 0 0 I NA Repair MIS Non A 6 0 0 1 2 3 C For Reconstruction Arthroscopic 19 0 0 0 12 7 C For Repair Arthroscopic 6 0 0 0 1 5 C For Reconstruction

Current Evidence MIS Approaches to Ankle Stabilization . Surgical Total Level Level Level Level Level Grade of For or Technique Papers I II III IV V Recommendation Against MIS Non A 0 0 0 0 0 0 I NA Limited Evidence to Support MIS for Rx of Ankle Instability!! Repair MIS Non A 6 0 0 1 2 3 C For Further Studies Needed !!1 Reconstruction Arthroscopic 19 0 0 0 12 7 C For Repair Arthroscopic 6 0 0 0 1 5 C For Reconstruction

Summary • Ankle Sprains Common • Clinical Diagnosis Best US & /or MRI best for diagnostic imaging • Must differentiate Mechanical Vs Functional Instability • • Mechanical Instability Requires Ankle Stabilization • Functional Instability requires Rx of different pathology • Literature to support Open Surg CAI GOOD Literature to support MIS Surg CAI POOR (studies needed) •

THANK-YOU !! Special Thanks James Stone (USA) MASATO TAKAO (Japan) Kentaro Matsui (Japan) Stephane Guillo (France) Xavier Martin (Catalonia/Spain) ESSKA-AFAS Ankle Instability Group 1