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

Mark Glazebrook

MSc., PhD, MD, FRCS(C), Dip Sports Med

Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia

Dalhosie University Halifax Nova Scotia

Functional Versus Mechanical Instability: Keys to Diagnosis, Physical Examination and Radiological Evaluation Mark Glazebrook MD PhD

Foot and Ankle 1:52 PM

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

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

Classification

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

exam and paradoxically less tender

• Signal and structural

changes on MRI w ith torn ends visible and fluid filled gap

Chronic Ankle Instability (CAI)

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

Anterior translation 5 mm greater than that

• n the uninvolved side or an absolute value
• f 9 mm is indicative of instability.

Talar tilt angle 5 degrees greater than

• n the uninvolved side or an absolute

value of 10 degrees is indicative of 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

Anatomic Repair

+/- augmentation w adjacent Extensor retinaculum

CAI: Open Operative Procedures

Brostrom-Gould

Anatomic Repair

+/- augmentation w adjacent Extensor retinaculum

Ligament Reconstruction

Partial or complete ligament reconstruction

CAI: Open Operative Procedures

Watson Jones Evans Chrisman-Snook

Brostrom-Gould

CAI: OPEN Stabilization Outcomes

Conclusion: OPEN ankle stabilization surgery provides good to excellent results

Procedure Level 1 Level 2 Level 3 Level 4 Level 5 Total Grade of Recommendation Open Anatomic Repair 6 4 7 4 21 B Open Non-anatomic Repair 1 1 I Open Anatomic Reconstruction 1 3 12 2 18 A Open Non-anatomic Reconstruction 1 4 23 1 29 B Internal Brace 1 1 2 I Total 1 7 13 43 7 71

Less is Better!!

Current Literature Available on MIS stabilization Techniques

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 for Treatment of Ankle Instability with MIS??

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

Current Evidence MIS Approaches to Ankle Stabilization.

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

Current Evidence MIS Approaches to Ankle Stabilization.

Limited Evidence to Support MIS for Rx of Ankle Instability!! Further Studies Needed !!1

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 Group1