5/8/2014 Syndesmotic and Midfoot DISCLOSURE Sprains in the Athlete: Consultant for: Arthrex, Wright Medical Beware of the Subtle Variety Royalties from: Arthrex, DJO, Wright Medical Robert B. Anderson, MD Research support from: Arthrex Chief, Foot & Ankle Service Carolinas Medical Center OrthoCarolina Team Orthopaedist, Carolina Panthers Charlotte, North Carolina You may not have seen it but it has seen you… PREFACE The eye sees what the mind knows… Dr. Bill Hamilton 1
5/8/2014 An error does not become a mistake Experience is the mother of until you refuse to correct it… knowledge… Nicholas Breton John F. Kennedy Orlando Battista Orthopaedic Surgery is not all about diagnotic studies/images SPORTS FOOT and ANKLE • Not everything is “frank” or apparent • Take a good history/examine the patient/review the video (when available) • Element of “gestalt” 2
5/8/2014 Sport-related Injuries Foot and Ankle Injuries • Foot and ankle at risk • Better – 50% of pro basketball recognized/reported – 25% of pro football • More physical – 20% all NCAA sports players, higher • 72% in football (Kaplan et energy injuries al, Am J Orthop) • The only part of the • Shoewear changes body with an apparent • Field/turf conditions increasing injury rate WHY? Foot and Ankle Injuries Foot and Ankle Injuries • Shoewear changes = less protective • Field/turf conditions – Lighter weight Vapor – 11oz. – Trend towards – More flexible more injuries in • Midsole cut-out certain turf/in-fill designs • i.e Field Turf 3
5/8/2014 Foot and Ankle Injuries Foot and Ankle Injuries • Cleat/surface • Cleat/surface interaction interaction – Wrestle between – If surface slick performance and risk longer cleats used • Traction relates to – Cleats catch deep performance in turf/between • Torque relates to seams (corn rows) injury and torque – Threshold not known increases Foot and Ankle Injuries • Cleat/surface interaction LISFRANC INJURIES – Ligament injuries can occur as a result of torque/twist and may be subtle • Frank diastasis not always present – Unstable joint segments may progress to deformity/DJD 4
5/8/2014 How Lisfranc Injuries Occur How Lisfranc Injuries Occur Classic description = Classic description axial load to the back of the heel = axial load to with foot fixed to the back of the the ground heel with foot fixed to the ground Indirect Lisfranc Injuries Case: Midfoot “Sprain” Not all are classic or • Failed to improve with readily apparent casting/boot x 3 months • Decision made to • 23 y/o NFL WR with proceed with open right foot injury on punt exploration return • Minimal clinical findings • Normal xrays/stress • MRI = edema 5
5/8/2014 Indirect Mechanism - Axial??? Case: Midfoot “Sprain” • Twisting • Managed with “home component actually run” screw – 3.7mm, solid, fully more common threaded – NFL Database • Does not require contact or axial loading Indirect Mechanism - Twisting Mechanism for Injury • More common Indirect etiology in NFL • Happens quickly – NFL Database • Quite subtle • Especially in defensive ends 6
5/8/2014 Noncontact Indirect Injuries Meyer et al, AJSM ’94 – 2 nd most common foot injury among Medial collegiate football players dislocation of • 4% annual incidence the TMT by supination of • 29% offensive linemen the hindfoot – 50% twist, 37% axial load followed by complete dislocation after fracture of 2 nd MT NFL Study: Reproducing the What we found (NFL/Uva) … Injury very Difficult! • To create the injury • Certain shoe types may be implicated – excessive forefoot bend – Forefoot, and especially the 2 nd ray, has to be engaged in turf – Must have dorsiflexion thru mp joints 7
5/8/2014 Wide Variety of Injury Injury Not Always Apparent Patterns Possible • Quenn and Kuss Indirect types may be (1909) subtle (20% missed) • Hardcastle (1982) • Painful WB • Myerson (1986) • Heel rise difficult – Mid-tarsal • Swelling and point involvement tenderness – Often medial column (n-c) Subtle Signs Radiographic Exam • 1 st TMT joint Exam • 2 nd TMT joint • Plantar ecchymosis may be a clue • 1-2 interspace • Intercuneiform • Naviculocuneiform 8
5/8/2014 Radiographs Radiographs NWB Initial Standing After 1 week After 2 weeks WB “fleck” sign • Serial exams recommended! • Obtain contralateral views – look for asymmetry – Progressive diastasis highlights instability • Standing AP can be a good stress test! – Single limb if feasible Subtle Signs Proximal Variant • Beware of the • Occurring in all field proximal variant ! sports – Increasing • Effect of artificial incidence in surfaces? American football –Cleat interaction??? • Hammit/Anderson – AOFAS ‘04 – TFAS ‘05 9
5/8/2014 Proximal Variant Proximal Variant • Force of injury • Results in an extends thru unstable first ray → intercuneiform joint difficulty with to exit out push-off naviculo-cuneiform joint Epitome of a significant ligamentous injury… Assessing Subtle Injuries Proximal Variant • Results in an Formal stress testing unstable first ray → • Requires anesthesia, difficulty with flouroscopy push-off – Very difficult to get • Also lead to joint relaxed in office deterioration if left • Maneuver untreated – Adduction-pronation 10
5/8/2014 Stress Testing Assessing Subtle Injuries CT • Not done routinely • Static test – May help guide treatment only if diastasis or intra- articular injury noted • Identifies unusual fx patterns Check 1 st Ray Instability on Lateral Assessing Subtle Injuries Assessing Subtle Injury MRI MRI = good for subtle changes • Helpful if a vague presentation; • Proximal variant identifies location with edema in and extent of injury navicular • Also a static test 11
5/8/2014 Treatment Goal Surgical Indications • No specific parameters! • Obtain/maintain • Treat individually anatomic reduction – Stabilize injured joints – Pain? Lack of improvement? • Eliminate risk for progression – Can not push-off? • Assist with rehab – Unable to heel rise? – Maintain a “normal” – Progressive diastasis? posture of the foot – Unstable pattern confirmed • Improved prognosis Weight-bearing by stress? Surgical Technique Recommendations for Fixation • Open reduction advantageous • “Subtle” proximal – Remove debris variant type with • Leave soft tissue/ligaments any displacement – Can assess articular surface needs surgery – Intercuneiform or other subtle – Tend to progress areas of instability? – Confirms anatomic reduction and stability 12
5/8/2014 Surgical Technique Surgical Technique • Bridge plates • Screws – Hardware breakage – Prefer solid/cortical not a concern, as it can be with • Bridge plates transfixation – Can use on 1 st and screws 2 nd TMT joints; • Risk for joint avoids cartilage damage damage It just makes sense… Case Example R.B. - Proximal Variant Lisfranc • 26 y/o running back with noncontact injury • “Home run” and and midfoot pain intercuneiform screw – Subtle proximal variant • RTP at 6.5 months 13
5/8/2014 Typical Postop Recommendations Hardware Removal • Splint, NWB x 2 wks • Stress intraop • Boot, NWB X 3-4 wks – Place suture-button if persistent • Screw/plate removal 4-6 instability months – Remove all crossing TMT – “Home run” optional – Keep intercuneiform • Lessens risk for late diastasis What if Pain and Dysfunction Chronic Pain with Normal Studies Persist? • 21 y/o DB failing to • Consider… improve after “stable” – Synovitis vs DJD Lisfranc – left foot – Subtle Instability • Difficulty with push-off • Exam suspicious for hypermobile 1 st ray Consider flouroscopic- directed injection 14
5/8/2014 Chronic Pain with Normal Studies Chronic Pain with Normal Studies • Intraop instability of 1 st • Intraop instability of 1 st TMT joint TMT joint Chronic Pain with Normal Studies Chronic Pain with Normal Studies • Intraop instability of 1 st • Intraop instability of 1 st TMT joint TMT joint 15
5/8/2014 Midfoot “sprain” that doesn’t get Chronic Pain with Normal Studies better • Intraop instability of 1 st TMT joint • 20 y/o LB w/ midfoot twisting injury • Initial xray negative, stress under anesthesia = stable • MRI = intact Lisfranc lig, mild midfoot edema at 2 nd TMT jt. • Persistent midfoot pain • Temporary relief with fluoro guided injection 2nd TMT jt. Outcomes/Prognosis: Subtle Midfoot sprain that doesn’t get better Injuries • OR at 6mo post-injury: chondral • Small case series of elite athletes injury and subtle instability → 2nd TMT fusion and home-run – Curtis et al, AJSM ‘93: 16/19 return to sport screw for 1-2 instability – Hammitt/Anderson, TFAS ‘05: Proximal variants • Post-op: = 9/9 returned to full athletic participation – 6 wks NWB, 6wks WB in • Don’t want to miss these – have a high boot suspicion if not getting better – CT at 12 wks confirmed union – Ultimate outcome related to adequacy of – Rehab w/ arch support reduction and severity of initial injury – Ran at 4 mo., RTP at 7 mo. • Kuo et al, JBJS 2000 16
Recommend
More recommend
