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Papenhoff MC, Habig K, Schmitz C, Lundin S, Schreier D, Tineghe J, Dudda M. [Complex Regional Pain Syndrome (CRPS) - State of the Art in Diagnostics and Therapy]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:337-352. [PMID: 37307853 DOI: 10.1055/a-1898-2454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The complex regional pain syndrome (CRPS) usually occurs within a few weeks in 2-5% of all patients after trauma or surgery or subsequent measures of the distal extremities. There are certain risk factors for its occurrence but no "CRPS personality", instead there are factors that negatively influence the course. The prognosis is generally good ("rule of thirds"), but remaining limitations are common. The diagnosis is clinically possible according to the "Budapest criteria". Additional examinations are possible in case of doubt but are neither conclusive nor exclusive. Corticoids and bisphosphonates are used alongside drugs that have an effect on neuropathic pain. Invasive therapies do not have good evidence and have therefore lost their importance. The rehabilitative therapy is carried out actively and with a lot of self-exercises at an early stage. Invasive anesthetic, passive therapies are obsolete. Special forms of treatment are "graded exposure" (GEXP) in the case of dominant anxiety and, e.g., "graded motor imagery" (GMI) in case of neglect-like symptoms. In addition to educational and behavioral therapy elements, psychotherapy for CRPS also includes participation as part of graded exposure.
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[The periosteal flap augmentation technique in chronic lateral ankle instability]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:180-190. [PMID: 31037329 DOI: 10.1007/s00064-019-0600-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Anatomic repair of the lateral ligament complex of the ankle joint and augmentation with an autologous pedicled periosteal flap of the distal fibula following identification and concomitant treatment of intra-articular pathologies. INDICATIONS Symptomatic chronic mechanical lateral ankle instability. As a modular step in the treatment of osteochondral lesions in conjunction with lateral ankle instability. CONTRAINDICATIONS Higher degree osteoarthritis of the ankle joint (>Kellgren/Lawrence 2 and 4 or Outerbridge 3 and 4) and/or hindfoot deformity; mechanical incompetence of both the fibulotalar anterior ligament and the fibulocalcaneal ligament preventing anatomical reinsertion; general risk factors. SURGICAL TECHNIQUE Diagnostic arthroscopy for identification and treatment of intraarticular pathologies; verification and grading of ligamentous instability (medial, lateral, combined). Open exposure of the distal fibula and the ruptured components of the lateral ankle ligament complex. Anatomic reinsertion of the original ligaments and assessment of their mechanical competence. Apart from the situation in the juvenile patient with a thick periosteal layer a doubled and pedicled periosteal strip of the distal fibular periosteum will suffice for the augmentation in one ligamentous component, only. Fixation in the talus or calcaneus is achieved via suture anchors, screws with a washer or transosseous fixation via interference screw. POSTOPERATIVE MANAGEMENT Postoperative immobilization in a lower leg split cast or a splint until wound healing (5-8 days), mobilization in a walker or an ankle orthosis with consecutive full weight-bearing for further 4-5 weeks. Proprioceptive and pronator muscle training, optionally insole or lateral wedge at the shoe sole for 6 months postoperatively. Avoidance of contact sports for 4-6 months. RESULTS Several studies have reported reliable restoration of ligamentous ankle stability with overall success rates >90% and good to excellent total results in >90% of patients with limited minor complications. In view of the heterogeneous data from previous studies, some recent studies have demonstrated that the outcome after periosteal augmentation is comparable to that after techniques employing free tendon graft for anatomic restoration of ligamentous ankle stability. The technique has been applied successfully in cases of poor mechanical properties of the formerly ruptured ligaments and in patients with a high functional demand.
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Baumbach SF, Braunstein M, Herterich V, Böcker W, Waizy H, Polzer H. [Arthroscopic repair of chronic lateral ankle instability]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:201-210. [PMID: 30918997 DOI: 10.1007/s00064-019-0595-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/03/2018] [Accepted: 10/06/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies. INDICATIONS Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability. CONTRAINDICATIONS Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome. SURGICAL TECHNIQUE Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using a suture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex. POSTOPERATIVE MANAGEMENT Partial weight-bearing and short leg cast for 2 weeks, then 4 weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months. RESULTS Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to a significant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3 temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2 temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported a significantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.
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Affiliation(s)
- S F Baumbach
- Sektion für Fuß- und Sprunggelenkchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU München, Ludwig-Maximilians-Universität, Nußbaumstraße 20, 80336, München, Deutschland
| | - M Braunstein
- Sektion für Fuß- und Sprunggelenkchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU München, Ludwig-Maximilians-Universität, Nußbaumstraße 20, 80336, München, Deutschland
| | - V Herterich
- Sektion für Fuß- und Sprunggelenkchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU München, Ludwig-Maximilians-Universität, Nußbaumstraße 20, 80336, München, Deutschland
| | - W Böcker
- Sektion für Fuß- und Sprunggelenkchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU München, Ludwig-Maximilians-Universität, Nußbaumstraße 20, 80336, München, Deutschland
| | - H Waizy
- Sektion für Fuß- und Sprunggelenkchirurgie, Donau-Ries Klinik Donauwörth, Neudegger Allee 6, 86609, Donauwörth, Deutschland
| | - H Polzer
- Sektion für Fuß- und Sprunggelenkchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU München, Ludwig-Maximilians-Universität, Nußbaumstraße 20, 80336, München, Deutschland.
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Lopes R, Andrieu M, Cordier G, Molinier F, Benoist J, Colin F, Thès A, Elkaïm M, Boniface O, Guillo S, Bauer T. Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients. Orthop Traumatol Surg Res 2018; 104:S199-S205. [PMID: 30245066 DOI: 10.1016/j.otsr.2018.09.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/03/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques. MATERIAL AND METHODS Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports. RESULTS The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients. DISCUSSION Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery. CONCLUSION Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.
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Affiliation(s)
- Ronny Lopes
- Polyclinique de l'atlantique (PCNA), avenue Claude-Bernard, 44800 Saint-Herblain, France
| | - Michael Andrieu
- Clinique Pont-de-Chaume, 330, avenue Marcel-Unal, 82000 Montauban, France
| | - Guillaume Cordier
- Clinique du Sport Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France
| | - François Molinier
- Clinique des Cèdres, route de Mondonville, 31700 Cornebarrieu, France
| | - Jonathan Benoist
- CHP Saint-Grégoire, 7, boulevard de la Boutière, 35760 Saint-Grégoire, France
| | - Fabrice Colin
- Clinique Mutualiste Catalane, 60, rue Louis-Mouillard, 66000 Perpignan, France
| | - André Thès
- Hôpital privé d'Eure-et-Loir, 2, rue Roland-Buthier, 28300 Mainvilliers, France; Service de chirurgie orthopédique et traumatologique, CHU Ambroise-Paré, AP-HP, groupe hospitalier universitaire Paris Île-de-France Ouest, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Marc Elkaïm
- Clinique de Tournan, 2, rue Jules-Lefebvre, 77220 Tournan-en-Brie, France
| | - Olivier Boniface
- Clinique Générale-Annecy, 4, chemin de la Tour-la-Reine, 74000 Annecy, France
| | - Stéphane Guillo
- Clinique du Sport Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France
| | - Thomas Bauer
- Service de chirurgie orthopédique et traumatologique, CHU Ambroise-Paré, AP-HP, groupe hospitalier universitaire Paris Île-de-France Ouest, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
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- 15, rue Ampère, 92500 Rueil Malmaison, France
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