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Gomaa AR, Mason L. Chronic syndesmotic instability - Current evidence on management. J Clin Orthop Trauma 2024; 50:102382. [PMID: 38435397 PMCID: PMC10904910 DOI: 10.1016/j.jcot.2024.102382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/21/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
This review article discusses the current evidence on the management of chronic syndesmotic instability. Conservative treatment has a limited role, and surgical intervention is most commonly reported as the mainstay of treatment, however the literature consists of small case series and descriptions of operative techniques, and thus the evidence base for any treatment is weak. Surgical options include arthroscopic debridement alone, static fixation with cortical screws, dynamic fixation with suture-button devices, and ligamentous repair or augmentation.
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Affiliation(s)
- Abdul-Rahman Gomaa
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lyndon Mason
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Sharafeldin K, Eltinay M, Al Qahtani M, Alblaui SM. Ankle syndesmotic reconstruction in chronic ankle syndesmotic injury. BMJ Case Rep 2023; 16:e251434. [PMID: 37041043 PMCID: PMC10106000 DOI: 10.1136/bcr-2022-251434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
Acute syndesmotic injury is a common problem treated with different surgical tools. If not managed appropriately, it can lead to chronic ankle syndesmotic insufficiency. Chronic syndesmotic insufficiency is challenging to diagnose, and the patient can suffer for a long time. There is no consensus in previous literature on the surgical treatment of chronic syndesmotic injury. We present a case of personnel who suffered from chronic syndesmotic injury treated by syndesmotic reconstruction 5 years after his ankle fracture dislocation and returned to his work. This case highlights the importance of a CT scan post-reduction of an acute syndesmotic injury to assess accurate reduction, especially in severe injuries with frank diastasis.
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Affiliation(s)
- Khalid Sharafeldin
- Orthopaedic Department, King Abdulaziz Airbase Hospital, Dhahran, Eastern State, Saudi Arabia
| | - Mohammed Eltinay
- Orthopaedic Department, King Fahd Military Medical Complex, Dhahran, Eastern State, Saudi Arabia
| | - Mohammed Al Qahtani
- Orthopaedic Department, King Abdulaziz Airbase Hospital, Dhahran, Eastern State, Saudi Arabia
| | - Sultan M Alblaui
- Orthopaedic Department, King Fahd Military Medical Complex, Dhahran, Eastern State, Saudi Arabia
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Beltran LS, Zuluaga N, Verbitskiy A, Bencardino JT. Imaging of Acute Ankle and Foot Sprains. Radiol Clin North Am 2023; 61:319-344. [PMID: 36739148 DOI: 10.1016/j.rcl.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ankle and foot injuries are very common injuries in the general population, and more so in athletes. MR imaging is the optimal modality to evaluate for ligamentous injuries of the ankle and associated conditions after ankle sprain. In this article, the authors discuss the epidemiology, biomechanics, normal anatomy, and pathology of the ankle as well as injuries of the hindfoot and midfoot that are often associated with ankle injuries.
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Affiliation(s)
- Luis S Beltran
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Nicolas Zuluaga
- Department of Radiology, University of Pennsylvania Health System, 3737 Market Street, Philadelphia, PA 19104, USA
| | - Anna Verbitskiy
- Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Jenny T Bencardino
- Department of Radiology, University of Pennsylvania Health System, 3737 Market Street, Philadelphia, PA 19104, USA
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Wang S, Liu P, Chen K, Zhang H, Yu J. Mouse model of subtalar post-traumatic osteoarthritis caused by subtalar joint instability. J Orthop Surg Res 2022; 17:537. [PMID: 36510269 PMCID: PMC9743676 DOI: 10.1186/s13018-022-03435-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Common ankle sprains are often accompanied by injury to the subtalar joint, which eventually leads to subtalar joint instability. Because the clinical manifestations for subtalar joint instability are similar to ankle joint injuries, these are often overlooked. This study aimed to establish an animal model of subtalar joint instability to study post-traumatic osteoarthritis of the subtalar joint caused by long-term subtalar joint instability and to provide a reference for future clinical research on chronic subtalar joint instability. METHODS In all, 24 C57BL/6 male mice were randomly divided into three groups: Sham, cervical ligament (CL) transection and CL + calcaneofibular ligament (CFL) transection groups. One week after surgical operation, all mice were trained to run in the mouse rotation fatigue machine every day. During this period, a balance beam test was used to evaluate the motor level and coordination ability of the mice before the operation and three days, one week, four weeks, eight weeks, and twelve weeks after operation. Further, post-traumatic osteoarthritis of the subtalar joint was quantified via micro-CT and histological staining. RESULTS The mice in the partial ligament transection group took significantly longer than those in the Sham group to pass through the balance beam and showed an increased number of hindfoot slips. Micro-CT analysis showed that the subtalar bone volume fraction in the CL + CFL transection group and CL transection group was 5.8% and 2.8% higher than that in the Sham group, respectively. Histological staining showed obvious signs of post-traumatic osteoarthritis (PTOA) in the subtalar joint of the ligament transection group. CONCLUSIONS The transection of CL and CL + CFL can cause instability of the subtalar joint in mice, resulting in a decrease in motor coordination, and long-term instability of the subtalar joint in mice can cause PTOA of the subtalar joint, which is manifested as destruction and loss of articular cartilage.
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Affiliation(s)
- Shuo Wang
- grid.429222.d0000 0004 1798 0228Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 Jiangsu People’s Republic of China ,grid.263761.70000 0001 0198 0694Orthopaedic Institute, Medical College, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006 Jiangsu People’s Republic of China
| | - Peixin Liu
- grid.429222.d0000 0004 1798 0228Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 Jiangsu People’s Republic of China ,grid.263761.70000 0001 0198 0694Orthopaedic Institute, Medical College, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006 Jiangsu People’s Republic of China , Department of Orthopedics, Suzhou Xiangcheng People’s Hospital, 1060 Huayuan Road, Suzhou, 215131 Jiangsu People’s Republic of China
| | - Kaiwen Chen
- grid.429222.d0000 0004 1798 0228Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 Jiangsu People’s Republic of China ,grid.263761.70000 0001 0198 0694Orthopaedic Institute, Medical College, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006 Jiangsu People’s Republic of China
| | - Hongtao Zhang
- grid.429222.d0000 0004 1798 0228Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 Jiangsu People’s Republic of China ,grid.263761.70000 0001 0198 0694Orthopaedic Institute, Medical College, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006 Jiangsu People’s Republic of China
| | - Jia Yu
- grid.429222.d0000 0004 1798 0228Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 Jiangsu People’s Republic of China ,grid.263761.70000 0001 0198 0694Orthopaedic Institute, Medical College, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006 Jiangsu People’s Republic of China
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Connors JC, Grossman JP, Zulauf EE, Coyer MA. Syndesmotic Ligament Allograft Reconstruction for Treatment of Chronic Diastasis. J Foot Ankle Surg 2021; 59:835-840. [PMID: 32111408 DOI: 10.1053/j.jfas.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 01/12/2020] [Indexed: 02/03/2023]
Abstract
Chronic diastasis after a syndesmotic injury can lead to ankle joint instability and loss of joint congruence. Failure to restore the fibula into the proper anatomic position within the incisura increases the focal stress on the talus and can accelerate degenerative joint destruction. In the case of failed syndesmotic repair, fixation options are limited. If promptly diagnosed, the syndesmosis may be amenable to open debridement and subsequent fixation with 2 interosseous screws. If latent diastasis is found, however, syndesmotic fusion by bone block arthrodesis is recommended. We present a syndesmotic allograft repair technique for surgical reconstruction of chronic unstable syndesmotic ruptures.
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Affiliation(s)
- James C Connors
- Assistant Professor, Division of Foot/Ankle Surgery and Biomechanics, Kent State University College of Podiatric Medicine, Independence, OH.
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Reconstruction of Chronic Injured Distal Tibiofibular Syndesmosis with Autogenous Tendon Graft: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3182745. [PMID: 33604371 PMCID: PMC7870304 DOI: 10.1155/2021/3182745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 01/05/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
Background Chronic injuries of the distal tibiofibular syndesmosis are common in patients who fail to receive adequate diagnosis and timely treatment. Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon graft in these patients is effective, although relatively rarely reported. Purpose To investigate clinical outcomes of syndesmosis reconstruction with an autogenous tendon graft for chronic injuries of the distal tibiofibular syndesmosis by reviewing the current literature. Methods An English literature search was conducted in the MEDLINE, CENTRAL, and Cochrane databases to identify published studies up to October 2017. Preset inclusion and exclusion criteria were applied to identify all eligible articles. Results Five studies (all with level IV evidence) that included a total of 51 patients who underwent reconstruction with an autogenous tendon graft were identified. It was reported that the symptoms were relieved postoperatively, including obviously improved functional outcomes and restoration of motions and exercise capacity. The mean American Orthopedic Foot and Ankle Society scale score of 16 patients was 53 preoperatively and 89 postoperatively. The visual analogue scale score of 14 patients decreased from 82.4 preoperatively to 12.6 postoperatively. A total of 5 (9.8%) complication cases were reported. Conclusion Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon for chronic syndesmosis injury showed a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The interosseous ligament could be an appropriate reconstruction target in the treatment of chronic syndesmosis injury.
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Imaging of Chopart (Midtarsal) Joint Complex: Normal Anatomy and Posttraumatic Findings. AJR Am J Roentgenol 2018; 211:416-425. [PMID: 29927330 DOI: 10.2214/ajr.17.19310] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this article is to review the normal anatomy and posttraumatic findings of the Chopart joint complex. Key imaging features of the normal ligaments and patterns of ligamentous and osseous injuries are discussed. CONCLUSION Traumatic midtarsal injuries, particularly midtarsal sprain, are often overlooked clinically and on imaging but are relatively common and typically are associated with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy and the imaging features of midtarsal injuries because early diagnosis may help optimize clinical management.
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Xu D, Wang Y, Jiang C, Fu M, Li S, Qian L, Sun P, Ouyang J. Strain Distribution in the Anterior Inferior Tibiofibular Ligament, Posterior Inferior Tibiofibular Ligament, and Interosseous Membrane Using Digital Image Correlation. Foot Ankle Int 2018. [PMID: 29533732 DOI: 10.1177/1071100717753160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ligament repair and augmentation techniques can stabilize syndesmosis injuries. However, little is known about the mechanical behavior of syndesmotic ligaments. The aim of this study was to analyze full-field strain, strain trend under foot rotation, and subregional strain differences of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM). METHODS Eleven fresh-frozen lower limbs were dissected to expose the AITFL, PITFL, and IOM. The foot underwent rotation from 0° to 25° internal and 35° external, with 3 ankle positions (neutral, 15° dorsiflexion, and 25° plantarflexion) and a vertical load of 430 N. Ligament strain was recorded using digital image correlation. RESULTS The mean strain on the AITFL with 35° external rotation was greater in the proximal portion compared with distal portion in the neutral position ( P = .009) and dorsiflexion ( P = .003). The mean strain in the tibial insertion and midsubstance near tibial insertion were greater when compared with other regions ( P = .018 and P = .009). The subregions of mean strain in the PITFL and IOM groups were not significantly different. The strain trend of AITFL, PITFL, and IOM showed common transformation, just when the foot was externally rotated. CONCLUSION The findings of this study show that a significantly high strain was observed on the proximal part and the midsubstance near the Chaput tubercle of the AITFL when the ankle was externally rotated. All 3 ligaments resisted the torque in the syndesmosis by external rotation of the foot. CLINICAL RELEVANCE This study allows for better understanding of the mechanical behavior of the syndesmosis ligaments, which could influence the repair technique and AITFL augmentation techniques.
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Affiliation(s)
- Daorong Xu
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China.,2 Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Yibei Wang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Chunyu Jiang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Maoqing Fu
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Shiqi Li
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Lei Qian
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Peidong Sun
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Jun Ouyang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
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JOURNAL CLUB: MRI Evaluation of Midtarsal (Chopart) Sprain in the Setting of Acute Ankle Injury. AJR Am J Roentgenol 2018; 210:386-395. [DOI: 10.2214/ajr.17.18503] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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10
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Lubberts B, van Dijk PAD, Calder JD, DiGiovanni CW. There is no best surgical treatment for chronic isolated syndesmotic instability: a systematic review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2016-000058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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11
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van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 2016; 24:1200-16. [PMID: 26704800 DOI: 10.1007/s00167-015-3942-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 12/09/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management. METHODS A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid. RESULTS The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries. CONCLUSIONS The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pino Florio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Ludovica Maltese
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
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Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 2014; 41:601-14. [PMID: 26037997 DOI: 10.1007/s00068-014-0466-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/20/2014] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy. METHODS The majority of purely ligamentous injuries ("high ankle sprains") is not sassociated with a latent or frank tibiofibular diastasis and may be treated with an extended protocol of physical therapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments that require surgical stabilization. Syndesmosis disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists in anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. Proposed means of fixation are refixation of bony syndesmotic avulsions, one or two tibiofibular screws and suture button. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. RESULTS/COMPLICATIONS The most frequent complication is syndesmotic malreduction and may be minimized with open reduction and intraoperative 3D scanning. Other complications include hardware failure, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. CONCLUSION The single most important prognostic factor is anatomic reduction of the distal fibula into the tibial incisura.
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Affiliation(s)
- S Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - P Obruba
- Department of Traumatology, Masarykova Nemocnice, Socíalní péče 3316/12A, 401 13, Ústí Nad Labem, Czech Republic.
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Abstract
Lateral ligament injuries are the most common sports injury and have a high incidence even in non-sportive activities. Although lateral ligament injuries are very common there is still a controversial debate on the best management. The diagnosis is based on clinical examination and X-ray images help to rule out fractures. Further imaging, especially magnetic resonance imaging (MRI) is used to diagnose associated injuries. According to the recommendations of the various scientific societies the primary therapy of lateral ligament injuries is conservative. Chronic ankle instability develops in 10-20 % of patients and the instability can be a result of sensomotoric deficits or insufficient healing of the lateral ligament complex. If the patient does not respond to an intensive rehabilitation program an operative reconstruction of the lateral ligaments has to be considered. Most of the procedures currently performed are anatomical reconstructions due to better long-term results compared to tenodesis procedures.
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Clanton TO, Chacko AK, Matheny LM, Hartline BE, Ho CP. Magnetic resonance imaging findings of snowboarding osteochondral injuries to the middle talocalcaneal articulation. Sports Health 2014; 5:470-5. [PMID: 24427420 PMCID: PMC3752195 DOI: 10.1177/1941738113497671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This report presents 2 cases of subtle injuries to the subtalar joint, specifically, osteochondral defects of the middle facet of the talus and concomitant involvement of the middle talocalcaneal articulation sustained while snowboarding. The 3T magnetic resonance image revealed fracture of the lateral talar process with osteochondral lesions of the middle talocalcaneal articulation. This injury can lead to severe and chronic disability if undetected and could ultimately end athletic participation prematurely.
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Affiliation(s)
| | - Anna K Chacko
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Charles P Ho
- Steadman Philippon Research Institute, Vail, Colorado, USA
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Upper ankle ligament rupture and long term problems in a patient with Ehlers Danlos Syndrome — a case report. Open Med (Wars) 2013. [DOI: 10.2478/s11536-013-0232-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractRupture of the upper ankle joint ligaments is a common injury. Therapy in patients with Ehlers Danlos Syndrome (EDS) is a challenge due to the autosomal-dominant collagenopathy. Therapeutic recommendations and long term results in treatment of patients with EDS are rare. Therefore uncertainty exists. We present a case of clinical and radiologic long term results after ligament rupture of the upper ankle joint in a patient with EDS. A literature review tries to reveal current therapeutic strategies in patients with EDS.
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Barg A, Tochigi Y, Amendola A, Phisitkul P, Hintermann B, Saltzman CL. Subtalar instability: diagnosis and treatment. Foot Ankle Int 2012; 33:151-60. [PMID: 22381348 DOI: 10.3113/fai.2012.0151] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Subtalar instability is challenging to diagnose. It rarely follows a complete subtalar dislocation, an event more likely to result in subtalar pain, stiffness, and arthritis. By history, subtalar instability can be suggested by the patient’s feeling of ankle instability, easy “rolling over,” and a need to look at the ground constantly when walking. Clinical measures for inversion and eversion do not accurately reflect isolated subtalar motion, as soft tissue and other joint motion confound the examination. Stress radiographs have high false positive rates. Magnetic resonance imaging can show injured or disorganized ligaments suggestive of recurrent subtalar strain, but are not dynamic studies and cannot alone diagnose instability. Operative treatment, when elected, should focus on determining the source of the problem. Generally direct repair of the lateral ligaments is sufficient. Bony malalignment should always be considered especially in the setting when previous ligament reconstruction has failed.
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Affiliation(s)
- Alexej Barg
- Clinic of Orthopaedic Surgery, Kantonsspital Liestal, CH-4410 Liestal, Switzerland.
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Schmitt JW, Werner CML, Ossendorf C, Wanner GA, Simmen HP. Avulsion fracture of the dorsal talonavicular ligament: a subtle radiographic sign of possible Chopart joint dislocation. Foot Ankle Int 2011; 32:722-6. [PMID: 21972769 DOI: 10.3113/fai.2011.0722] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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Affiliation(s)
- Jürgen W Schmitt
- Division of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland.
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Abstract
Chronic ankle and subtalar joint (STJ) instability is a common clinical entity and the physician must be able to determine the exact pathologic condition for proper treatment. There are many diagnostic techniques that can be used to evaluate the ankle joint and STJ. These diagnostic techniques do not take the place of a proper patient history taking. Appropriate and aggressive rehabilitation should be attempted in all cases of chronic ankle and subtalar instability before electing surgical reconstruction.
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Partenheimer A, Geerling J, Voigt C, Lill H. [Early functional treatment and full weight-bearing of surgically treated isolated ankle fractures in the elderly]. Unfallchirurg 2010; 113:308-12. [PMID: 20195841 DOI: 10.1007/s00113-009-1724-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
QUESTION Fractures of the ankle joint belong to the most often occurring injuries. The aftercare in plaster lasts several weeks and is problematic especially in elderly patients. METHODS In a retrospective study patients over the age of 50 years who underwent surgical treatment of ankle fractures and early functional mobilization were examined in a follow-up. The range of motion, the circumferential measurements and the radiological course were examined by comparing preoperative and postoperative X-ray images after 13-24 months. The subjective results were collected using the Olerud-Molander score (OMS). RESULTS A total of 30 out of 42 patients who qualified for the follow-up were included in the study. The distribution of the gender was equal as was the right/left distribution and the mean age was 68 years. The magnitude of movement and comparison between the two sides showed no significant differences. The average score for subjective satisfaction was 90 in the OMS. The radiological results showed few changes and no deviations from the axis. No redislocations or implant fractures could be observed. Early functional full weight-bearing showed satisfactory preliminary results. CONCLUSION This treatment concept can be recommended because patient comfort is increased and the risk of immobilization is excluded.
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Affiliation(s)
- A Partenheimer
- Klinik für Unfall- und Wiederherstellungschirurgie, Abteilung des BG Krankenhauses Hamburg im Friederikenstift, Diakoniekrankenhaus Friederikenstift Hannover gGmbH, Humboldstr. 5, 30169, Hannover, Deutschland.
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Lui TH. Tri-ligamentous reconstruction of the distal tibiofibular syndesmosis: a minimally invasive approach. J Foot Ankle Surg 2010; 49:495-500. [PMID: 20634103 DOI: 10.1053/j.jfas.2010.06.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Indexed: 02/03/2023]
Abstract
The distal tibiofibular syndesmosis provides stability to the ankle mortise, and it is composed of the anterior inferior tibiofibular, posterior inferior tibiofibular, interosseous, and inferior transverse tibiofibular ligaments and the interosseous membrane. Subacute or chronic syndesmosis injuries can present after missed diagnosis in the acute period or after failed or inadequate nonoperative management. It can result in chronic ankle pain and progressive degeneration of the ankle. Reconstructive options for chronic syndesmosis disruption include arthroscopic debridement and screw fixation, arthrodesis of the syndesmosis, advancement of the anterior tibiofibular ligament, reconstruction of the interosseous and anterior inferior tibiofibular ligament, or tri-ligamentous reconstruction of the syndesmosis. We describe a minimally invasive technique of nearly anatomical reconstruction of the 3 syndesmotic ligaments. The syndesmosis is debrided and reduced under arthroscopic guidance and anatomical reduction of the syndesmosis can be achieved. Although we describe this technique for surgeons to consider, we recognize that a thorough clinical review of the method, complete with objective and subjective clinical outcome measurements, is warranted before widespread use of the technique.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, NT, Hong Kong SAR, China.
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21
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22
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Abstract
HYPOTHESIS Subtalar instability is thought to be one of the possible causes for chronic functional instability of the foot and ankle. The purpose of this study was to determine the extent of ligament injury that is followed by subtalar instability and to depict consecutive pathologic joint motion. METHODS Twelve fresh human cadaver lower legs were investigated with respect to pathologic motion and mobility of the subtalar joint in a modified spinal column simulator after arthrodesis of the talocrural articulation and selective sectioning of the lateral ligaments of the subtalar joint. In order to simulate several injury mechanisms, ligaments were dissected starting anteriorly in group one (n = 6) and posteriorly in group two (n = 6). RESULTS Dissection of the bifurcate ligament in group one resulted in a significant increase in plantar- and dorsiflexion, dissection of the inferior extensor retinaculum resulted in a significant increase in eversion and inversion. Additional dissection of the lateral talocalcaneal ligament resulted in a significant increase in internal and external rotation. Dissection of the calcaneofibular ligament in group two was followed by significant kinematic changes regarding all degrees of motion in the subtalar joint. CONCLUSIONS The calcaneofibular ligament plays a key role in lateral stabilisation of the subtalar joint. Therefore, ligaments of the subtalar joint should be included in surgical repair.
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Tang YM, Wu ZH, Liao WH, Chan KM. A study of semi-rigid support on ankle supination sprain kinematics. Scand J Med Sci Sports 2009; 20:822-6. [DOI: 10.1111/j.1600-0838.2009.00991.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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A new one-DOF fully parallel mechanism for modelling passive motion at the human tibiotalar joint. J Biomech 2009; 42:1403-1408. [DOI: 10.1016/j.jbiomech.2009.04.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 04/02/2009] [Accepted: 04/07/2009] [Indexed: 12/26/2022]
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25
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Hubbard TJ. Ligament laxity following inversion injury with and without chronic ankle instability. Foot Ankle Int 2008; 29:305-11. [PMID: 18348827 DOI: 10.3113/fai.2008.0305] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Not all patients develop chronic ankle instability (CAI) after one or more lateral ankle sprains; some seem to heal or adjust to the ankle laxity after injury. Why do some patients develop CAI and others are able to cope and return to normal function? The purpose of this study was to examine ligament laxity between subjects with and without CAI. MATERIALS AND METHODS Sixteen subjects with unilateral CAI and 16 subjects without participated in the study. Ligament laxity was measured with an instrumented ankle arthrometer. The arthrometer measured ankle joint motion for anterior/posterior displacement (mm) during loading at 125 N and inversion/eversion rotation (degrees of ROM) during loading at 4000 N/mm. For each dependent variable a 2 x 2 mixed model ANOVA was run with the between factor being group (CAI, No CAI) and the within factor with repeated measures being side (involved, uninvolved). RESULTS A significant group by side interaction for anterior displacement (F(1,30) = 370.085, p < 0.001), and inversion rotation (F(1,30) = 7.455, p = 0.010) was found. There was significantly more anterior displacement and inversion rotation for the involved ankles of the CAI group than the involved ankles of the stable group and the uninvolved ankles of the CAI group. CONCLUSION Based on the results of this study it appears that the increased anterior displacement and inversion rotation compared to patients without instability may be why subjects develop CAI. Although the patients without instability have a history of more than one lateral ankle sprain, they did not demonstrate increased laxity, which may be the reason why they do not complain of the functional impairment demonstrated in subjects with CAI.
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Affiliation(s)
- Tricia J Hubbard
- University of North Carolina Charlotte, Department of Kinesiology, Charlotte, NC 28223, USA.
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26
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Di Gregorio R, Parenti-Castelli V, O'Connor JJ, Leardini A. Mathematical models of passive motion at the human ankle joint by equivalent spatial parallel mechanisms. Med Biol Eng Comput 2007; 45:305-13. [PMID: 17295023 DOI: 10.1007/s11517-007-0160-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 01/03/2007] [Indexed: 12/26/2022]
Abstract
The paper presents a theoretical model of the ankle joint, i.e. tibio-talar articulation, which shows how the articular surfaces and the ligaments, acting together as a mechanism, can control the passive kinematics of the joint. The authors had previously shown that, in virtually unloaded conditions, the ankle behaves as a single degree-of-freedom system, and that two ligament fibres remain nearly isometric throughout the flexion arc. Two different equivalent spatial parallel mechanisms together with corresponding kinematic models were formulated. These assumed isometricity of fibres within the calcaneal-fibular and tibio-calcaneal ligaments and rigidity of the articulating surfaces, taken as three sphere-plane contacts in one model, and as a single spherical pair in the other. Geometry parameters for the models were obtained from three specimens. Motion predictions compare quite well with the measured motion of the specimens. The differences are accounted for by the simplifications adopted to represent the complex anatomical structures, and might be reduced by future more realistic representations of the natural articular surfaces.
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Affiliation(s)
- R Di Gregorio
- Department of Engineering, University of Ferrara, Ferrara, Italy
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27
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Abstract
Lateral ankle sprains are one of the most common athletic injuries. Even more concerning is the high recurrence rate after an initial sprain. The development of repetitive ankle sprains and persistent symptoms after injury has been termed chronic ankle instability (CAI). One of the purported causes of CAI is mechanical ankle instability (MAI).MAI results in abnormal ankle mechanics. Both hypermobility and hypomobility may change a joint's axis of rotation and result in abnormal joint mechanics. The role of hypermobility, or laxity, has been examined extensively in the literature, but more recently the role of hypomobility has also been examined. There may be a relationship between the two, with implications at the talocrural, subtalar, and inferior tibiofibular joints.Assessment and treatment should focus on both hypermobility and hypomobility and although injury may seem to be isolated to the talocrural joint, the inferior tibiofibular and subtalar joints should also be thoroughly examined.
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Affiliation(s)
- Tricia J Hubbard
- Department of Kinesiology, University of North Carolina at Charlotte, Charlotte, North Carolina 28223, USA.
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28
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Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther 2006; 36:372-84. [PMID: 16776487 DOI: 10.2519/jospt.2006.2195] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. The purpose of this clinical commentary is to review the mechanisms of syndesmotic injuries, clinical examination methods, diagnosis, and management of the injuries. Cadaveric studies of the syndesmosis and deltoid ligaments are also reviewed for further understanding of stress transmission and the roles of different structures in stabilizing the distal syndesmosis. External rotation and excessive dorsiflexion of the foot on the leg have been reported as the most common mechanisms of injury. The injury is most often incurred by individuals who participate in skiing, football, soccer, and other sport activities played on turf. The external rotation and squeeze tests are reliable tests to detect this injury. The ability of imaging studies to assist in an accurate diagnosis may depend on the severity of the injury. The results of cadaveric studies indicate the importance of the deltoid ligament in maintaining stability of the distal tibiofibular syndesmosis and the congruency of the ankle mortise. Intervention programs with early rigid immobilization and pain relief strategies, followed by strengthening and balance training are recommended. Heel lift and posterior splint intervention can be used to avoid separation of the distal syndesmosis induced by excessive dorsiflexion of the ankle joint. Application of a rigid external device should be used with caution to prevent medial-lateral compression of the leg superior to the ankle mortise, thereby inducing separation of the distal syndesmosis articulation. Surgical intervention is an option when a complete tear of the syndesmotic ligaments is present or when fractures are observed.
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Affiliation(s)
- Cheng-Feng Lin
- Center for Human Movement Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7135, USA
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30
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Abstract
There has been extensive research and investigation into the subtalar joint (STJ), yet the biomechanics that relate to its anatomic function, especially instability after injury, are surrounded by controversy. With a mechanism of injury closely related to the classic inversion ankle sprain, chronic instability can result following trauma to the lateral ligamentous support network of either joint. Over the past decades there have been countless examples in the literature challenging the current standard of evaluation and treatment of the "subtalar sprain." New technologies have offered varied approaches to diagnostic capability, each with its own strengths and weaknesses, ranging from standard radiographs to CT and MRI. A review of the literature should aid in deciphering the controversy surrounding this aspect of podiatric medicine.
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Affiliation(s)
- Adam Budny
- St. Vincent's Charity Hospital, 2351 East 122nd Street, Cleveland, OH 44125, USA.
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31
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Abstract
The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.
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Affiliation(s)
- Stefan Rammelt
- Department of Trauma & Reconstructive Surgery, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany.
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32
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Abstract
Sprains of the hindfoot, midfoot and forefoot are being diagnosed with more regularity in athletes. Each of these injuries can go on to develop chronic instability with associated disability. With early diagnosis and appropriate treatment significant morbidity and loss of playing time can be avoided. Knowledge of the relevant anatomy, mechanism of injury, and available diagnostic tools is essential for making the proper diagnosis. Once the correct diagnosis is made, proper treatment can be implemented to avoid long term complications of instability.
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Affiliation(s)
- John E Mullen
- New Milford Hospital, 131 Kent Road, New Milford, CT 06776, USA
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Westlin NE, Vogler HW, Albertsson MP, Arvidsson T, Montgomery F. Treatment of lateral ankle instability with transfer of the extensor digitorum brevis muscle. J Foot Ankle Surg 2003; 42:183-92. [PMID: 12907928 DOI: 10.1016/s1067-2516(03)70027-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, some injuries may be followed by chronic lateral pain and instability, and surgical stabilization is sometimes necessary. In select cases, there is little or no residual ligament or scar tissue remaining for late reconstruction. Proximal transfer of the origin of the extensor digitorum brevis muscle as a substitute for deficient ligament tissue can be used in these difficult cases. During the years 1971 to 1992, 13 ankles in 10 patients underwent surgery using the proximal extensor digitorum brevis muscle transfer method. At follow-up, all the ankles manifested functional stability and were stable with no clinical drawer sign. All had a normal range of motion in the ankle joint but showed a desired decreased supination range of motion throughout the hindfoot and ankle. The functional Karlsson scores were 84.5 +/- 18.8 before injury, 26.4 +/- 18.7 before surgery, and 83.6 +/- 18.7 at follow-up. Thus, the extensor digitorum brevis muscle transfer seems to be a useful alternative method of long-term ankle stabilization in these difficult chronic case; the results correlate well with a few other studies using this method.
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