Ankle Ligament Injuries: Missed Opportunities2019 AOAO Foot & Ankle Section Discussion on Complications
Ankle Ligament Injuries: Missed Opportunities
2019 AOAO Fall Meeting
Disclosures:‐Paid Consultant: Artelon
Conclusions!• When possible, scope your ankle
fractures• Scope your Brostrum/lateral ankle
repairs• Repair syndesmosis avulsion
injuries/fractures• Fix more deltoid ligament injuries• Catch acute spring ligament tears
and fix them• An anchor‐free Brostrum repair is
a great operation
The role of ankle arthroscopy in ankle fracture surgery:
• Chan et al 2016• Gonzalez et al 2016• Fuchs et al 2016• Fuchs et al 2016
Should we Pre‐Scope all Modified Brostroms?
• Choi AJSM 2008 (97%)• Ferkel FAI 2007 (95%)• Ferkel FAI 1999(93%) • Hua JARS 2010 (91%)• Yeo FAI 2016 (68%)• Hintermann 2002 (66%)
Arthroscopy’s Role in Lateral Ligament Repair Surgery
Guelfi et al, F&A Sx, 2018• 13 studies, 505 pts• 6.1 year avg f/u• AOFAS 90.1 avg, 2 studies with
Karlsson scope 95, 88.2• G&E 91.7%• Buerer et all RTSport 4.7 mo• Schmidt RTW 38.5 days• 7.92% compl (supr wound 2%,
sensory disturbances2%, swelling >6 mo 1.4%, rerupture 1%)
So et al, JFAS 2017• 11 studies, 669 pts• 8.4 year avg f/u• 1.2% revision rate
• Overconstraint #1 reason
• 5.6% complication rate• 42% nerve related
Evolution of Lateral Ankle Ligament Repair
• All patients had arthroscopic exam
• Clinical and radiographic outcomes were equal between both groups and in line with established high standards
Yeo et al, FAI, 2016 says YES• Roger Mann Award Winner• Level I study• 1 year f/u • All‐inside scope repair vs
anchor‐less open MB• AOFAS,
Karlsson/VAS/stress radiographs
Can we then make the leap to all‐arthroscopic MB?
• Less invasive? ‐ yep• Quicker recovery? ‐maybe• Petrera 2014 AJSM immediate WB
with 2 anchors• Lower complications? ‐not yet• Just as strong? – Yep
Giza 2013Lee 2016
• Just as effective? – yep• More efficient? – I think YES
Can’t deny the inevitable: “arthroscopy IS the future”....Can we?
Special thanks to Dr Anderson for the fibula stress fracture radiograph copied from VuMedi Deltoid repair lecture
Foot & Ankle International, 2018• Woo et al• 37 ankle fx ORIF w/non‐op deltoid• 41 ankle fx ORIF with deltoid repair• Medial clear space (MCS) sig.
smaller in deltoid repair group• Deltoid repair in syndesmosis ORIF
patients had sig. smaller MCS and improved pt. subj. outcomes
• Are they reducing post‐op / post‐traumatic OA?
Journal of Orthopedic Trauma, 2015• Jones, Nunley• SER‐4 ankle fx with intact
medial malleolus• 15 pt with syndesmosis ORIF• 12 pts with deltoid repair• Avg 50 month f/u• One reduction loss in syndesmosis
group• 6 different subjective outcome
scores equal between groups• All syndesmosis screws removed
Fixing the Deltoid – The Scores are Coming In!
Foot & Ankle International, 2015• Hsu et al• Described open deltoid repair
during ankle fx ORIF in 14 NFL players
• Scoped all ankles• Superficial deltoid avulsion from
medial malleolus• 86% return to play
Deltoid repair picsWe are the ones dealing with the valgus instability later, the flatfeet, the medial compartment OA. Can we do better at the index procedure to prevent these late sequela of deltoid insufficiency?We know that the majority of ankle OA is post‐traumatic. Are we doing enough to prevent OA when we advocate ignoring deltoid ruptures?
Fixing the Deltoid – The Scores are Coming In!
Subtalar Joint Instability
• 80% of patients with chronic ankle instability (Denegar et al, Med Sci, 1999)
• Make STJ stability exam part of your routine
• Ehlers Danlos patients beware• ALWAYS manually inspect the CFL
(MRI can miss tears)
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