STG LAS 2024 PDF - Chronic Lateral Ankle Instability

Chronic Lateral Ankle Instability Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot a...

Chronic Lateral Ankle Instability Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot and Ankle Surgeons 1 Objectives Demonstrate knowledge of the etiology of ankle instability Recognize imaging techniques to identify instability of the ankle Demonstrate knowledge of the management of ankle instability 2 Ankle Injuries Among the most common injuries presenting to primary care providers and emergency departments. Approximately 2 million ankle sprains occur in the USA annually. Ankle sprains can result in significant time lost to disability. Repeated sprains can result in chronic ankle instability, degenerative joint changes, and chronic pain. Med Clin North Am. 2014 Mar;98(2):313-29. 3 Lateral Anatomy 4 Lateral Anatomy 5 Lateral Anatomy 6 Chronic Ankle Instability Acute ankle sprains can lead to chronic ankle instability Biomechanical causes: Pathologic laxity Recurrent ankle sprains Connective soft tissue disorder Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. 7 General Recovery 6 weeks to 3 months Up to 42% of patient will still have some feeling of instability at 1 year 3-34% Re-Sprains Poor Prognostic Factor Training 3 or more times per week 8 Types of Instability Functional Instability Mechanical Instability Presence of symptoms of giving way without clinical or radiographic signs of laxity Patients who have demonstrable ligamentous laxity 9 Symptoms… Repetitive episodes of “giving way” History severe ankle sprain or multiple ankle sprains Sense of “looseness” Apprehension about their next instability episode Difficulties with walking on uneven ground Pain is not a predominant symptom 10 Physical Exam Talar Tilt ✴Area’s of Tenderness ✴Evaluate strength of peroneal tendons ✴Evaluate proprioception via modified ✴Clinical Stress Exam 11 Anterior Drawer Biomechanical and Structural Etiologies ✓ Fixed calcaneal Varus ✓ Tibial Varum ✓ Rigid plantarflexed first ray ✓ Phasic overactivity of the anterior and posterior tibial tendons ✓ Calcaneal and Talar Torsional abnormalities 12 Physical Exam 13 Hypermobility 14 Stress Exam 15 Subtalar Joint Instability 16 STJ Instability Diagnosed as: Medial displacement of more than 5mm of the talus to the calcaneus Talocalcaneal tilt of more than 5° Brostrom , ACTA Chir Scand, 132: 551-565 1966 17 MRIs 18 Conservative Treatment Taping and Bracing are both effective, especially in preventing recurrent sprains Bracing is more cost effective and faster Semirigid braces with stirrup design Proprioception effective for preventive training Peroneal Strengthening Plyometric training 19 Indications for Surgical Intervention ✦ Non-Operative failure ✦ Pain with “giving away” ✦ Mechanical / Functional instability ✦ Positive stress test 20 21 Treatment of Chronic Ankle Instability Surgical Treatment Indirect Repair (Historical) A – Watson-Jones B – Evans C – Chrisman-Snook Sacrifice the PB 22 23 24 25 26 27 28 29 30 31 32 Treatment of Chronic Ankle Instability Surgical Treatment Direct repair Brostrom 33 Treatment of Chronic Ankle Instability Surgical Treatment Direct repair Brostrom-Gould 60% increase in strength 34 Primary ATF Repair 35 35 36 Contraindications for Brostrom Failed Brostrom Generalized Laxity Poor Tissue/BMI 37 38 Anatomic Reconstruction Peroneus Longus Allograft 39 Anatomic Reconstruction Surgical Treatment Indirect Repair (Contemporary) Synthetics Arthrex Internal Brace 40 Summary 41 Questions? 42