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Ankle Injury Treatment Options
Benjamin R. Proto, DPM Matthew A. Hopson, DPM Ankle Osteoarthritis & Related Conditions Ankle Osteoarthritis & Related Conditions • Pathogenesis and Etiology • Clinical Findings • Radiographic Findings • Treatment Algorithm Diagnostic Studies/Procedures • X-ray • CT scan • MRI • Diagnostic Local Anesthesia Injection Pathogenesis and Etiology • Intrinsic -Supporting Muscle Weakness -Ligamentous Laxity -Proprioceptive Deficiency -Joint Malalignment • Extrinsic -Injury -Obesity • Systemic -Age -Gender -Genetics -Nutrition Clinical Findings • Pain (worse in the morning and end of the day) • Loss of motion and flexibility • Joint crepitation and clicking • Locking of the joint • Swelling • Joint instability • Difficulty ambulating Radiographic Findings Asymmetrical joint space loss • Loose bodies • Subchondral sclerosis • Joint malalignment • Normal Joint Arthritic Joint Treatment Algorhrim Nonoperative Therapy • Anti-inflammatories • Bracing, rocker-bottom footwear • Local anesthesia patches • Immobilization • Cortisone injections • Physical therapy • Dietary supplements (glucosamine 1500mg-chondroitin 800-1200mg daily) When is Surgery Necessary? • When non-operative treatment fails to provide pain relief and control of deformity • Pain and deformity that alters gait pattern • Ankle instability Surgery Treatment Algorhrim •Debridement - arthroscopic, arthrotomy Arthrodiastasis - joint distraction w/ or w/o debridement • Ankle Arthroplasty - total ankle joint replacement • Ankle Arthrodesis – tibiotalarfibular fusion • Debridement Goals Pain Reduction • • Increase Joint Range of Motion • Restore Gait Pattern • Reduces Further Risk of Joint Deterioration Debridement Ankle Joint Pathology Synovitis • Anterior Impingement • Meniscoid Bodies(fibrous bands) • Cartilaginous Lesions • Osteochondral Bodies • Chondromalacia • Talar Dome Lesions • Arthroscopic Debridement Synovitis Anterior Impingement Anterior Exostosis Meniscoid Lesions Meniscoid lesions - fibrotic inflammation of the synovial membrane in the ankle, usually resulting from an inversion ankle sprain. They resemble a torn meniscus of the knee and usually must be removed surgically. Early meniscoid lesion Meniscoid lesion Cartilage Lesion Osteochondral Bodies Chrondromalacia Normal Joint Grade III chondromalacia Grade II chondromalacia Stage IV chondromalacia Talar Dome Lesions Berndt and Harty Classification Stage I - Caused by compression between the talar dome and tibial plafond or medial fibular surface - Arthroscopic treatment involves abrasion arthroplasty or curettage Stage II - Lesions can be saucerized with a curette, probe, or they can be abraded Stage III - Usually diagnosed radiographically - Tx same as Stage II plus extraction of lesion and abrasion Stage IV - Tx same as Stage III - OATS if microfracture fails Talar Dome Lesions Talar Dome Lesions Stage III lesions Ankle Joint Arthrodiastasis • The term Arthrodiastasis comes the Greek word “arthros” = joint and “diastis” = separation or gap. • Although the concept was discussed as early as 1978, the use of joint distraction as a means of treating cartilaginous defects became more common in Europe during the late „80s and early „90s. • The term was coined in 1993 by Canadell, Gonzalez, Barrios, and Amillo. They used the term to describe a procedure, which involved the stretching of hip joints in adolescent patients with Legg-CalvesPerthes disease to relieve intraarticular pressure. Ankle Joint Arthrodiastasis • This concept has been applied to the arthritic ankle joint to increase joint space and allow for cartilage repair. • Mechanism -The distracted joint can adapt to pressure changes in the synovial fluid which increases proteoglycan (Aggrecan and Versican) metabolism. Stabilizes and stimulates cartilage formation. -Reestablishes cartilage health, stabilizes and strengthens the joint. • Application of circular external fixator. • Weight bearing on the foot is required. • Can be performed w/ or w/o joint debridement. Arthrodiastasis • • Indications – Early stage arthritis – Age 14-70 – Congruous joint – May be expanded to include talar AVN Contraindications – Poor skin quality – Vascular compromise – Non-compliance – Severe osteopenia Arthrodiastasis Advantages • Minimally invasive • Outpatient procedure • Postpones ankle replacement or arthrodesis • Reduces pain and disability by: -Increasing joint space -Joint surface regeneration -Removal of spurs and synovitis Arthrodiastasis Technique – Distraction nuts on threaded rods between leg and foot rings. – Distract 7-10mm in surgery and maintain for 6-10 weeks. Arthrodiastasis Post-operative Recovery • Immediate weight-bearing following surgery • Fixator duration 6-10 weeks • Physical therapy following fixator removal • May take up to 12 -14 months to receive maximal improvement Osteoarthritis Osteoarthritis • Open arthrotomy debridement • Arthrodiastasis Osteoarthritis Osteoarthritis Post-op •Increase ROM •Decreased pain Post-traumatic Chondrolysis 15 yoa male sustained a Gustillo grade 2, Salter Harris grade 3 distal tibial fx and grade 1 distal fibular fx Post-traumatic Chondrolysis Post-traumatic Chondrolysis Post-traumatic Chondrolysis Post-traumatic Chondrolysis Osteoarthritis •Debridement and arthrodiastasis Osteoarthritis Talar OCD •39 y/o male with ankle pain •Previous ankle arthroscopic debridement and subchondral drilling Talar OCD •Medial malleolar osteotomy, osteochondralbone graft OATS = osteochondral autogenous/allograft transport system Talar OCD Arthrodiastasis Talar OCD Talar OCD Talar OCD Total Ankle Joint Replacement Indications •Osteoarthritis •Rheumatoid Arthritis •Post Traumatic Arthritis •Failed Ankle Arthrodesis •AVN of the Talus Contraindications •Infection •Poor Skin Quality •Severe Varus or Valgus Ankle •Pt weight over 250 lbs •Compromised Vascular Status •Deltoid Insufficiency •Decreased Bone Stock •Complex Regional Pain Syndrome Total Ankle Joint Replacement Considerations •50 yoa and older •Low level activity •Concomitant deformities Total Ankle Joint Replacement Total Ankle Joint Replacement Advantages •Motion at the ankle joint •More normal gait pattern •Decreased stress on surrounding joints Disadvantages •Longevity of the implant •Requires low level activity Total Ankle Joint Replacement Risks •Infection •Implant loosening •Implant failure Total Ankle Joint Replacement Total Ankle Joint Replacement Total Ankle Joint Replacement T.P.M.G. ORTHO ANKLE ANKLE AP AP 9/12/2011 9:57:04 AM 20110912094757ONN ------- Total Ankle Joint Replacement Total Ankle Joint Replacement 63 yoa female with chronic right ankle pain, failure to improve with injections, bracing, PT, and antiinflammatories. Total Ankle Joint Replacement Total Ankle Joint Replacement Rouilliard, Rouilliard, Ann Ann 177586736 177586736 2/22/1964 2/22/1964 46 46 YEAR YEAR FF Total Ankle Joint Replacement T.P.M.G. ORT FO F AP STAND 1/21/2011 1:27:12 20110121125943 T.P.M.G. ORTHO FOOT FOOT AP STANDING 1/21/2011 1:23:44 PM 20110121125943ONN ------- Z: 0 C: 8 W: 16 Total Ankle Joint Replacement Rouilliard, Rouilliard, Ann Ann 177586736 177586736 2/22/1964 2/22/1964 47 47 YEAR YEAR FF T.P.M.G. ORTHO ANKLE ANKLE AP AP 7/13/2011 8:38:44 AM 20110713083159ONN ------- T.P.M 7/13/2011 201107130 ncy ncy 6 6 Total Ankle Joint Replacement Adams, Adams, Nancy Nancy 227681346 227681346 5/28/1948 5/28/1948 63 63 YEAR YEAR FF TPMG WBG ORTHO ANKLE ANKLE LAT LAT 7/11/2011 10:30:33 AM 20110711102154OWM ------- S: 85 TP 9/6/2 9/6/2 201109 Total Ankle Joint Replacement Total Ankle Joint Replacement Total Ankle Joint Replacement Recovery – 4 to 6 weeks cast NWB – Followed by 3 weeks Cam walker boot – Physical therapy for increased motion – Home ROM exercises Ankle Joint Arthrodesis •Performed for over a century •Over 40 procedures described in the literature •Approaches: open, mini-arthrotomy, arthroscopic Indications End-stage arthritis Malalignment Charcot deformity AVN Gout Failed ankle replacement Infection Maliginancy Dropfoot Congenital deformities Ankle Joint Arthrodesis Contraindications •Poor Skin Quality •Compromised Vascular Status •Complex Regional Pain Syndrome Risks •Non-union •Adjacent Joint Deterioration Ankle Joint Arthrodesis Methods of Fixation •Pins •Screws •Plate and screws •External fixation •Intramedullary nail Ankle Joint Arthrodesis •Traumatic arthritis with screw fixation Retrograde Intramedullary Nail Retrograde Intramedullary Nail Retrograde Intramedullary Nail Cothra Cothran, n, Re Rebe becca cca S S 255152442 255152442 7/18/1960 7/18/1960 51 51 YEAR YEAR F F T.P .M.G. ORTHO ANKLE ANKLE AP AP 8/31/2011 1:24:45 P M 20110831131533ONN ------- Z: 0.41 C: 8192 W: 16383 P Pa age ge:: 1 1 of of 3 3 cm cm IM: 1 Arthroscopic Arthrodesis Ankle Joint Arthrodesis 38 y/o female, smoker, hep c 1 year hx of ankle pain and swelling Failed PT, anti-inflammatory meds, cortisone shots, bracing, splinting, NWB MRI Ankle Joint Arthrodesis Ankle Joint Arthrodesis Nonunion from previous arthroscopic arthrodesis Ankle Joint Arthrodesis •Open revisional arthrodesis •External fixation Ankle Joint Arthrodesis Ankle Joint Arthrodesis Allograft Joint Replacement On the horizon •Total joint replacement with allograft bone •Indicated for younger patients •Exiting graft processing limitation Thank You
