Ligamentous and Tendon Ligamentous and Tendon Injuries About the AnkleInjuries About the Ankle

UCMC Trauma Conference 5/2/12

Talus

Medial

Superficial

Superficial talotibial, naviculotibial, and calcaneotibial fibers

Deep–Deep anterior talotibial and posterior talotibial fibers from posterior colliculus to talus–Strongest portion of the Deltoid ligament

Lateral Collateral Ligaments

Anterior Talofibular Ligament

– First injured in lateral sprain with plantarflexed ankle

Calcaneofibular Ligament

– Strongest lateral ligament

– First injured in lateral sprain with dorsiflexed ankle

Posterior Talofibular Ligament

Syndesmosis

Anterior inferior tibiofibular ligament

Posterior inferior tibiofibular ligament

Transverse tibiofibular ligament

Interosseous membrane

Ankle Sprains

Most common ligamentous injury One sprain per day per 10,000 people 40% will have intermittent chronic problems (Garrick, Am J Sports Med, 1977) More common on the lateral aspect of the ankle

Physical Exam– Palpation over medial and

lateral malleoli– Palpation over deltoid ligament– Palpation over ATFL, CFL, and

PTFL– Neurovascular exam– Anterior drawer test for ATFL– Talar tilt to assess CFL– Squeeze test to look for

syndesmotic injury

EXAM

Most common mechanism of ankle injury is inversion stress with plantarflexion

– May lead to ankle fracture, sprain, or syndesmotic injury

Abduction or adduction are other mechanisms

AP of the Ankle– Tibio-Fibular Clear

Space AB < 5mm is

normal– Tibio-Fibular

Overlap BC > 10 mm is

normal

Mortise View– Ankle internally

rotated– AB clear space– BC overlap– Talocrural angle (83

degrees)– Medial clear space

<4 mm

Ankle Stress Radiographs

Talar tilt view– Demonstrates complete

ligamentous instability– Talar tilt <2 mm

External rotation view– Useful in identifying

syndesmotic injury

Ankle Stress Radiographs Anterior drawer

stress view– No fracture seen– >3 mm anterior

translation compared to contralateral side or >10 mm translation

– Incongruency of ankle joint present

– Ligamentous instability present

Lateral Ankle Sprains Commonly missed diagnoses

– Peroneal tendon injuries– Achilles injuries– FX’s

Lateral process of talus Anterior process of

calcaneus Fifth metatarsal Lisfranc injuries

– Osteochondral Lesion of the Talus

Lateral Ankle SprainsLateral Process FX of the Talus

“Snowboarders” injury

Ankle Sprain Treatment

RICE ROM exercises Peroneal strengthening and proprioceptive training

Ligament Reconstructions

These procedures use the peroneal tendons to reconstruct the lateral ligamentous complex

Higher complication rates than Brostrom More restricted ankle and subtalar motion (Colville, JAAOS,

1998)

Medial Ankle Sprain

5% ankle sprains Forced eversion Injury to deltoid ligament May be associated with

syndesmotic injury and/or Weber C fibula FX

Syndesmotic (High) Ankle Sprains

Syndesmosis Exam

Squeeze Test– Squeeze the

syndesmosis above the ankle→pain

Abduction-External Rotation Stress Test– Further instability with

external rotation (may be shown with x-ray)

Gravity Stress Test– Foot hanging free in

lateral position with mortise view taken

Stress Radiograph - Technique

Stress View

SER-2

Negative Stress view

External rotation of foot with ankle in neutral flexion (00)

Stable Treatment FWBAT

+ Stress View

Widened Medial Clear Space

Syndesmosis Injury Surgical Treatment

– Maximally dorsiflex hindfoot

– Reduce the syndesmosis with a large clamp under fluoro by internally rotating the fibula and compressing it to the tibia

– Perform medial arthrotomy if unable to reduce in order to debride medial ankle joint

Fixation

Screws are not lagged!

Syndesmosis Controversies

Number of Screws– One vs. two, 3.5 mm screw vs. 4.5 mm

screw Number of Cortices

– Three vs. four corticesAnkle position during placement

– Classically dorsiflexion was advocated– Tornetta showed no difference with

plantarflexion

Endobutton and Heavy SutureEndobutton and Heavy Suture– Potential Benefits Potential Benefits

flexible fixation, no need for implant flexible fixation, no need for implant removal, earlier weight bearingremoval, earlier weight bearing

Improved subjective outcomes similar Improved subjective outcomes similar objective outcomesobjective outcomes

Ankle Dislocations

Isolated ankle dislocation is rare Mechanism is forced inversion

that results in a posteromedial dislocation

Anterolateral ligaments damaged

Commonly open 30 - 90% Rule out neurovascular injury

Tibiotalar Dislocations

Management closed injury

– Check neurovascular status

– Prompt closed reduction

– Cast for 6 weeks in plantigrade position

– Results generally good

– Results not improved with acute ligament repair

– Late instability rare

Achilles Tendon Ruptures AnatomyAnatomy

– 10-12 cm long10-12 cm long– 0.5-1.0 cm diameter0.5-1.0 cm diameter– Avascular zone 2-6 cm proximal to Avascular zone 2-6 cm proximal to

insertioninsertion– Fibers rotate 90 degrees at insertionFibers rotate 90 degrees at insertion

Achilles Tendon Rupture

– Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain– Average age 35– Steroids, fluorquinolones, and chronic overuse may predispose to rupture

Pathology– Rupture occurs 3-4 cm above the Achilles insertion in a watershed area

Physical Exam– Tenderness over

achilles tendon– Palpable defect– Positive Thompson’s

test– No evidence to support

routine use of MRI, U/S, or Xray

Achilles Tendon Rupture

Achilles Tendon Ruptures

Surgical repairSurgical repair– Younger active patientsYounger active patients

Nonoperative treatmentNonoperative treatment– Older sedentary patientsOlder sedentary patients– Patients with increased risk of soft tissue complicationsPatients with increased risk of soft tissue complications

IDDMIDDM SmokersSmokers Vascular diseaseVascular disease BMI > 30BMI > 30

Management of Non-Operative Tx

Short leg cast strategy (SLC)– SLC is applied w/ ankle in plantarflexion– Cast is brought out of equinus over 8-10

weeks– Walking is allowed (in the cast) at 4-6 weeks– Alternatively, consider using functional brace

starting in 45 degrees of flexion– Following casting, a 2 cm heel lift is worn for

an additional 2-4 monthsLong leg cast (LLC)

– Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks

Clinical Evidence to Support Nonoperative Treatment Benefits: no wound complications, no scar, decreased patient cost.

Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and endurance.

Gillies and Chalmers- – 80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively

Wills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%.– skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual

anesthesia risks

Surgical treatmentSurgical treatment– Preferred for Preferred for

athletesathletes– Medial incision Medial incision

avoids the sural avoids the sural nervenerve

– Percutaneous vs. Percutaneous vs. Open treatments Open treatments describeddescribed

– Isolate the Isolate the paratenon as a paratenon as a separate separate layer

Clinical Results Surgical Clinical Results Surgical ReconstructionReconstruction

Benefits: 0-5% re-rupture rate, > percentage patients Benefits: 0-5% re-rupture rate, > percentage patients return to sport, improved power, strength, and endurance.return to sport, improved power, strength, and endurance.

Disadvantages: > patient cost and wound complicationsDisadvantages: > patient cost and wound complications Clinical series: many techniquesClinical series: many techniques

– Most Bunnel or Modified Kessler sutureMost Bunnel or Modified Kessler suture– Some with augmentation EHL vs. Gastrocnemius Some with augmentation EHL vs. Gastrocnemius

fascia vs. Plantaris tendonfascia vs. Plantaris tendon

Operative Support Cetti et al. compared operative versus

non-operative treatment in a prospective study with 111 patients

– In the operative group (56 patients), there were three re-ruptures (5%) and two deep infections, as compared with eight re-ruptures (15%) in the non-operative group (55 patients)

– The operative group had a significantly higher rate of resuming sports activities at same level prior to rupture (57.1% vs 29.1% of pts), a lesser degree of calf atrophy (1.6 cm vs 1.1 cm calf circum.), significantly fewer complaints at 1 year (29% vs 49% of pts), and better ankle movement at 1 year (82% vs 53% of pts, op vs non-op, respectively)

Percutaneous Achilles Repair

Chronic Achilles Tendon Rupture

History– Remote hx trauma, post

pain, gradual improvement of symptoms, palpable tendon defect.

– No hx trauma, gradual thickening of tendon, AM startup pain, pain ascending/descending stairs.

Physical Exam– “Hatchet” posterior calf at

site of defect at resolution of swelling

– Positive Thompson test– Weakened plantar flexion

MRI

<3 cm gap, <3 months old—primary repair

>3cm gap—scar tissue debridement and V-Y lengthening of proximal gastroc tendon granted that remaining tissue no evidence inflammation

Evidence chronic inflammation—augmentation with FHL tendon

Chronic Achilles Rupture Chronic rupture may

be reconstructed with FHL, FDL, or slip from gastrocnemius

Achilles Tendon RupturesReconstruction of neglected rupture with Reconstruction of neglected rupture with peroneus longus and plantaris weaveperoneus longus and plantaris weave

V-Y Lengthening: >3 cmDebride necrotic tissue

Advance Tendon

Suture Repair

FHL Transfer: >3cm with tendinopathy

•Reflect abductor hallucis and flexor

hallucis brevis

•FHL medial to FDL

FHL Transfer

Tag each end of tendon

FHL Transfer

Distal FHL sutured to FDL with ankle and toes in neutral

Confirm full hallux MTP dorsiflexion, otherwise retension and residual clawing

FHL Transfer

Peroneal Tendon DislocationPeroneal Tendon Dislocation

Peroneal tendons course behind the distal Peroneal tendons course behind the distal fibula fibula

The peroneus brevis may have The peroneus brevis may have degenerative changes if the injury is not degenerative changes if the injury is not identified in a timely fashionidentified in a timely fashion

Peroneal Tendon Dislocation

X-ray– May show avulsion of retinaculum from

fibula

Conservative treatment– Casting in slight plantarflexion and

inversion for 6 weeks non weight bearing– Allows the retinaculum to heal if the

tendons can be reduced closed– Successful if the injury is identified early

Peroneal Tendon DislocationPeroneal Tendon Dislocation SurgerySurgery– ORIF retinacular piece if possible ORIF retinacular piece if possible – Repair retinaculum if possibleRepair retinaculum if possible– Soft tissue reconstruction with sling for Soft tissue reconstruction with sling for

retinaculumretinaculum

Peroneal Tendon Dislocation

Peroneal Tendon Dislocation

Posterior Tibial Tendon Rupture AnatomyAnatomy

– Arises from posterior aspect intermuscular septumArises from posterior aspect intermuscular septum– Inserts on tarsal bonesInserts on tarsal bones– Avascular zone posterior to medial malleolusAvascular zone posterior to medial malleolus– High frictional load posterior to medial malleolusHigh frictional load posterior to medial malleolus

Posterior Tibial Tendon Rupture Function

– Inverter of hindfoot– Locks transverse tarsal joint– Maintains height longitudinal arch– Maintains neutral position of hindfoot at 7-10

degrees

Posterior Tibial Tendon History

– More commonly an attritional rupture over time than an acute rupture– Patient may complain of flat foot and midfoot pain– Sports with quick changes of direction may put increased force on tendon

X-ray– Foot x-ray may show medial talar displacement

AP Radiograph

Talonavicular coverage- as arch collapses the talarhead coverage by the navicular is lost

Talus-1st MT diverges or angle increases

Anterior talocalcaneal angle increases

Lateral RadiographA. Increased Talus-

forefoot angleB. Increased Talus

Calcaneous angle - plantarflexed talusC. Decreased Calcaneal

Pitch

Negative Med Cun-5th MT- normally the 5th MT is more plantar than the medial cuneiform

A

B

C

Talus-1st MT and Calcaneal Pitch

Colinear Talus-1st MTNormal calcaneal pitch

Divergent Talus-1st MTLoss of calcaneal pitch

Posterior Tibialis Reconstruction

Surgery for the flexible deformity– Reconstruction of the

posterior tibial tendon with FDL or FHL

– Medial calcaneal wedge osteotomy or lateral column lengthening through the calcaneus

– Fig 14, page 1705 from “Acquired adult flatfoot deformity” in Orthopaedics, 2002

Posterior Tibial Tendon Rupture

Chronic rupture– Develop gradually– Women over 40– Tenderness/swelling

over tendon– Forefoot abduction– “too many toes” sign– Absent single heel

raise

–Loss of height of arch

–Hindfoot valgus

Posterior Tibial Tendon Rupture Chronic rupture

– Stage I Pain, weakness, no

deformity– Stage II

Flexible flatfoot deformity– Stage III

Rigid flatfoot deformity Radiographic

subluxation/arthritis

Posterior Tibial Tendon Rupture

Management – Chronic rupture

Stage I– Nonop (NSAID, arch support, AFO)– Tenosynovectomy if SXs persist

Stage II– nonop (medial wedge, arch support, or AFO)– Surgical TX controversial– Reconstruction utilizing FDL or split anterior tibial tendon– Deformity frequently recurs– Calcaneal osteotomies hold promise

tenosynovectomy

Thanks!