07 15 Syndesmotic Injuries Syllabus
2015-07-07
: Pdf 07 07 15 Syndesmotic Injuries Syllabus 07_07_15_Syndesmotic_Injuries_Syllabus 7 2015 pdf
Open the PDF directly: View PDF 
.
Page Count: 36
| Download | |
| Open PDF In Browser | View PDF |
7/3/2015 Daniël Haverkamp Syndesmotic Instability Physical Exam & Imaging Disclosure Research Support from: Implantcast Mathys Medical Imove Medical Cotera Carbylan Consultancy agreement IMove Medical Cotera 1 7/3/2015 Consensus Meeting Rome 2013 Consensusmeeting Budapest 2015 2 7/3/2015 Acute High index of suspicion Rome, consensus meeting 2013 Acute High index of suspicion The tenderness length measurement Rome, consensus meeting 2013 Acute High index of suspicion The tenderness length measurement Deltoid ligament Rome, consensus meeting 2013 3 7/3/2015 Acute High index of suspicion The tenderness length measurement Deltoid ligament Stable/Unstable Rome, consensus meeting 2013 Cotton Test Squeeze test 4 7/3/2015 Fibula Translation test External Rotation test 5 7/3/2015 Stress X-ray Polzer 2012, Orthopedic Reviews MRI Howard, Sports Health 2012 6 7/3/2015 Ultrasound Arthroscopy Imaging Comparative Weightbearing X-rays should be made Stress views might be an option MRI is the most appropriate addiotonial tool Dynamic Sonography might play a role in selected centers Diagnostic arthroscopy can be performed in cases with a high clinical suspicion with a nonconclusive MRI (Chronic instability). Consensusmeeting Budapest 2015 7 7/3/2015 8 7/2/2015 Principles of conservative management of syndesmosis injuries James Calder TD, MD, FRCS(Tr & Orth) FFSEM(UK) Chelsea & Westminster Hospital, London The Fortius Clinic, London www.fortiusclinic.com Key to success Accurate assessment of degree of instability / grading Early stabilisation / immobilisation Assessment during rehabilitation Longer recovery than ATFL/CFL injuries Nussbaum, AJSM 2001 Wright, AJSM 2004 Jones, CORR 2007 What are the aims / pitfalls? Subtle instability antero-lateral synovitis / impingement Chronic instability Medial deltoid instability / pain 1 7/2/2015 Which injuries are suitable for conservative management? Isolated syndesmosis injury: AITFL +/- IOL ?PITFL ATFL/CFL injury protective? Which injuries are suitable for conservative management? Isolated syndesmosis injury: AITFL +/- IOL ?PITFL ATFL/CFL injury protective? Concomitant ATFL/CFL injury indicates: SER with syndesmosis extension Milder injury Calder & Roche, FA meeting St George’s 2014 Which injuries are suitable for conservative management? Isolated syndesmosis injury: AITFL +/- IOL ?PITFL ATFL/CFL injury protective? Concomitant ATFL/CFL injury indicates: Consider fixation / intervention: Medial deltoid injury Fibula fracture Posterior malleolar fracture SER with syndesmosis extension Milder injury Calder & Roche, FA meeting St George’s 2014 2 7/2/2015 What does this translate into clinically? West Point Classification syndesmosis no fracture Gerber Foot Ankle 1998 Grade I – mild AITFL sprain Conservative Mx Grade III – definite instability with complete disruption of all ligaments Operative Mx What does this translate into clinically? West Point Classification syndesmosis no fracture Gerber Foot Ankle 1998 Grade I – mild AITFL sprain Conservative Mx Grade III – definite instability with complete disruption of all ligaments Operative Mx Grade II – vague “slight instability” with tear of AITFL and partial tear IOL What does this translate into clinically? West Point Classification syndesmosis no fracture Arthroscopy Grade II? Wolf & Amendola, Cur Op Orthop 2002 Gerber Foot Ankle 1998 Grade I – mild AITFL sprain Conservative Mx Grade III – definite instability with complete disruption of all ligaments Operative Mx Grade II – vague “slight instability” with tear of AITFL and partial tear IOL Grade II a – stable Conservative Mx Grade IIb – “latent” instability Operative Mx Mcollum, KSSTA 2013 3 7/2/2015 Conservative Management - Grade I and IIa injuries Nussbaum, AJSM 2001 Phase I - 1-4 days 60 pts “aggressive” rehabilitation Phase II – PWB with ankle immobilisation NWB brace (proprioception, ROM, resistance/functional training) Phase III – when 10 single leg Level 4 toe-hops RTS – with tape & brace after functional testing Conservative Management - Grade I and IIa injuries Nussbaum, AJSM 2001 Results Mean RTS 13.4 days (5-24) 60 pts “aggressive” rehabilitation Length of tenderness = longer RTS At 6/12: 6/53 – pain/stiffness 3/53 – recurrent sprains 1/53 – heterotropic ossification Level 4 35/53 – excellent; 18/53 – good No MRI ?ATFL sprain not syndesmosis Conservative Management - Grade I and IIa injuries Hopkinson, FAI 1990 1334 military pts Partial syndesmosis longer recovery vs ankle sprain (55 vs. 28 days) Significant +ve squeeze test @ 20 months 9/10 heterotopic ossification Problems: Retrospective; No MRI ?diagnosis; few late f/u Level 4 4 7/2/2015 Conservative Management Principles - Grade I and IIa injuries Few level 4 studies on conservative Mx No level 2 or 3 studies Specific conservative management: Grade I recommendation Conservative Management Principles - Grade I and IIa injuries Few level 4 studies on conservative Mx No level 2 or 3 studies Specific conservative management: Grade I recommendation What follows is a summary but Level 5!! Conservative Management Principles - Grade I and IIa injuries Phase I Week 1: RICE NWB boot Avoid NSAIDs Week 2: PWB as tolerate boot Physio supervised ROM & proprioception 5 7/2/2015 Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 3 FWB boot / if no pain - tape Strength & proprioception Plyometric exercises (leg press, aeromat, toe standing, single leg hop) Clinical marker: Improved pain with forward lunge Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 4+ Support brace / tape Light running: 30 sec single leg toe hop Improved knee-to-wall ?Progress to multidirectional training Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 4+ Support brace / tape Light running: 30 sec single leg toe hop Improved knee-to-wall ?Progress to multidirectional training 6 7/2/2015 Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 4+ Support brace / tape Light running: 30 sec single leg toe hop Improved knee-to-wall ?Progress to multidirectional training Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 4+ Support brace / tape Light running: 30 sec single leg toe hop Improved knee-to-wall ?Progress to multidirectional training Conservative Management Principles - Grade I and IIa injuries Phase 2 Week 4+ Support brace / tape Light running: 30 sec single leg toe hop Improved knee-to-wall ?Progress to multidirectional training Clinical markers: Forward lunge test Pain-free single leg toe hop 30 secs Pain-free ext rotation on exam couch 7 7/2/2015 Conservative Management Principles - Grade I and IIa injuries Phase 3 Continue taping 12 weeks Return to training Running – Alter-G treadmill Multi-directional training Conservative Management Principles - Grade I and IIa injuries Phase 3 Continue taping 12 weeks Return to training Running – Alter-G treadmill Multi-directional training Summary Accurate assessment of grade ATFL injury “good sign” Beware higher grade injury: Medial deltoid & PITFL injury +ve squeeze test “high ankle pain” Consider arthroscopy to differentiate Grade IIa/b 8 7/2/2015 Summary Accurate assessment of grade Early “aggressive” immobilisation (not rehabilitation) ATFL injury “good sign” Beware higher grade injury: Medial deltoid & PITFL injury +ve squeeze test “high ankle pain” Consider arthroscopy to differentiate Grade IIa/b Progress depends on clinical assessment Maintain taping Warn of RTS 6-10 weeks 9 7/6/2015 University Campus Bio-Medico of Rome Department of Trauma and Orthopaedic Surgery Head Prof Vincenzo Denaro Acute Syndesmotic Injury in the Athlete: Indications & Approach for Operative Treatment Presenter: Umile Giuseppe Longo MD, MSc, PhD Conflicts of interest No conflicts to declare “Acute” injury: Definition M.Vd Bekerom, CN van Dijk - 2009 Espinoza 2012 • Acute < 3 weeks • Subacute > 3 weeks • Chronic> 3 months • Acute • Subacute > 6 w • Chronic > 6 m Valkering 2012 - Scraton - 2000 • Acute < 6 weeks • Subacute > 6 weeks • Chronic > 3 months Porter - 2009 • Acute < 4 weeks • Subacute > 4 weeks • Chronic > 3 months Magan A, Golano P, Maffulli N, Khanduja V. Br Med Bull. 2014;111(1):101-15. 1 7/6/2015 Treatment of syndesmotic - Flow Chart “Acute”instability injury: Definition Acute < 6w Syndesmotic Subacute > 6w Syndesmotic screw fixation Inadeguate remnants of ligaments Ligamentoplay + screw placement Adequate remnants of ligaments Suturing + screw placement Slack but continuos ligament Traslation + screw placement Ligament Repair Chronic > 6m Synostosis/fusion + screw placemnt Classifications Porter Classification I. injury is characterized by lesion of the AITFL, IOL and anterior deltoid ligament II. injury is characterized by lesion of a significant portion of the syndesmosis, and disruption of the anterior and deep deltoid ligaments. Occult instability. III. injury consists of extensive disruption of the syndesmosis and complete disruption of the deltoid ligament Sikka Classification I. lesion is an isolated injury of the AITFL II. injury of the AITFL, IOL and interossesous membrane. Edwards and DeLee classification I. lesion of the AITFL without involvement of the deltoid ligament. II. rupture of the AITF and deltoid ligaments leading to occult instability III. fibular bowing (plastic deformation of fibula) and widening of tibiofibular space visible on standard plain radiographs. West Point Ankle Grading System I. injury consists of a mild sprain or tear of the AITFL with no instability of the ankle. III. injury of the AITFL, IOL, interossesous membrane and PITFL. IV. disruption of all the previous ligaments associated with the rupture of the deltoid ligament. II. lesion of the AITFL and partial tear of the IOL with slight instability of the joint. Latent instability. III. complete disruption of all the ligaments with frank instability of the ankle Magan A, Golano P, Maffulli N, Khanduja V. Br Med Bull. 2014;111(1):101-15. Stable ankle Conservative Unstable ankle Surgery 2 7/6/2015 Indications Stable ankle: • Syndesmotic ruptures without injury of the deltoid ligament Conservative Management Unstable ankle • Frank diastasis or • Latent instability with proved deltoid ligament rupture Surgical Management Indications Sprains without instability: nonoperative • Short leg cast or brace • Rehab program as pain allows • Double the time to recover compared to a typical lateral ankle sprain Indications Frank diastasis: operative • Repair of the ligament? • If reduction blocked by deltoid ligament: exploration and repair Removal of interposed soft tissue • Syndesmosis screw • NWB short leg cast 3 7/6/2015 Approach for Operative Treatment Available surgical techniques: – Traditional metal screw fixation – Bioabsorbable screws – Suture-Button – Fixation with a staple – Cerclage wires – Kirschner wires Approach for Operative Treatment Syndesmotic screw – Aims to temporarily stabilize the reconstructed mortise – Potential complications • Synostosis or ossification of the distal tibiofibular joint • Impairment of full ankle dorsiflexion, limit tibiotalar range of movement in terms of rotation (Data from Experimental cadaveric studies) Approach for Operative Treatment Suture-button (TightRope®) – Similar outcome compared with the syndesmotic screw or bolt fixation – Might lead to a quicker return to work – Rate of implant removal is lower compared to the syndesmotic screw – Insufficient evidence on the long-term effects of the TightRope® 4 7/6/2015 Approach for Operative Treatment Diameter of the screw • No consensus on the optimal screw size for syndesmotic fixation (3.5 mm or 4.5 mm cortical screw) • Experimental data: screw of larger diameter provide greater resistance to an applied load Approach for Operative Treatment Number of cortices – No consensus (three or four cortices) – Four-cortical fixation: more rigidity and stability of the ankle, but higher risk of screw breakage – Three-cortical fixation: better syndesmosis biomechanics (possibility of hardware failure is diminished while the risk of loosen the screw is increased than fourcortical fixation) Approach for Operative Treatment Absorbable screw – To prevent the removal of the screw and the risks associated with this procedure – Inferior biomechanical properties compared with those of conventional metallic implants. – Good clinical outcomes – No differences compared to metallic screws 5 7/6/2015 Approach for Operative Treatment Position of the ankle during fixation – Debated issue. – Recommended to fix an injured syndesmosis with the foot in dorsiflexion to prevent a limited dorsiflexion of the ankle. – Recent studies show that the position of the ankle during syndesmotic fixation is probably irrelevant Approach for Operative Treatment Positioning of the screw • Screw should be positioned parallel to the joint line and angled about 30° anteriorly (anatomically the fibula is posterior and lateral to the tibia) • Optimal position of the screw with respect to the tibial plafond is still debated – Sproule et al.: the screw 4 cm proximal to the ankle joint – McBryde et al. less syndesmotic widening when using the screw at 2 cm than at 3.5 cm. • Screw positioned too far proximally, it can deform the fibula and the mortise is more likely to widen. Approach for Operative Treatment Retain or remove a syndesmotic screw prior to weight-bearing – Still debated – At 6–8 weeks to prevent the possibility of breakage of the screw? – Leaving the screw in place may save patients from one extra surgical procedure – Outcome appears to be similar or better when the screw is retained – Van den Bekerom et al.: removal of fourcortical screws after 6–8 weeks, and removal on indication in three-cortical screws. 6 7/6/2015 Approach for Operative Treatment – – – – – – – – – – – Syndesmotic injuries require an early recognition Late repairs are less favourable 3.5 or 4.5 screw? Proposal: 3.5 mm 3 cortices or 4 cortices? Proposal: 4 cortices in heavy patient, 3 in patients with low BMI Screw or suture-button? Proposal: both Absorbable non absorbable? Proposal: non absorbable Position for fixation Proposal: neutral to slightly dorsiflexion position Lag or positioning screw? Proposal: Both possible (prob positioning more safe) Removal of soft tissue Proposal: between 3-6 weeks Removal of screw Proposal: at 8 weeks Partial weightbearing: Proposal: 6-8 weeks Umile Giuseppe Longo - Email: ug.longo@gmail.com University Campus Bio-Medico of Rome Department of Trauma and Orthopaedic Surgery 7 7/5/2015 Operative Techniques for chronic syndesmotic injury Pieter D'Hooghe Aspetar Orthopaedic Surgery Dept, Doha, Qatar • • • • Orthopaedic Sportssurgeon ISAKOS Chair "Leg, Ankle & Foot Committee ESSKA AFAS Member No disclosures Courtesy Pau Golano - Niek van Dijk anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) as well as the interosseous tibiofibular ligament (IOL). The transverse tibiofibular ligament (TTFL) is considered a continuation or deep portion of the posterior PITFL 1 7/5/2015 Mechanism of injury Courtesy James Calder 2 7/5/2015 3 7/5/2015 Late syndesmotic widening History: • Persistent pain after fracture/sprain • Giving way • Difficulty with walking on uneven ground Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Physical examination 1. Swelling pressure pain over syndesmosis 2. Stiffness/ limited dorsiflexion upper ankle joint 3. Cotton test, fibular translation test 4. External rotation test is not reliable ( false negatives ) Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Radiology: • • • Arthrogaphy (Olsen 1981) (Katznelson 1983) MRI (Han 2007) (Kim 2007) Arthroscopy (Lui 2005) (Sri-Ram 2005) Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw PAJ, van Dijk CN Injury 2009 4 7/5/2015 IMAGING • Comparative weightbearing X-rays should be made • MRI is the most appropriate additionial tool • CT (comparitive) might be usefull in assessing rotational deformities • Dynamic sonography might play a role in selected centers • Diagnostic arthroscopy can be performed in cases with a high clinical suspicion with a non-conclusive MRI. Arthroscopic syndesmotic instability assessment Hook test Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw PAJ, van Dijk CN Injury 2009 5 7/5/2015 TREATMENT • Untreated have poor prognosis • No distinction between subacute and chronic • Syndesmotic enhancement with lag screw or positioning screw (3 or 4 cortices) or suture button technique or combination • Arthroscopic debridement with lag screw or positioning screw (3 or 4 cortices) or suture button technique or combination 6 7/5/2015 Late syndesmotic widening • Treatment options for late syndesmotic widening • • • • • • • Syndesmotic screw fixation Debridement (with screw fixation) Repair (with screw fixation) Reconstruction (with screw fixation) Bone block transfer (with screw fixation) Correction osteotomy Arthrodesis Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw PAJ, van Dijk CN Injury 2009 7 7/5/2015 Late syndesmotic widening Syndesmotic screw stabilisation • Late syndesmotic screw fixation was advocated by Key (1934) and Mullins (1958) • Opinion: only screw fixation for chronic instability is not sufficient Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Arthroscopic debridement and screw stabilisation • Harper MC, FAI, 2001 – 6 patients, 4 males, 2 females, mean age 41 – PER stage IV – 15 months post-trauma – 23 months follow-up – 5/6 patients are satisfied • Opinion: only debridement to aim for a fibrotic union (with screw fixation) is not sufficient Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw PAJ, van Dijk CN Injury 2009 Late syndesmotic widening Repair ( + arthroscopic debridement and screw stabilisation) • Mosier-LaClair, Foot Ankle Clin, 2000 – 8 patients – 5 Weber C #, 3 ankle sprains – 48 months post-trauma – 24 months follow-up – 8/9 satisfied. 1/9 dissatisfied • Opinion: only possible when there are adequate remnants of the syndesmotic ligament. Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 8 7/5/2015 Late syndesmotic widening Reconstruction (+ arthroscopic debridement and screw stabilisation) • Grass, FAI, 2003 – Reconstruction with peroneus longus – 16 patients, 2 males, 14 females, mean age 40 – 14 PER, 2 PA – 14 months post-trauma – 16 months follow-up – 16 are relieved of chronic instability, 15 are relieved of pain Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Reconstruction (arthroscopic debridement and screw stabilisation) • Other options – Extensor Dig V (Kelikian) – Plantaris tendon (van Dijk, Kelikian) – Fascia (Kelikian) – Dura mater (Kelikian) • Opinion: Reconstruction with plantaris tendon or gracilis tendon is a good option when there are no adequate remnants and there is no slack intact ligament Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Bone block transfer (screw stabilisation) • Beumer, Acta Orthop Scand, 2000 – Bone block transfer with syndesmotic screw fixation, 9 patients. – 45 months post-trauma – 9/9 are relieved of chronic instability, 2 developed dystrophy, 1 nerve entrapment • Van Dijk, Tech Foot Ankle Surg, 2006 – Bone block transfer with syndesmotic screw fixation, 6 patients. – No patient was symptom free, 2 patients had a later synostosis 9 7/5/2015 Late syndesmotic widening Bone block transfer ( + screw stabilisation) • • • Opinion: a good technique when there is a slack but intact ligament Beumer (2000) stated that even in late cases, the ligament was slack but always present Bahr (1997) stated that anatomic repair with the original (TibioFibular) ligament should be better Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Correction osteotomy ( + arthroscopic debridement) • Opinion: when there is a syndesmotic widening and a malunion, an osteotomy is regarded the first treatment step. • All components of the malunion should be corrected • When there is a severly disturbed ankle function, an arthrodesis should be considered. Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 Late syndesmotic widening Tibiofibular fusion • Katznelson et al, Injury, 1983 – 5 patients, 3 males, 2 females, mean age 20 yr. – Ankle sprains – 10 months post trauma – 5/5 pain free, 4/5 free ROM • Opinion: this technique can be used for syndesmotic instability lasting > 6 months. Delayed operative treatment of syndesmotic instability. Current concepts review. Van den Bekerom M, de Leeuw P, van Dijk CN Injury 2009 10 7/5/2015 Chronic Syndesmotic injury TAKE HOME MESSAGE • • • • • • First consider the fibular malalignment Repair of the ligament with/when adequate remnants Otherwise a reconstruction ( ligamentoplasty )with gracilis tendon is advised When there is a slack but intact ligament: a bone block translation osteotomy is advised Debridement to aim for a fibrotic union Tibiofibular joint fusion ( synostosis with graft ) 11 7/5/2015 Syndesmotic impingment Arthroscopically resection of the distal fascicle of the AITFL should be considered when there: (1) is contact between the AITFL and the talus, (2) is increased contact between the talus and the ligament and this continued until maximum dorsiflexion with abrasion of the articular cartilage, (3) bending of the fascicle on the anterolateral edge of the talus with dorsiflexion and dorsiflexion-inversion, (4) is a distally inserting fascicle on the fibula, close to the origin of the ATFL on the fibula. This finding may be missed if the distraction is preserved throughout the procedure The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review. van den Bekerom MP, Raven EE. Knee Surg Sports Traumatol Arthrosc 2007 Thank You 12
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Modify Date : 2015:07:07 01:55:40-04:00 Creator : PDFMerge! (http://www.pdfmerge.com) Create Date : 2015:07:07 01:55:40-04:00 Producer : iText® 5.5.2 ©2000-2014 iText Group NV (ONLINE PDF SERVICES; licensed version) Page Count : 36EXIF Metadata provided by EXIF.tools