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Mercan N, Yurteri A, Dere Y. Do lateral ankle ligaments contribute to syndesmotic stability: a finite element analysis study. Comput Methods Biomech Biomed Engin 2024; 27:1768-1780. [PMID: 37728074 DOI: 10.1080/10255842.2023.2258251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Whether the lateral ankle ligaments contribute to syndesmotic stability is still controversial and has been the subject of frequent research recently. In our study, we tried to elucidate this situation using the finite element analysis method. Intact model and thirteen different injury models were created to simulate injuries of the lateral ankle ligaments (ATFL, CFL, PTFL), injuries of the syndesmotic ligaments (AITFL, IOL, PITFL) and their combined injuries. The models were compared in terms of LFT, PFT and EFR. It was observed that 0.537 mm LFT, 0.626 mm PFT and 1.25° EFR occurred in the intact model (M#1), 0.539 mm LFT, 0.761 mm PFT and 2.31° EFR occurred in the isolated ATFL injury (M#2), 0.547 mm LFT, 0.791 mm PFT and 2.50° EFR occurred in the isolated AITFL injury (M#8). The LFT, PFT and EFR amounts were higher in the both M#2 and M#8 compared to the M#1. LFT, PFT and EFR amounts in M#2 and M#8 were found to be extremely close. In terms of LFT and PFT, when we compare models with (LFT: 0.650 mm, PFT: 1.104) and without (LFT: 0.457 mm, PFT: 1.150) IOL injury, it is seen that the amount of LFT increases and the amount of PFT decreases with IOL injury. We also observed that injuries to the CFL, PTFL and PITFL did not cause significant changes in fibular translations and PFT and EFR values show an almost linear correlation. Our results suggest that ATFL injury plays a crucial role in syndesmotic stability.
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Affiliation(s)
- Numan Mercan
- Department of Orthopaedic and Traumatology, Kahramanmaras Necip Fazıl City Hospital, Kahramanmaras, Turkey
| | - Ahmet Yurteri
- Department of Orthopaedic and Traumatology, Konya Sehir Hastanesi, Konya, Turkey
| | - Yunus Dere
- Department of Civil Engineering, Necmettin Erbakan University, Meram, Turkey
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Voight ML, Norman C, Wilk KE, Lucas M, Wolfe C. Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play. Int J Sports Phys Ther 2024; 19:513-521. [PMID: 38707856 PMCID: PMC11065778 DOI: 10.26603/001c.116862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice. Level of Evidence V.
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Elite Athletes Successfully Return to the Preinjury Level of Sport Following Ankle Syndesmosis Injuries: A Systematic Review and Meta-Analysis. Clin J Sport Med 2023; 33:90-96. [PMID: 36599363 DOI: 10.1097/jsm.0000000000001019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 12/31/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To comprehensively review and report the outcomes of ankle syndesmotic injury management in elite athletes. DATA SOURCES Three databases were searched for articles reporting the rate of return to sport following treatment of ankle syndesmotic injuries in elite athletes (collegiate or professional level). Ten articles and 440 athletes were included. Articles reporting the rate of return to sport following high ankle sprain injury in elite athletes. Data collected included demographics, type of treatment received, and return to sport (RTS) information. A random effects model was used. MAIN RESULTS The estimated overall rate of RTS was 99% (95% CI, 95.5-99.9). The mean time to RTS was 38 ± 18 (range, 14-137) days. Of the 440 athletes, 269 (269/440%, 61%) were treated nonoperatively (nonoperative group); the rate of RTS was 99.6%, and the athletes returned at a mean time of 29 ± 14 (range, 13-45) days. A total of 171 athletes (171 of 440%, 39%) underwent surgical treatment (operative group). All (171 of 171%, 100%) athletes returned at a mean time of 50.3 ± 13 (range, 41-137) days. Almost all athletes who underwent surgery had suture button fixation (164 of 171 athletes, 96%), and the mean time to RTS was 7 weeks with 9.1% complication rate. CONCLUSIONS Elite athletes with ankle syndesmosis injury return to sport at an extremely high rates, following operative or nonoperative treatment. Return to the preinjury level of competition should be expected at 4 weeks and 7 weeks in high-level athletes who undergo nonoperative and operative management, respectively. Suture button fixation was used by the majority of studies reporting surgical management of ankle syndesmosis injuries in athletes.
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Mercan N, Yıldırım A, Dere Y. Biomechanical Analysis of Tibiofibular Syndesmosis Injury Fixation Methods: A Finite Element Analysis. J Foot Ankle Surg 2022; 62:107-114. [PMID: 35732561 DOI: 10.1053/j.jfas.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 02/03/2023]
Abstract
The optimal treatment strategy after syndesmotic injuries is still controversial. In our study, we aimed to evaluate ideal fixation method in syndesmotic injury by using finite element analysis method. A 3D SolidWorks model file was created by taking computed tomography (CT) images of the area from the right foot base to the knee joint level of a healthy adult male. The intact model, injury model, and 8 different fixation models were created that 3.5 mm screw and suture-button were used in. The models were compared in terms of lateral fibular translation, posterior fibular translation and external rotation of fibula compared to tibia and stress values occurred on screws and suture-buttons. In the hybrid-1 model, lateral fibular translation and external fibular rotation values were obtained as close to the intact model. Von Mises stresses occurred in the screw (435.7 MPa) and suture-button (424.7 MPa) that used in hybrid-1 model was more than single screw at 4 cm model (316.8 MPa) and single suture-button at 2 cm model (160.7 MPa). In the Hybrid-1 model, the screw compensates for posterior fibular translation and external fibular rotation, while the suture-button compensates for lateral fibular translation. Also, the effect of the distal suture-button preventing diastasis in case of proximal screw failure, it was concluded that the hybrid-1 model can be used as a good treatment alternative in the surgical treatment of distal tibiofibular syndesmotic injuries.
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Affiliation(s)
- Numan Mercan
- Physician, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey
| | - Ahmet Yıldırım
- Associate Professor, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey.
| | - Yunus Dere
- Assistant Professor, Department of Civil Engineering, Necmettin Erbakan University, Konya, Turkey
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Wever S, Schellinkhout S, Workman M, McCollum GA. Syndesmosis injuries in professional rugby players: associated injuries and complications can lead to an unpredictable time to return to play. J ISAKOS 2022; 7:66-71. [DOI: 10.1016/j.jisako.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/20/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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Hunt KJ, Bartolomei J, Challa SC, McCormick JJ, D'Hooghe P, Tuffiash M, Amendola A. Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective. J ISAKOS 2022; 7:13-18. [DOI: 10.1016/j.jisako.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Canton SP, Gale T, Onyeukwu C, Hogan MV, Anderst W. Syndesmosis Repair Affects in Vivo Distal Interosseous Tibiofibular Ligament Elongation Under Static Loads and During Dynamic Activities. J Bone Joint Surg Am 2021; 103:1927-1936. [PMID: 34043595 DOI: 10.2106/jbjs.20.01787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ligamentous ankle injuries are the most common injuries sustained by athletes and by the general population, with an incidence of approximately 2 million per year in the U.S. Injuries to the ankle syndesmosis (i.e., "high ankle sprains") are generally treated operatively. Although cadaveric studies can evaluate syndesmosis fixation strength, they cannot predict how healing, neuromuscular adaptation, or dynamic loading will affect in vivo biomechanics. Using dynamic biplane radiography (DBR), we tested the hypothesis that syndesmosis repair would restore ankle kinematics and ligament elongation during static and dynamic loading. METHODS A convenience sample of 6 male patients who had undergone fixation (2 screw, 3 suspensory, 1 hybrid) of syndesmosis injury were assessed with use of DBR during forward running, backpedaling, a 45° angled single-leg hop, and 1 static standing trial at 2 to 4.5 years postoperatively. Three-dimensional ankle kinematics and elongation of the distal interosseous ligament, anterior inferior tibiofibular ligament, and the posterior inferior tibiofibular ligament were measured bilaterally. Comparisons were made between the operative and uninjured sides. Clinical outcomes were evaluated with use of the Foot and Ankle Ability Measure. RESULTS Static load increased the lengths of the distal interosseous ligament (p = 0.02 to 0.05) and middle segment of the anterior inferior tibiofibular ligament (p = 0.02) in the operative ankle. The distal syndesmosis length was greater on the operative side during the static unloaded and loaded conditions (p = 0.02). Length of the distal syndesmosis on the operative side was greater than the corresponding healthy syndesmosis length during all 3 dynamic activities. On average, the operative ankle was in less dorsiflexion over the support phase of the angled hop (p = 0.05) and running (p < 0.01). The average Foot and Ankle Ability Measure Activities of Daily Living and Sports subscale scores were 95 and 88, respectively. CONCLUSIONS This study provides the first in vivo evidence of post-fixation changes in biomechanics after syndesmosis repair. Syndesmosis repair fails to restore healthy static and dynamic distal tibiofibular anatomy, even in patients who report good to excellent clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stephen P Canton
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chukwudi Onyeukwu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - MaCalus V Hogan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Foot and Ankle Injury Research [F.A.I.R] Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Anderst
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Pogliacomi F, De Filippo M, Casalini D, Longhi A, Tacci F, Perotta R, Pagnini F, Tocco S, Ceccarelli F. Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts. World J Orthop 2021; 12:270-291. [PMID: 34055585 PMCID: PMC8152437 DOI: 10.5312/wjo.v12.i5.270] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
| | - Massimo De Filippo
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Daniele Casalini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Alberto Longhi
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Fabrizio Tacci
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Rocco Perotta
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Francesco Pagnini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Silvio Tocco
- Centro Riabilitativo della Mano e Arto Superiore, Parma 43121, Italy
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Burssens A, Krähenbühl N, Weinberg MM, Lenz AL, Saltzman CL, Barg A. Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries. Foot Ankle Int 2020; 41:1256-1268. [PMID: 32672067 DOI: 10.1177/1071100720936596] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current imaging techniques try to quantify 3-dimensional displacement of syndesmotic ankle injuries using 2-dimensional measurements, which may obscure an exact diagnosis. Therefore, our aim was to determine 3-dimensional displacement of syndesmotic ankle injuries under load and torque using a weightbearing computed tomography (WBCT) and to assess the relation with previously established 2-dimensional measurements. METHODS Seven paired cadaver specimens were mounted into a radiolucent frame. WBCT scans were obtained to generate 3-dimensional models after different patterns of axial load (0 kg, 85 kg) combined with external torque (0, 10 Nm). Sequential imaging was repeated in ankles containing intact syndesmotic ligaments, sectioning of the anterior inferior tibiofibular ligament (AITFL; condition 1A), deltoid ligament (DL; condition 1B), combined AITFL+DL (condition 2), and AITFl+DL+interosseous membrane (condition 3). Reference anatomical landmarks were established relative to the intact position of the fibula to quantify displacement. A subsequent correlation analysis was performed between the obtained 2- and 3-dimensional measurements. RESULTS Axial load increased lateral translation (mean = -0.9 mm, 95% confidence interval [CI]: 1.3, -0.1) significantly in condition 2 relative to the intact ankle (P < .05) but did not demonstrate other significant displacements. External torque increased displacement significantly in all directions (P < .05), except for dorsal translation of the fibula (P > .05). The highest displacement could be detected when external torque was applied in condition 3 and consisted of posterior translation (mean = -3.1 mm; 95% CI: -4.8, -2.7) and external rotation (mean = -4.7 degrees; 95% CI: -5.6, -2.9). Pearson correlation coefficients between the 2-dimensional and 3-dimensional measurements were moderate and ranged from 0.31 to 0.56 (P < .05). CONCLUSION External torque demonstrated superiority over axial load in detecting syndesmotic ankle instability. Axial load increased lateral translation; however, differences were submillimeter in magnitude until torque was applied. A moderate correlation was found with previously established 2-dimensional measurements. CLINICAL RELEVANCE In clinical practice these findings substantiate application of external torque in current imaging modalities to improve detection of syndesmotic ankle injuries.
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Affiliation(s)
- Arne Burssens
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Amy L Lenz
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Alexej Barg
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA.,Deartment of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Hamburg, Germany
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10
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Lubberts B, Guss D, Vopat BG, Johnson AH, van Dijk CN, Lee H, DiGiovanni CW. The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses. Knee Surg Sports Traumatol Arthrosc 2020; 28:193-201. [PMID: 30367196 DOI: 10.1007/s00167-018-5229-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability. METHODS Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured. RESULTS As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p < 0.001 to p = 0.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translation + 0.82*PA sagittal translation + 1.17*anterior third coronal plane translation-0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1 mm indicated an unstable syndesmosis. CONCLUSIONS This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.
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Affiliation(s)
- Bart Lubberts
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA.
| | - Daniel Guss
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
| | - Bryan G Vopat
- Department of Orthopaedic Surgery, Kansas Medical Center, Kansas City, USA
| | - Anne H Johnson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christopher W DiGiovanni
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
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Lopes R, Orhant E, Guillo S, Bouvard M, Brasseur J, Brunot S, Collado H, Frey A, Guillodo Y, Kuentz P, Maillet P, Tamalet B, Rousseau R. La cheville du footballeur : résumés des communications de la 1re journée francophone des fédérations de la Société française de traumatologie du sport (SFTS) en partenariat avec la Fédération française de football (FFF). JOURNAL DE TRAUMATOLOGIE DU SPORT 2019; 36:120-137. [DOI: 10.1016/j.jts.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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12
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Kromka JJ, Chambers MC, Popchak A, Irrgang J, Hogan MV. In a small retrospective cohort of patients with syndesmotic injury, only athletes benefited from placement of a suture button device: a pilot study. J ISAKOS 2018. [DOI: 10.1136/jisakos-2018-000234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ObjectivesInjuries to the ankle are common, with a significant number of ligamentous injuries involving the syndesmosis. In syndesmotic injuries severe enough to require surgical fixation, the two leading techniques are rigid screw and suture button fixation. The literature has shown that both techniques are effective, but there remains debate on the optimum method of treatment. The goal of this study was to evaluate patient-reported outcomes for these repair methods in a population of athletes.MethodsThis study was a retrospective cross-sectional study of patients who had undergone rigid screw or suture button fixation for an injury to the ankle syndesmosis. Specifically, a subpopulation of athletes was examined as it was hypothesised that these high-demand patients would have higher patient-reported outcomes with ongoing suture button fixation. Study participants were identified through a search of the medical record and were recruited through mailed letters and phone calls. Participants completed patient-reported outcome questionnaires including the Activities of Daily Living and Sports Subscales of the Foot and Ankle Ability Measure (FAAM) survey, FAAM Sports Subscale survey, Veteran’s Rand 12-item Health Survey (VR-12) and a customised athletic activity questionnaire. These patient-reported outcomes were compared between those who underwent screw fixation and those who underwent suture button fixation.Results32 patients completed the study, with 17 of these designated as ‘athletes’ competing in strenuous sports activities that involve jumping, cutting and hard pivoting including football, soccer, basketball, volleyball and gymnastics at the high school level or above. Patients were on average 3.9 years post op (SD 2.2). With the numbers available, no difference in outcomes between patients with rigid screw or suture button fixation was observed in the study as a whole. In a subpopulation of athletes, patients who received suture button fixation had higher FAAM scores compared with those treated with rigid screw fixation (p=0.02). Still, in the subpopulation of athletes, no statistical difference was observed with the available numbers for the other patient-reported outcomes.ConclusionThis pilot study of outcomes in an athletic population suggests that athletic patients may benefit from suture button fixation and lays the groundwork for future work examining the use of suture button fixation in high-demand patients.Level of evidenceLevel III—Retrospective Comparative Study.
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13
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Syndesmotic stability: Is there a radiological normal?-A systematic review. Foot Ankle Surg 2018; 24:174-184. [PMID: 29409215 DOI: 10.1016/j.fas.2017.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 12/10/2016] [Accepted: 02/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Syndesmotic injury and instability poses a diagnostic challenge with unreliable clinical tests and inconsistent radiologic measures. Thus, used widely in clinical practice, there is huge debate pertaining to the reliability and validity of the radiologic parameters used for syndesmotic instability. OBJECTIVE Hence the purpose of the review was to explore the normal radiologic measures and morphometrics of distal tibiofibular syndesmosis and its relationships, which can aid in diagnosing syndesmotic instability. METHOD Computerised literature searches was performed for articles published in English using Pubmed, from inception through June 2016. All published articles reporting the normal anatomic and morphometric measures of distal tibiofibular syndesmosis with the use of any radiological modality individually or in combination, either in cadaveric or in live subjects were included. Studies done on or reporting of measures in healthy ankles or radiologically normal ankles were only included. RESULTS In this review wide anatomic and morphologic variability was observed amidst the landmarks used commonly for assessing syndesmotic instability and hence the normal measures. Further age and gender based variations were seen across the most commonly used radiologic measures for syndesmotic instability diagnosis, demanding the modification of existing radiologic criteria.
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14
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Xu D, Wang Y, Jiang C, Fu M, Li S, Qian L, Sun P, Ouyang J. Strain Distribution in the Anterior Inferior Tibiofibular Ligament, Posterior Inferior Tibiofibular Ligament, and Interosseous Membrane Using Digital Image Correlation. Foot Ankle Int 2018. [PMID: 29533732 DOI: 10.1177/1071100717753160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ligament repair and augmentation techniques can stabilize syndesmosis injuries. However, little is known about the mechanical behavior of syndesmotic ligaments. The aim of this study was to analyze full-field strain, strain trend under foot rotation, and subregional strain differences of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM). METHODS Eleven fresh-frozen lower limbs were dissected to expose the AITFL, PITFL, and IOM. The foot underwent rotation from 0° to 25° internal and 35° external, with 3 ankle positions (neutral, 15° dorsiflexion, and 25° plantarflexion) and a vertical load of 430 N. Ligament strain was recorded using digital image correlation. RESULTS The mean strain on the AITFL with 35° external rotation was greater in the proximal portion compared with distal portion in the neutral position ( P = .009) and dorsiflexion ( P = .003). The mean strain in the tibial insertion and midsubstance near tibial insertion were greater when compared with other regions ( P = .018 and P = .009). The subregions of mean strain in the PITFL and IOM groups were not significantly different. The strain trend of AITFL, PITFL, and IOM showed common transformation, just when the foot was externally rotated. CONCLUSION The findings of this study show that a significantly high strain was observed on the proximal part and the midsubstance near the Chaput tubercle of the AITFL when the ankle was externally rotated. All 3 ligaments resisted the torque in the syndesmosis by external rotation of the foot. CLINICAL RELEVANCE This study allows for better understanding of the mechanical behavior of the syndesmosis ligaments, which could influence the repair technique and AITFL augmentation techniques.
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Affiliation(s)
- Daorong Xu
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China.,2 Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Yibei Wang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Chunyu Jiang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Maoqing Fu
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Shiqi Li
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Lei Qian
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Peidong Sun
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
| | - Jun Ouyang
- 1 Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Southern Medical University, Guangzhou, China
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15
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Latham AJ, Goodwin PC, Stirling B, Budgen A. Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ Open Sport Exerc Med 2017; 3:e000175. [PMID: 28761696 PMCID: PMC5530120 DOI: 10.1136/bmjsem-2016-000175] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background/aim The distal tibiofibular joint is described as a syndesmosis. Traditionally, severe syndesmotic injuries with diastasis have been treated surgically with screw fixation. This case series details an ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol that reduces the amount of time to return to professional rugby league in the UK. The aim of this study was to describe players’ journey from injury, through diagnosis to surgery, rehabilitation and return to participation, detailing time scales and methods used at each stage to highlight the change in current practice. Methods Players were identified via a single orthopaedic surgeon in the UK who specialises in ankle syndesmosis repair. Between January 2010 and September 2015, adult men playing full-time professional rugby league in the UK Super League with ankle syndesmosis injuries were identified. Results Eighteen players from six different clubs were included. The most common mechanism of injury was forced dorsiflexion/eversion. The average return to participation was 64 days (SD 17.2, range 38–108). This compares favourably to reports of between 120 and 180 days following screw fixation. Conclusion Ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol is as safe as traditional methods. The accelerated rehabilitation protocol promotes early weight-bearing and has shown to expedite the return to sport for professional Rugby League players. It is possible to return to sport 2 months after a tightrope repair and accelerated rehabilitation, compared with 3–6 months post screw fixation. This is extremely encouraging for the professional sporting population.
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Affiliation(s)
- Alex James Latham
- East Cheshire NHS Trust, Macclesfield District General Hospital, Macclesfield, Cheshire, UK
| | | | - Ben Stirling
- Warrington Wolves RLFC, The Halliwell Jones Stadium, Warrington, UK
| | - Adam Budgen
- York Hospitals NHS Foundation Trust, York, UK
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16
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Abstract
Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.
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Affiliation(s)
- Matthew C Solan
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK; Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK.
| | - Mark S Davies
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK
| | - Anthony Sakellariou
- Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK
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17
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Vopat ML, Vopat BG, Lubberts B, DiGiovanni CW. Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 2017; 10:94-103. [PMID: 28101828 DOI: 10.1007/s12178-017-9389-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.
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Affiliation(s)
- Matthew L Vopat
- Department of Orthopaedics, University of Kansas School of Medicine-Wichita, Via Christi Health, 929 N. St. Francis, Room 4076, Wichita, KS, 67214, USA.
| | - Bryan G Vopat
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Bart Lubberts
- Massachusetts General Hospital/ Harvard University, 55 Fruit St, Boston, MA, 02114, USA
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18
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Ballal MS, Pearce CJ, Calder JDF. Management of sports injuries of the foot and ankle. Bone Joint J 2016; 98-B:874-83. [DOI: 10.1302/0301-620x.98b7.36588] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874–83.
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Affiliation(s)
- M. S. Ballal
- Fortius Clinic, 17
Fitzhardinge Street, London, W1H
6EQ, UK
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19
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Lubberts B, van Dijk PAD, Donovan N, van Dijk CN, Calder JD. Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in functional outcomes: a systematic review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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20
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Calder JD, Bamford R, Petrie A, McCollum GA. Stable Versus Unstable Grade II High Ankle Sprains: A Prospective Study Predicting the Need for Surgical Stabilization and Time to Return to Sports. Arthroscopy 2016; 32:634-42. [PMID: 26725452 DOI: 10.1016/j.arthro.2015.10.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/12/2015] [Accepted: 10/02/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate grade II syndesmosis injuries in athletes and identify factors important in differentiating stable from dynamically unstable ankle sprains and those associated with a longer time to return to sports. METHODS Sixty-four athletes with an isolated syndesmosis injury (without fracture) were prospectively assessed, with a mean follow-up period of 37 months (range, 24 to 66 months). Those with an associated deltoid ligament injury or osteochondral lesion were included. Those whose injuries were considered stable (grade IIa) were treated conservatively with a boot and rehabilitation. Those whose injuries were clinically unstable underwent arthroscopy, and if instability was confirmed (grade IIb), the syndesmosis was stabilized. Clinical and magnetic resonance imaging assessments of injury to individual ligaments were recorded, along with time to return to play. A power analysis estimated that each group would need 28 patients. RESULTS All athletes returned to the same level of professional sport. The 28 patients with grade IIa injuries returned at a mean of 45 days (range, 23 to 63 days) compared with 64 days (range, 27 to 104 days) for those with grade IIb injuries (P < .0001). There was a highly significant relationship between clinical and magnetic resonance imaging assessments of ligament injury (anterior tibiofibular ligament [ATFL], anterior-inferior tibiofibular ligament [AITFL], and deltoid ligament, P < .0001). Instability was 9.5 times as likely with a positive squeeze test and 11 times as likely with a deltoid injury. Combined injury to the anterior-inferior tibiofibular ligament and deltoid ligament was associated with a delay in return to sports. Concomitant injury to the ATFL indicated a different mechanism of injury-the syndesmosis is less likely to be unstable and is associated with an earlier return to sports. CONCLUSIONS A positive squeeze test and injury to the ATFL and deltoid ligament are important factors in differentiating stable from dynamically unstable grade II injuries and may be used to identify which athletes may benefit from early arthroscopic assessment and stabilization. They may also be important in predicting the time frame for athletes' expected return to play. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
| | - Richard Bamford
- Medical Department, England Rugby Football Union, Twickenham, England
| | - Aviva Petrie
- Biostatistics Unit, University College London Eastman Dental Institute, London, England
| | - Graham A McCollum
- Department of Orthopaedic Surgery, University of Cape Town Private Academic Hospital, Cape Town, South Africa
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21
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Editorial Commentary: Does Early Arthroscopy of Subtle Instability in High Ankle Sprains Hasten Return to Play in Elite Athletes? Arthroscopy 2016; 32:643-4. [PMID: 27039685 DOI: 10.1016/j.arthro.2016.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/19/2016] [Indexed: 02/02/2023]
Abstract
Anterior inferior tibial fibular ligament tenderness to palpation, a positive squeeze test, and a positive external rotation test correlate well with syndesmosis instability after high ankle sprain. However, it is still unknown whether subtle unstable high ankle sprains (grade IIB) could heal satisfactorily with nonoperative treatment and whether their recovery would be prolonged compared with operative treatment.
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22
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Kose O, Yuksel HY, Guler F, Ege T. Isolated Adult Tillaux Fracture Associated With Volkmann Fracture-A Unique Combination of Injuries: Report of Two Cases and Review of the Literature. J Foot Ankle Surg 2015; 55:1057-62. [PMID: 26711834 DOI: 10.1053/j.jfas.2015.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Indexed: 02/03/2023]
Abstract
Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously reported.
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Affiliation(s)
- Ozkan Kose
- Associate Professor, Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Halil Yalcin Yuksel
- Associate Professor, Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ferhat Guler
- Associate Professor, Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Tolga Ege
- Assistant Professor, Department of Orthopedics and Traumatology, Gulhane Military Medical Academy, Ankara, Turkey.
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23
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Switaj PJ, Mendoza M, Kadakia AR. Acute and Chronic Injuries to the Syndesmosis. Clin Sports Med 2015; 34:643-77. [DOI: 10.1016/j.csm.2015.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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24
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Hunt KJ, Goeb Y, Behn AW, Criswell B, Chou L. Ankle Joint Contact Loads and Displacement With Progressive Syndesmotic Injury. Foot Ankle Int 2015; 36:1095-103. [PMID: 25948693 DOI: 10.1177/1071100715583456] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ligamentous injuries to the distal tibiofibular syndesmosis are predictive of long-term ankle dysfunction. Mild and moderate syndesmotic injuries are difficult to stratify, and the impact of syndesmosis injury on the magnitude and distribution of forces within the ankle joint during athletic activities is unknown. METHODS Eight below-knee cadaveric specimens were tested in the intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular, anterior deltoid (1 cm), interosseous/transverse (IOL/TL), posterior-inferior tibiofibular, and whole deltoid. In each condition, specimens were loaded in axial compression to 700 N and then externally rotated to 20 N·m torque. RESULTS During axial loading and external rotation, both the fibula and the talus rotated significantly after each ligament sectioning as compared to the intact condition. After IOL/TL release, a significant increase in posterior translation of the fibula was observed, although no syndesmotic widening was observed. Mean tibiotalar contact pressure increased significantly after IOL/TL release, and the center of pressure shifted posterolaterally, relative to more stable conditions, after IOL/TL release. There were significant increases in mean contact pressure and peak pressure along with a reduction in contact area with axial loading and external rotation as compared to axial loading alone for all 5 conditions. CONCLUSION Significant increases in tibiotalar contact pressures occur when external rotation stresses are added to axial loading. Moderate and severe injuries are associated with a significant increase in mean contact pressure combined with a shift in the center of pressure and rotation of the fibula and talus. CLINICAL RELEVANCE Considerable changes in ankle joint kinematics and contact mechanics may explain why moderate syndesmosis injuries take longer to heal and are more likely to develop long-term dysfunction and, potentially, ankle arthritis.
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Affiliation(s)
- Kenneth J Hunt
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Yannick Goeb
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Anthony W Behn
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Braden Criswell
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Loretta Chou
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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25
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How CH, Tan KJ. Doctor, I sprained my ankle. Singapore Med J 2015; 55:522-4; quiz 525. [PMID: 25631892 DOI: 10.11622/smedj.2014134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ankle sprains constitute the majority of ankle injuries, and result in pain, limited mobility/exercise and loss of school/work days. Ankle sprains involve at least one of the ankle ligaments and range from a micro tear to complete tear of the ligament or group of ligaments. The most common mechanism of ankle sprains is inversion stress of a plantar-flexed foot, while the most frequently injured ligament is the anterior talofibular ligament. The attending clinician needs to stratify the risk of fracture through history-taking and physical examination, manage the pain, assess long‑term complications and provide certification for rest and recovery. The Ottawa ankle rules may be useful. Graduated exercises to maintain the ankle's range of motion should be started early, after the resolution of initial pain and swelling. The risk of recurrent ankle injuries is often a combination of both mechanical and functional disabilities.
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Affiliation(s)
| | - Ken Jin Tan
- OrthoSports - Clinic for Orthopedic Surgery and Sports Medicine, #10-41, Mt Elizabeth Novena Specialist Centre, 38 Irrawaddy Road, Singapore 329563.
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26
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27
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Porter DA, Jaggers RR, Barnes AF, Rund AM. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med 2014; 5:173-82. [PMID: 25177153 PMCID: PMC4128849 DOI: 10.2147/oajsm.s41564] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.
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Affiliation(s)
- David A Porter
- Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA
| | - Ryan R Jaggers
- Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA
| | | | - Angela M Rund
- Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA
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28
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Laprade RF, Surowiec RK, Sochanska AN, Hentkowski BS, Martin BM, Engebretsen L, Wijdicks CA. Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries. Br J Sports Med 2013; 48:4-10. [PMID: 24285783 DOI: 10.1136/bjsports-2013-093020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and time-loss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sport-specific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play. LEVEL OF EVIDENCE Level IV.
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29
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Abstract
Ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey, and soccer, accounting for 1 %-18 % of all ankle sprains. The evolution is unpredictable: When missed, repeated episodes of ankle instability may predispose to early degenerative changes, and frank osteoarthritis may ensue. Diagnosis is clinical and radiological, but arthroscopy may provide a definitive response, allowing one to address secondary injuries to bone and cartilage. Obvious diastasis needs to be reduced and fixed operatively, whereas less severe injuries are controversial. Nonoperative treatment may be beneficial, but it entails long rehabilitation. In professional athletes, more aggressive surgical treatment is warranted.
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30
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Pocecco E, Ruedl G, Stankovic N, Sterkowicz S, Del Vecchio FB, Gutiérrez-García C, Rousseau R, Wolf M, Kopp M, Miarka B, Menz V, Krüsmann P, Calmet M, Malliaropoulos N, Burtscher M. Injuries in judo: a systematic literature review including suggestions for prevention. Br J Sports Med 2013; 47:1139-43. [DOI: 10.1136/bjsports-2013-092886] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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