Long-Term Effects of Complications After Ankle Surgery

Things are changing in the treatment of severe ankle arthritis. What was once treated with ankle fusion can now be managed with a joint replacement. Improved surgical techniques and better implant designs have made the shift possible. But the question remains: are the long-term results comparable?

That’s what the authors of this study set out to see for themselves. They compared two groups of patients with severe, disabling ankle arthritis that did not respond as hoped to conservative care. As you might suspect, one group had the fusion procedure.

The second group received a total ankle replacement (TAR), also known as an ankle arthroplasty. The ankle replacement group did not all get the same type of implant. There were four different implants used. Not everyone had the same surgical approach either. Some patients had open incision surgery while others were treated with arthroscopy.

Besides looking at final function after two years, they also paid attention and compared complications along the way for both groups. X-rays were used to evaluate the joint itself. CT scans added information on the status of the healing process. The Ankle Osteoarthritis Scale (AOS) was used as a measure of pain, function, and disability. Before surgery and postoperative values were recorded for each patient.

Everyone in both groups had significant (and fairly equal) improvements. Pain relief, increased ankle range-of-motion, and improved function (e.g., walking, going up or down stairs, managing uneven terrain) were observed. The complication rate was high for both groups, but twice as high in the ankle arthroplasty group compared with the fusion group.

What kind of complications are we talking about? Well, fractures, skin and deep wound infections, and chronic pain after surgery are possible with either procedure. Likewise, infection that spreads to the bone called osteomyelitis can develop after any surgical procedure that disrupts bone as these two procedures do. Then there is the risk of cutting or damaging nerves and/or blood vessels.

Ankle fusion is well-known for complications such as off angles, poor alignment and deformity, nonunion, and arthritis in the surrounding joints. Altered gait or abnormal walking pattern is typical with an ankle fusion. And of course, activities like jogging or running will never be the same if even possible.

Ankle arthroplasty (total ankle replacement) comes with its own set of potential problems. Common complications with ankle joint replacement include loosening of the implant, impingement (pinching), and malalignment. There can also be subsidence (implant sinks down into the bone), the wrong implant size used, and/or excessive wear on any part of the implant. Though rare, the implant can also fracture or break as well.

Let’s take a look at the results after surgery and after all the complications were noted and treated. Everyone was followed for at least two years and some patients for up to 10 years. As it turned out, the affect different complication varied. For example, an implant that had come loose often required a second surgery, whereas even a deep infection could be treated and cleared up with antibiotics.

Anyone in either group with ongoing pain and discomfort from a nerve lesion caused by the surgery was less likely to be satisfied with the long-term results compared with patients who had less significant complications.

The authors concluded that some complications can have significant effects on outcomes in both groups (fusion and joint replacement). Patients receiving a total joint replacement are more likely to have problems. Older, less active adults seem to weather the complications better than younger patients who expect to do more and expect to have fewer problems so are surprised when they have any.

Studies like this help point the direction for future comparisons. One of those will be to compare the results between and among the various implant types. The goal now is to reduce the high level of complications following fusion or ankle arthroplasty (replacement).

Are We Ready For Arthroscopic Surgery for Ankle Fractures Yet?

Arthroscopic reduction and internal fixation (ARIF) of ankle fractures is an emerging procedure. Until now, the complexity of the ankle joint has required an open procedure called open reduction and internal fixation, more commonly known as ORIF.

In this review article, orthopedic surgeons from the United States team up with surgeons from Italy to discuss six conditions for which arthroscopic reduction and internal fixation (ARIF) can be used. These include: 1) transchondral fracture, 2) talar fracture, 3) distal tibial fracture, 4) syndesmotic disruption, 5) malleolar fracture, and 6) chronic ankle pain after treatment.

For each problem, the authors discuss the diagnosis, management, and results. Management refers to both the surgical treatment as well as the postoperative care and rehabilitation.

Photographs taken during each arthroscopic procedure provide an “inside” look at how the procedure was done. Follow-up X-rays show the placement of screws, rods, and metal plates used to stabilize the fractures.

Here’s a brief summary of the main concepts, including the advantages and disadvantages of the arthroscopic reduction and internal fixation (ARIF) compared with open reduction and internal fixation (ORIF).

Arthroscopic surgery is less invasive than an open incision that cuts through soft tissues that protect and stabilize the joint. Arthroscopic surgery is image-guided through a tiny TV camera on the end of the scope.

A picture is projected up on a screen for the surgeon to see. This technology makes it possible to reach places in the joint that would require extensive dissection (cutting and opening) to see otherwise.

With less tissue disruption, there is much less swelling and potentially faster healing. One other advantage of arthroscopic ankle surgery is the reduced risk of accidentally cutting a nerve or important blood vessel.

For all those positive factors associated with arthroscopic reduction and internal fixation (ARIF), there are a few disadvantages. The procedure takes longer than an open reduction and internal fixation (ORIF). The risk of complications from anesthesia and surgery itself go up with increased time on the operating table.

In terms of costs, the ARIF is more expensive in the short-term. But if it prevents the chronic pain that can develop after ORIF, ARIF could potentially lower overall costs in the long-run.

The most important factor is effectiveness of these two procedures when compared against each other. And that’s where research has not yet been done. Without the assurance that ARIF is indeed superior to ORIF when treating ankle fractures, most ankle fractures will continue to be managed using the open method.

Regardless of the method chosen to perform the surgery, pre-operative diagnosis and evaluation are very important. The surgeon will use X-rays, CT scans, and/or MRIs to view the location and extent of the damage.

The surgeon will look to see if the joint cartilage is affected. MRIs are especially good at showing the presence of swelling around the bone called bony edema. CTs show the pattern of fracture. All of this information is helpful in deciding the best surgical approach to take. For example, large displaced (separated) fractures may require open surgery.

The information gathered from imaging studies also help the surgeon decide whether to enter the joint arthroscopically from the front (anterior approach) or the back (posterior approach). The authors provide details about the best foot and ankle position and portal (opening for the scope) entry to use for each approach.

Even with careful and thorough imaging studies, it is possible to miss an important finding. The lesion depth for visible injuries isn’t always readily apparent with imaging studies. Damage to the surface of the joint or a displaced fracture may not show up on imaging. There may be secondary fractures that haven’t shown up at all on imaging studies.

Impacted fractures (the broken ends are smooshed together) or comminuted fractures (broken into tiny pieces) require special planning and attention. The surgeon must be prepared for any and all possibilities once inside the joint.

Fortunately, arthroscopy allows the surgeon to see the joint surface clearly when reducing the fracture (bringing the broken surfaces back together). Arthroscopy also makes it possible to look for tiny fragments of bone, cartilage, or other debris that would create problems later if not recognized and removed.

There are a few more challenges to consider with ankle fractures. Children and teens who have not completed their growth have growth plates that will allow further bone growth. The surgeon must be careful to avoid injury to these growth plates.

Finally, the care each patient receives after surgery is just as important as the procedure itself. The surgeon advises the patient, physical therapist, and nursing staff what to do based on what he or she (the surgeon) saw and did during the procedure.

Sometimes the patient can put weight on the foot right after surgery but full weight-bearing isn’t usually allowed for several weeks. It may be necessary to wear a cast for six to eight weeks (sometimes longer). If there is any concern about the stability of the ankle, the patient will be transitioned from a cast to a walking boot.

Joint motion exercises are started around six weeks post-op for those who didn’t have a cast or when the cast is removed. The surgeon uses X-rays to see how well the bone is healing and advise the patient and therapist when to advance weight-bearing, joint range-of-motion, and exercises.

Hardware used to fix (hold) the fracture stable during healing is often removed eight to 10 weeks later. The goal is to remove the screws or other instrumentation before bone and scar tissue grow over and around it making removal more difficult. Timing is important because removing it too soon could leave the ankle unstable.

The authors conclude that arthroscopy is a valuable tool for identifying all problems present in complex ankle fractures and injuries. Consideration should be given for the use of arthroscopic reduction and internal fixation (ARIF).

This technique is less invasive and allows the surgeon to take care of problems that might not be seen otherwise. Arthroscopic surgery should not be used when there is a fracture and dislocation.

Studies are needed to compare the results of surgery between arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF) before the arthroscopic technique will be adopted by all surgeons.

More Bone for Grafting with Fewer Problems

There are new and wondrous developments in the area of bone grafts. In this article, new techniques for bone grafting in the foot and ankle are discussed and demonstrated through description, photos, and drawings. Bone grafts are often used in ankle and foot surgery to fill in areas of bone or to fuse joints that have lost their stability because of injury or trauma (e.g., fractures, ligamentous tears).

Bone graft materials can come from the patient (that’s called an autograft) or donated from someone else. Donated bone called an allograft comes from a bone bank. New methods of preparing bone grafts have changed the way patients respond to bone grafting with better results and fewer complications. At the same time, the use of bone marrow from inside the bone and growth factors and interleukins now speed up bone healing.

The biggest problem has always been the donor site for autografts. Most often, bone was taken from the iliac crest. The iliac crest is the top of the pelvic bone — it’s located where you place your hands on your hips.

Bone harvested from this area is plentiful but can cause excessive bleeding and postoperative pain. For some procedures, like ankle and foot reconstruction, the patient could go home the same day if it wasn’t for problems with the bone graft donor site.

Because of major complications with graft site pain, deep infections, ugly scars, and sensory loss, surgeons started looking elsewhere for another source of autograft with fewer problems. With the advances in graft techniques, it’s now possible to take bone from places other than the iliac crest.

The most popular sites have become the front of the tibia (lower leg bone) just below the knee, the lower part of the tibia (just above the outer ankle), the calcaneus (heel bone), and the greater trochanter (area of bone at the top of the femur or thigh bone).

If the graft donor site is close to the area where the donor bone is needed, it’s considered a local source of autogenous graft material. If the bone is harvested from an area away from the main surgical site (usually in order to get more bone), it’s referred to as a regional bone graft.

Whenever harvesting bone from these alternate sites, the surgeon must be careful to make the incision where the most bone can be removed without cutting into nearby nerves, blood vessels, or soft tissues. Incision sites for each of the alternate donor sites are provided.

Techniques and tools to use for removing bone graft are also provided in this article. The position to place the patient for bone harvesting is also discussed. Positioning can be tricky if the patient has a difficult bone fracture and movement might displace or shift the broken pieces.

Another important consideration in selecting bone graft material is the type of bone used. There are two main types of bone: cancellous and cortical. Cancellous bone is the spongy, less dense bone between the outer layer (perisoteum) and inner layer (bone marrow).

Cancellous bone has a better blood supply and that’s helpful in getting new bone cells to survive. There’s also more of it compared with cortical bone. And it is easier to form and shape cancellous bone around difficult or tight spots during bone grafting procedures. This last benefit is important when working in the ankle because of the many oddly shaped bones and joints.

Cortical bone is the stronger, denser, supportive bone that forms the outer shell of most bones. It provides good mechanical support. But with less of a natural blood supply, it is much slower to build blood vessels for the new bone.

Both types of bone (cancellous and cortical) are selected based on where the bone will be used and its specific purpose (e.g., fracture repair versus fusion). Once the best bone site for the problem has been selected and bone harvested, it must be transplanted to the location where it is needed.

The surgeon uses a tool called a high-speed burr to shape a trough in the bone where the graft can be placed. The bone graft forms a scaffold where other bone will fill in and around. It must be able to stimulate more bone cells to grow.

Until the bone fills in, the area won’t be strong enough to support the patient. That’s where instrumentation or fixation comes in. Metal plates, screws, and/or wires are used to hold everything together until healing takes place.

The authors admit there can be complications using these alternate donor sites. Problems can occur with poor wound healing, infection at the donor site, bone fracture of the donor bone, and failure of the bone graft to fuse the surgical site. The iliac crest is still an excellent source of donor bone (both cancellous and cortical). Fusion rates are the best when using iliac crest bone graft.

In conclusion, if there are concerns about bone graft donor site problems, allografts from the bone bank are still an option as is taking autografts from alternate sites. This article reviews all possibilities, pros and cons of each, as well as risks and benefits.

New Study Challenges Surgery for Achilles Tendon Ruptures

The debate continues among surgeons about the best way to treat Achilles tendon ruptures early on after they have happened. The first question is whether to operate and repair the torn tendon or treat it conservatively (without surgery). It would seem that whichever way gives the best outcomes is the way to go. But the problem is that different studies come up with different results. There just don’t seem to be consistent results to support one approach over the other.

In a recent study by this author (Dr. Kevin R. Willits), a high-quality study was designed to put this argument to rest. Dr. Willits recognized that one reason study results vary so much is because different post-operative rehab programs are used. He started to wonder if the patients who had the best results were doing so well because of a more aggressive rehab protocol. He based this hypothesis on the fact that so many studies that had poor outcomes used a very conservative, slow rehab program.

So he put his idea to the test. He compared two groups of patients. They all had an acute Achilles tendon rupture. They all followed the same fast-paced (called accelerated) rehab program. The only difference was that one group had surgery right away and the other group didn’t. The natural question that comes to mind is what makes up an accelerated program?

There are two key features to the accelerated functional rehab program. One is getting up and putting weight on that foot and leg. The second is early ankle motion. Scientists have already shown that load and pressure on healing collagen tissue speeds up the healing process.

But the worry with Achilles tendon rupture has always been that the tendon would re-rupture with too much too soon. So, in the past, these injuries were always treated with cast immobilization with no weight on the foot. That protocol was used for both conservative care and after surgery.

Now this study showed that, in fact, the early mobilization group had the best results. There were less (not more) re-ruptures. They did have a period of non-weight-bearing and immobilization– but only for two weeks. During that two-week period of time, they were put in a special splint and kept weight off the foot.

The splint was exchanged for a boot brace with a heel that protected the healing tendon for the next four weeks. During that time, they were allowed to move the ankle from a toe pointed down position (called plantar flexion) to a neutral alignment. By the end of eight weeks, they were out of any protective boot at all and allowed to move the foot freely and put full weight on it.

The conclusion of the study was that early motion and early weight-bearing (early, not immediate) were keys to a successful outcome. With equal results between conservative (nonoperative) care and surgery, the natural conclusion is that surgery isn’t needed after all. An aggressive functional rehab program is what people really need. This formula is especially helpful for athletes who want to get back into action as soon as possible.

Even with conservative care and an aggressive rehab program, Achilles tendon ruptures simply take a long time to heal. Eliminating the added risks that come with surgery improves the odds that the athlete will stay on course and get full recovery without delays. The author concludes that his group will continue investigating this topic. There may be other ways to aid recovery and reduce the amount of time it takes to go from injury back to the field or court.

Surprising Results From Using Platelet-Rich Plasma for Achilles Tendon Rupture

In the last few years, scientists have discovered that injecting platelets from blood into damaged tendons helps them heal faster and better. This has been good news for professional athletes who are eager to get back to work on the playing field.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has much more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

In a surprising twist on the subject, researchers in Sweden reported on their not-so-successful results. They used platelet-rich plasma (PRP) injections in the Achilles tendon of 16 patients. They were not all professional athletes but the injury did occur while engaged in recreational sports.

Results were compared to another group of patients who also had a recent Achilles tendon rupture (within three days). The second group was the control group — they did not have the PRP injection. Patients in both groups ranged in age from 18 to 60 and were in good general health.

The Achilles tendon was chosen for several reasons. It is a commonly injured area in athletes as well as in others who do not participate in sports. The tendon does not heal well — it takes a long time to recover from an Achilles tendon rupture. And the risk of rupturing it again is fairly high. For all those reasons, finding a more effective treatment with better long-term results would be a great boon to all.

This group of researchers has been studying tendon healing for a long time. They have developed a way to measure tendon elasticity. In this study, they measured both tendon elasticity and function at regular intervals after PRP injection. Follow-up was for a full year.

Before the procedure was done, everyone donated a unit of blood to be used for themselves. The lab removed platelets from the blood and the surgeon injected a solution that was 10 times higher in platelets than regular blood. The tendon was repaired surgically and then the PRP was injected into the area of rupture.

Postoperative treatment included a short-leg cast with the foot in a slightly plantar-flexed position (toes pointed down). This position takes pressure and load off the healing Achilles tendon. It is a standard post-operative treatment after surgery to repair ruptured. After three and a half weeks, the foot and ankle were re-cast in a more neutral position.

At the end of seven weeks post-op, no further casting was needed. Patients wore shoes with a slight heel (again to avoid overstretching the healing tendon) for a month. During all this time, they were allowed to put as much weight on the leg and foot as they could comfortably tolerate. Patients in both groups were enrolled in a typical physical therapy rehab program.

The authors were surprised to find no differences between the two groups. The PRP group did not heal faster or have a stronger Achilles tendon at any point in the follow-up. In fact, if anything, the PRP group had slightly worse functional results. Functional refers to their ankle motion, ability to rise up on toes, and jump vertically. The PRP group did not see themselves as limited in daily activities but there is still a concern that their risk of re-injury is greater than normal.

Taking a look back on how the experiment was done, the authors could not find any obvious reason why the PRP group did not have better results than the control group. The preparation of the injection was followed according to standard protocols used in other studies. The platelet concentration was higher than reported in other studies (17 times normal blood compared to three times higher in another similar study).

They suggested that perhaps using tendon elasticity as a measure of “success” may not be correct. Their basis for thinking elasticity was an accurate measure comes from the belief that healing tendons heal in an elastic manner. Maybe there is an error in this assumption. Another possibility is the concentration of platelets. Is it possible that too high a concentration yields worse results than lower amounts?

This was the first study to treat Achilles tendon ruptures with PRP compared with a control group. More studies will be needed to clear up the mystery of why Achilles tendon healing was not enhanced.

More Good News From the Operating Room

The ankle is a very complex joint and a bad break affecting the joint itself can lead to considerable pain and disability. Older age and certain health factors can add misery to an already difficult situation. That’s been the case with intraarticular (inside the joint) calcaneal fractures.

The calcaneal bone is your heel bone. It sits right under the tibia (lower leg bone) and right above the talus and forms part of the ankle joint. In the past, surgery to fix a fracture affecting this area in an older patient had a dismal record for recovery. That’s why many surgeons recommended conservative (nonoperative) care for a fracture of this type in anyone over age 65.

But that’s changing now thanks to improved implants used to hold the bones together. And the use of real-time X-rays called fluoroscopy during the procedure has also helped improve results.

In this study, the use of internal fixation (metal plates, screws, wires, and/or pins) to hold the broken bones together until they heal was investigated. The surgeons were particularly interested in knowing how long-term results looked in patients based on age.

They searched their medical records for all patients who had internal fixation for an intra-articular calcaneal fracture. Everyone who was treated between 1992 and 2007 was included. Data collected from the records included fracture pattern, how the injury occurred, and postoperative pain and function.

Each patient was contacted by mail and asked to complete a survey asking questions about current symptoms, activities, and foot function. They were also asked if any further surgeries were done on that ankle or foot.

Patients ranged in age from 18 to 84 and were broken into two groups for comparison (under age 50 and age 50 or older). Analysis of the data collected showed that most of the injuries (70 per cent) in the older group were caused by a fall. Car accidents accounted for 44 per cent of the injuries in the younger group with 55 per cent linked with falls in the same age group.

The final results showed a significant difference between the two groups based on age. Younger adults did NOT have better outcomes as predicted. Instead, it was the older adults who had less pain and better function.

The rate of complications between the two groups was about the same. Although the older patients were at greater risk for problems with anesthesia, there weren’t really any more complications in this group compared with the younger group.

The authors note that being older doesn’t always mean surgery is out of the question for this particular injury. Careful patient selection may be the key. Patients with a health history of tobacco use, diabetes, poor circulation, or decreased immune function should be screened carefully. Any of these factors may suggest conservative care instead of surgical fixation for intra-articular calcaneal fracture fixation.

With the aging of America and the fact that our seniors are remaining more active later in life, surgeons may expect to see an increase in the overall number of ankle fractures. Older age may no longer be the deciding factor in treatment options.

How did they account for the better results among the older patients? Decreased physical demands in adults in the older age group may actually be a benefit to healing. The only other possible (apparent) factor was the larger number of Worker’s Compensation patients in the younger group.

The authors conclude that surgery with internal fixation for intra-articular calcaneal fractures is a “reasonable option” for older adults. Those who are in good health, with good bone strength, and minimal risk factors may be very good candidates for this type of treatment.

This study did not include a group of patients who had nonoperative care for comparison. The authors suggest a future study to include this additional group (also based on age differences) should be done before making final recommendations.

Footballer’s Ankle, Otherwise Known as Medial Ankle Impingement

What are footballer’s ankle, kissing osteophytes, andpeek-a-boo heels? And what do they have in common? Athletes involved in running and jumping sports can develop a condition called footballer’s ankle or medial ankle impingement. Medial refers to the side of the ankle closest to the other leg.

Typical symptoms include ankle pain, a clicking sensation when moving the ankle, and loss of ankle motion. These symptoms are the result of “impingement”. The term “impingement” always tells us something is getting pinched.

In cases of medial ankle impingement, there are bone spurs (osteophytes) opposite one another (hence, the term “kissing osteophytes”). With certain movements of the ankle (e.g., dorsiflexion or moving the ankle toward the face), the opposing bumps of bone butt up against each other, stopping motion. Sometimes the deltoid ligament gets caught between the two bone spurs, another example of impingement.

Anyone with a foot deformity called cavus (high arch) is at risk for medial ankle impingement. And that’s where the term “Peek-a-boo” heels comes in. The high arch is accompanied by a shift in the foot. When looking at someone’s cavus feet from the front (the person is standing), the heels are visible on the medial (inside) edge of the foot. Normally, the inner edge of the heel is not visible from the front.

Football players aren’t the only ones who can develop this condition. Other athletes engaged in sports like basketball, soccer, distance running, and gymnastics have developed medial ankle impingement. Most of the affected individuals have a subtle (mild) cavus foot malalignment. Changes in foot position after nonsporting injuries such as ankle and foot fractures can also lead to medial ankle impingement.

What can be done about this problem? First, the cavus foot can be treated with a special shoe insert called an orthotic. This firm piece of plastic is molded in such a way to support the arch in a slightly lower position than normal for that person. Dropping the arch down this way helps realign the ankle and foot and may help resolve the impingement problem.

For patients who have an unstable ankle, bracing may be necessary. And for those who don’t get better with orthotics or bracing, surgery to remove the bone spurs and any loose pieces of bone or cartilge may be needed.

The surgeon may tighten up loose ankle ligaments at the same time. In all cases, a reduction in exercise helps decrease the symptoms. And the reverse is also true: increased exercise makes things worse.

Does the athlete have to retire forever after surgery? Fortunately, no — results are usually very good and even young athletes can get back into action fairly quickly. They will probably always have to use at least the shoe orthotic if there is a cavus foot present.

But there is one word of caution: the bone spurs can come back with intense activity and repetitive ankle motions. Athletes with the cavus foot deformity are also at increased risk for stress fractures of the navicular bone in the foot and the long bone of the fifth toe.

Can this problem (medial ankle impingement) be prevented? A good question but not one that has been explored yet. Since not all athletes with a subtle cavus foot develop bone spurs or fractures leading to impingement, there may be other factors at work. Finding out what those risk factors may be will help guide surgeons in finding ways to prevent medial ankle impingement in athletes.

Three-Phase Rehab for High Ankle Sprains

Ankle sprains can be very debilitating — especially for sports athletes who are eager to get back into action. Since most ankle sprains are treated conservatively (without surgery), physical therapists study the best ways to go about getting athletes back into full participation.

In this article, physical therapists at the University of Iowa describe their approach to high ankle sprains. Anatomy, mechanisms of injury, and assessment of the problem are also covered.

A high ankle sprain refers to tearing of the connective tissue that connects the lower part of the tibia to the fibula. The tibia is the larger of the two bones in the lower leg. Your shin is the front of the tibia.

The fibula is the smaller bone (along the outside of the leg). Syndesmosis is the name of the connecting tissue between these two bones. Another word used to describe high ankle sprains is syndesmotic.

The syndesmosis is actually more than just a single layer of connective tissue between the tibia and fibula. That’s certainly part of it but there are also four strong ligaments involved (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, transverse tibiofibular ligament).

With that much ligamentous support, you can imagine the kind of force it takes to tear them. Most of these high ankle sprains occur when the player collides with another player or gets hit with enough speed and force to fracture one or both of the bones and the ligaments. In all cases, the foot is planted on the ground while load is applied above the ankle.

A similar mechanism (pathway to injury) occurs in skiers or skaters who have the foot planted firmly, then twist or torque suddenly. Pressure applied along the top of the rigid boot from the sudden force is enough to tear the stabilizing soft tissues (ligaments and connective tissues) just described.

Without a normal, healthy, intact syndesmosis, the ankle becomes unstable. Of course the athletes who need a stable ankle the most are the very ones who injure this area: ice hockey players, soccer players, and football and rugby players.

Syndesmotic of high ankle sprain injuries are fairly easy to diagnose. There’s the expected history of trauma along with typical symptoms. Pain is the main symptom but bruising, swelling, and tenderness over the injured ligaments and interosseous membrane are often present. Any of those symptoms plus an inability to put weight on the foot is an additional telltale symptom of high ankle sprains.

Diagnostic clinical tests can be applied to stress each ligament. Either the examiner applies a manual force to each soft tissue structure or the patient assumes certain positions to create similar loading patterns.

The amount of pain and length of tenderness are important findings to predict results. For example, the farther up the leg tenderness is felt, the longer the athlete will be away from participation in sports. Likewise, the amount of pain matches how much of the ligamentous support has been damaged (severe pain likely means more damage).

Therapists have devised new ways of testing for syndesmotic damage. Rather than stressing the potentially unstable joint, they tape the lower leg and provide external support. If the painful symptoms are reduced or go away with taping, it’s considered a positive test for a high (syndesmotic) sprain.

But these clinical tests are not the end of the evaluation. It’s important to find out exactly what’s injured and the extent of that injury before beginning rehab. X-rays and MRIs provide additional information needed along these lines. If there are any other injuries (e.g., fractures, damage to the bone or cartilage), they will show up with imaging studies.

The three-phase rehab program proposed by and studied at the department of Physical Therapy and Rehabilitation Science at the University of Iowa is made up of 1) the acute phase, 2) subacute phase, and 3) advanced training phase. Each phase has its own goals, treatments, and criteria for progression (moving along to the next phase or getting back into sports participation).

Every athlete is evaluated individually in order to determine the best treatment approach. Once the three-phase program is tailored for the athlete, the therapist carefully monitors symptoms, concerns, goals, and each part of the program.

In the acute phase, the goal is to protect the joint and decrease symptoms, especially pain, swelling, weakness, and loss of motion. A variety of tools are used to accomplish these goals such as immobilization in a cast or brace and limiting weight-bearing if needed. Modalities such as ice, compression, electrical stimulation, manual therapy, and/or complementary therapies (e.g., acupuncture) may be used.

When the patient can walk with minimal difficulty on different types of surfaces (uneven ground, stairs, grass, curbs), then they are progressed to the subacute phase. Now the goal is to get normal joint motion, strength, and motor control back.

The early phase of a strength-training program is started during the subacute phase. The foot and ankle will be challenged with balance activities (e.g., rocker board, wobble board, air cushion). A foot cycle, aquatic therapy, ankle weights or elastic resistance, and weight machines are just a sampling of the many ways training continues.

Advanced training is begun when the athlete can jog and hop with little discomfort and can perform all daily activities. The goal, of course, is to get back into sports action. Running, hopping, figure-8, and jumping drills are an important first step in the advanced training series of exercises.

The athlete will progress through advanced strengthening, plyometrics, speed drills, and running patterns. Plyometrics involve making fast changes with momentum (speed). This is kept up until they can perform sport tasks at game speed without pain or discomfort. Correct movement patterns and quality motor control are also required. That’s when they are released to return to full participation in whatever sport they want to participate in.

The authors conclude by saying that this three-phase rehab program is one sample of how the problem of high ankle sprains in athletes can be handled. There is a need for research to validate the best treatment for this problem. Comparing techniques and modalities in each phase of healing and recovery with results will help guide future treatment recommendations.

Special Program Proven to Prevent Repeat Ankle Sprains

Health care reform has given researchers reason to study the cost-effectiveness of medical treatment and find ways to improve results with less expense. Athletic injuries make up a huge proportion of health care costs in young adults.

In particular, lateral ankle sprains (the outside of the foot) are the focus of this study. There are literally thousands of ankle sprains occurring everyday in the United States and over half a million per year in The Netherlands. With that in mind, this report from The Netherlands on how to save money by preventing recurring (repeated) ankle sprains is very timely.

More than 500 adults (men and women athletes) were enrolled. They came from emergency department referrals, general practice and physical therapy offices, and some nonmedical channels (e.g., newspaper ads, the Internet, sports events). Everyone had a lateral ankle sprain.

Half of the men and women were placed in an intervention group. The other half made up the control group. Everyone in both groups was treated with what is called usual care. The basic R.I.C.E. formula is used: rest, ice, compression, and elevation during the acute phase (first 48 hours). Early movement and weight-bearing are encouraged with usual care.

The intervention group was also instructed in a special program of proprioceptive training. Proprioceptive exercises are designed to restore the joint’s sense of position change. Finely tuned proprioception is important so that the foot and ankle respond to tiny changes in position.

Good proprioception allows the ankle to readjust its position when you walk on uneven ground, step on a rock, or get pushed off balance suddenly. Without an accurate sense of position, the ankle may twist or rotate too far in one direction before pulling back. And by that time, it’s too late and another sprain has occurred. The program consisted of 30-minute sessions performed at home (unsupervised) three times per week for eight weeks.

Outcomes were measured in two ways: first, the number of recurrent (repeated) ankle sprains and second, costs. Costs were broken down into two segments: productivity loss (absence from work) and medical costs (referred to as health care utilization).

Medical costs included any visits to a health care professional for the ankle sprain and any tests (X-rays or other imaging) or procedures performed. Health care utilization also included any devises used (e.g., crutches, tape, ankle brace, balance board) and any medications taken during recovery for the ankle sprain. The cost of the intervention program was also factored in.

When the information collected was broken down and carefully analyzed, they found higher costs per athlete in the control group. That’s because there were twice as many repeat ankle sprains in that group compared with the intervention group.

So, even though the intervention group cost more, the results were better. With fewer ankle sprains, there were lower medical costs and less work money lost (productivity) because of fewer work (or sports) absences. The authors used charts, graphs, and tables to show the results. They also provided a breakdown of the cost differences between the two groups
They concluded that an unsupervised at-home program of proprioceptive exercises is not only effective, but also cost-effective. Preventing recurrent ankle sprains saves money. The benefits of a proprioceptive training program far exceed the cost. The savings to society could be in the millions with a simple proprioceptive training program.

Evolving Diagnosis and Theories on Ankle Impingement

Ankle pain in athletes of all kinds is a fairly common problem. When X-rays show bone spurs called osteophytes along the front part of the joint, the condition is referred to as anterior ankle impingement. Impingement is another word for “pinching”.

What’s getting pinched and why? Sometimes there are bone spurs called osteophytes that form along the joint line. Every time the foot and ankle move, the extra bone jams up against the joint preventing full motion. There can also be an overgrowth of joint synovium (lining with fluid to give smooth movement of the bones) called synovial hyperplasia. And in some cases, the Deltoid ligament of the ankle gets folded over and pinched between two bones.

There are several theories about why ankle impingement develops. No one knows for sure why it happens. It makes sense that athletes who use kicking motions repetitively put a force or pull (traction) on the joint capsule. The body sets up a natural response to protect that area by laying down some extra bone. Over time, this extra bit of bone forms into a ball shape. The bone mass is rarely a smooth, round ball but often has jagged edges, which is why it is referred to as a bone spur.

Any repeated action or impact force can damage the ankle joint. The soccer player comes in contact with the ball over and over. The ballet dancer or gymnast bears his or her entire body weight on pointed toes (and ankle). The end result can be ankle impingement. It is also suspected that previous ankle injuries (sprains and strains) with ligamentous damage may be part of the picture.

Depending on which side of the ankle is involved, the impingement may be labeled anteromedial (front inside ankle affected) or anterolateral (front outside ankle affected). Before MRIs were available to show the exact location and extent of the problem, this condition was just referred to as athlete’s ankle.

All types of athletes have developed this problem from dancers and gymnasts to soccer players and distant runners. Triathletes, baseball players, football players, and basketball players have also been diagnosed with ankle impingement.

In this study, a group of 41 athletes with anteromedial ankle impingement were followed for at least two years after arthroscopic surgery. The patients were male and female of all ages from 13 to 57. No one had any previous ankle surgery. Anyone with arthritis was not included in the study.

The surgeon performed arthroscopic surgery with video recording of the procedure. Any scar tissue, overgrowth of synovial tissue in the joint, and bone spurs present were removed. Basically, all tissue preventing ankle dorsiflexion (motion of pulling toes and ankle toward the face) was resected (trimmed, cut, or shaved away).

As you can imagine, a dancer, gymnast, or other athlete who can’t move the ankle or kick a ball without excruciating pain has a major problem. In order to document results or outcomes of the surgery, before and after measurements were taken.

The patients filled out health survey forms indicating their symptoms and level of function (daily activities as well as sports participation). After surgery, they followed a rehab program under the supervision of a physical therapist. Throughout the study, all patients reported on their satisfaction with the results of treatment.

What were the results? Good-to-excellent! There was a 93 per cent level of satisfaction among all patients. All but one athlete was back in full action by the end of 13 weeks (some as early as seven weeks). There were a few complications (temporary nerve injury, excess scar tissue formation). Some athletes needed additional ankle surgery later for other problems.

The authors conclude from the data collected in this large set of patients that arthroscopic treatment of anteromedial ankle impingement is successful. The condition is probably more common than is normally recognized.

Surgeons are advised to be suspicious of impingement in athletes complaining of medial ankle pain. With early diagnosis and arthroscopic treatment, dancers, gymnasts, and sports players can return to full participation in a relatively short amount of time.

Future studies are needed to identify specific causes of ankle impingement. Most likely, there isn’t a single cause but a group of patient factors including previous injuries that contribute to this problem. It may be possible to recognize athletes at risk and prevent the need for surgery.

Review of Ankle Tendon Disorders

Every muscle in the body has a specific purpose and job to do. Nothing makes that clearer than when an injury or degenerative changes of a muscle result in deformity and disability. In this article, the role of the posterior tibial tendon (PTT) in the lower leg, ankle, and foot is reviewed. Anatomy, function, and dysfunction are discussed in detail.

The posterior tibial tendon (PTT) runs behind the inside bump on the ankle (the medial malleolus), across the instep, and into the bottom of the foot. The tendon is important in supporting the arch of the foot and helps turn the foot inward during walking. Tendon pathology may begin with an acute injury from a traumatic fall, an ankle fracture or dislocation, or even laceration (cut) of the tendon.

Other factors that seem to put people at risk of PTT deficiency and even rupture include female gender, obesity, diabetes, high blood pressure, taking steroids, or previous trauma or surgery to the mid-foot.

Posterior tibial tendon dysfunction can be classified into four (progressive) stages. Stage 1 is characterized by tenosynovitis (inflammation of the tendon sheath and fluid between the sheath and the tendon). The patient reports mild pain around the ankle bone (the one on the inside of the ankle) and along the instep of the foot. There may be some mild weakness when trying to turn the foot inward (inversion).

Stage 2 represents degeneration that occurs as a result of the tenosynovitis when it doesn’t heal. The tendon loses some of its flexibility and support and starts to lengthen (or elongate). In some cases, the tendon may rupture, due to weakening of the tendon by the inflammatory process. The patient is still having painful swelling and beginning to see the effects of the weakness.

Without the strong support of this tendon, the arch of the foot starts to collapse, a condition called pes planovalgus. You would recognize this deformity as a “flat foot”. By now, the patient with stage 2 posterior tibial tendon dysfunction is experiencing quite a bit of pain when trying to raise up on the toes of that foot. In fact, he or she may be unable to perform this action.

By the time stage 3 sets in, the heel raise is impossible to do, there can be pain on both sides of the ankle, and the flat foot position has become a rigid deformity (no longer correctable). Stage 4 is marked by pain and crepitus (snapping, grinding sensation and/or sound). The foot is in a “turned out” position, which causes the soft tissue structures along the lateral (outside edge) of the foot and ankle to get pinched even more.

This classification scheme is important because it guides the surgeon when determining the best plan-of-care. Treatment depends on the severity of the PTT disorder and can include conservative (nonoperative) care or surgery. Conservative care consists of adapting shoes, using an insert called an orthotic) inside the shoe, and sometimes, immobilization in a cast or boot.

Physical therapy may be helpful in regaining alignment through postural adjustments, strengthening exercises, and manual therapy to restore tissue tensegrity (balance of tension and compression). Other nonoperative forms of treatment may include a rigid (nonflexible) ankle-foot-orthosis or AFO. Some patients will end up wearing the AFO permanently to support the foot and ankle.

What about surgery? When is that appropriate and what does the surgeon do? This is an area of considerable debate and an area for continued study. Transferring another tendon to take the place of the torn, ruptured, or degenerated PTT is one option. One of the goals of surgery is to stabilize the joint and improve alignment. Procedures to accomplish this goal can be quite complex with lengthening of some muscles, repair of damaged ligaments, and/or fusion of certain ankle bones.

The authors present their preferred (surgical) treatment of PTT for each stage (1 through 4). The exact surgical procedure is described in detail. Briefly, in stage 1, they open the area, remove any dense adhesions (scar tissue) and clean out areas of synovial tissue that has solidified or overgrown.

In stage 2, the Achilles tendon is lengthened and a tendon transfer is done when needed. All other surrounding structures are checked for damage and stability. Anything that needs repair or reconstruction is taken care of right away. Sometimes it is necessary to stitch two of the tendons (flexor digitorum longus and flexor hallucis longus) together to assist in the tendon transfer. If the hindfoot (heel and attaching Achilles tendon) are out of alignment too much, a procedure may be done to realign that area as well.

The authors’ preferred surgical treatment for stages 3 and 4 follow the steps used for stages 1 and 2 but go much deeper into the foot to provide support for the rigid flat foot deformity. As much as possible, the bones of the ankle are put back in their normal, anatomic placement and held there with screws, staples, and wires. All surgical procedures are followed by immobilization, a period of non-weight bearing, and then rehab with a physical therapist. Full recovery can take 12 weeks or more.

The authors conclude that their preferred management may not be the best or only approach but their results have been satisfactory and patients are pleased with the results. Having a thorough knowledge of posterior tibial tendon (PTT) anatomy is essential in recognizing problems that are developing and knowing ways to treat PTT disorders of the foot and ankle. Since this tendon-muscle unit is the one that turns the foot in and supports the arch of the foot, knowledge of its anatomy and treatment are important for orthopedic surgeons.

Decision-Tree for Treatment of Osteochondral Lesions of the Ankle

Ankle pain when putting weight on the foot can come from a wide range of problems. One of those problems can be identified using an anesthetic injection into the joint. It’s called osteochondral lesions of the talus (OLT).

In this article, orthopedic surgeons specializing in the treatment of OLT share their knowledge and expertise with other surgeons. Detailed descriptions of the lesions, the evaluation process, and management (both operative and nonoperative) are provided. Photos taken during surgery along with pearls (what to do) and pitfalls (what not to do) make this a very practical discussion of the problem.

What are osteochondral lesions of the talus? Well, first, the talus is a bone in the ankle. It is sandwiched between the lower leg bone (tibia) above and the calcaneus (heel bone) below.

Osteochondral lesions refer to defects in the joint surface, specifically the articular cartilage that lines the joint. Chondral refers to cartilage. Osteo- tells us that the damage goes clear down to the first layer of bone.

Surgeons have been grappling for years how to repair painful, debilitating osteochondral lesions of the knee. Now the same techniques (debridement, microfracture, osteochondral autograft transfer or OAT, autologous chondrocyte implantation or ACI) are being used on the ankle.

But osteochondral repair on the ankle is more difficult than on the knee because there is limited access to the ankle joint. The surgeon must do a thorough and extensive work-up on the patient in order to make sure the real underlying problem is determined. Accurate diagnosis is important in planning treatment as well.

That’s why the authors have developed their own decision-making process (algorithm) for the preoperative evaluation of osteochondral lesions of the talus (OLTs). As mentioned, the first step is to perform a diagnostic injection. Relief of symptoms requires a CT scan to stage the lesion.

Staging is a way of determining the location, extent, depth, and overall severity of the defect. With mild (early stage) disease, it may be possible to treat the patient conservatively with nonoperative care (rest, immobilization in cast or splint). Deep fissures or displaced fragments require more extensive surgical procedures.

If the OLT is free of cysts, then a simple debridement (smooth the area, remove frayed edges) may be all that’s needed. Another treatment option early on is called microfracture — after debridement, the surgeon drills tiny holes in the area of the defect down into the bone. This stimulates bleeding and a healing response.

For larger defects (or for any size defect that doesn’t respond to a more conservative approach), the lesion is filled with graft material. The donor graft may come from a bank (allograft) or from the patient (autograft).

Many of these procedures can be done arthroscopically, which avoids an open incision and disruption of the soft tissues around the ankle. Another advantage of an arthroscopic approach is the pre-procedure diagnostic information it provides.

Before setting to work with the osteochondral repair or reconstruction, the surgeon uses the scope to look the joint over carefully. Every aspect of the lesion is reviewed and measured in preparation for the surgery. In fact, the diagnostic arthroscopic exam really helps the surgeon make the final treatment decision as to which procedure should be used.

The authors provide a step-by-step description of each implant procedure, including where to insert the arthroscope for surgeries on either side of the joint. Color photographs of the graft procedures, suture techniques, and results are included.

Results reported from various studies are reviewed. So far, it looks like the short- to mid-term results are good-to-excellent for each procedure when treatments are selected carefully for each patient.

The authors conclude that these reconstructive procedures are not 100 per cent guaranteed. When patients fail to recover after arthroscopic procedures, it may be necessary to perform a second operation — this time with an open incision. Again, the selection of which approach to use depends on the type of lesion and stage. Some problems just can’t be treated with the types of reconstructive procedures discussed in this article. That’s when an ankle fusion or joint replacement might be more appropriate.

Understanding the Ins and Outs of Ankle Sprains in the United States

Ever twist your ankle (or sprain it) badly enough to go to the emergency department? Every year two million Americans suffer an acute ankle sprain. About half of those people hurt themselves during an athletic event — but not everyone. The other half were men and women like you and me.

Why does it even matter how many people sprain their ankles? As the authors of this epidemiological study point out, the economic (health care) cost of ankle sprains each year in the United States is two billion dollars! And that doesn’t even include the cost of time lost at work, loss of productivity on-the-job, or the cost of long-term disability.

Long-term disability for an ankle sprain? Yup — as the results of this study show, up to 60 per cent of the folks who go to the emergency department have an ankle sprain severe enough to alter their function for the rest of their lives.

And these figures don’t even represent the numbers of teens and adults who see their primary care physician for an ankle sprain. And they certainly don’t represent the numbers of people who don’t see anyone but just try and treat it themselves.

By the way, an epidemiological study is one that looks at the patterns of health and illness. By looking at who sprains their ankle, it is possible to identify associated risk factors with the idea of preventing the problem.

Understanding who sprains their ankles and why this happens also helps health care professional determine optimal treatment approaches for these patients. Reducing the costs associated with ankle sprains and especially preventing long-term disability are two important goals of a study like this one.

So what do we know now from a study like this one? From examining the records of emergency departments, it was possible to see that overall, men and women sprain their ankles in equal numbers. Some specific age patterns are evident: there is a peak incidence of ankle sprains in women over 30 and men between the ages of 15 and 24.

Ankle sprains occur most often during athletic activities, in particular, during basketball, football, and soccer (in that order). Athletes involved in other sports such as gymnastics, volleyball, and running are also at increased risk of ankle sprains.

Not too surprising is the fact that the peak of sprains occurs in children between ages 10 and 19 as a result of sports, athletics, or other physical activity. But half of all ankle sprains occur while people are at home from falls on stairs or a stumble on a ground-level surface.

What are the conclusions about ankle sprains in the general population from an epidemiologic study like this? Well, first there is a definite association with sports and athletic activates. With more and more young people participating in school sports, competitive physical activities, and recreational events, the likelihood of this injury occurring may increase.

That means it may be a good idea to find cost-effective ways to prevent the problem. Finding the right solution(s) will be the focus of future studies. Some ideas presented included: identifying high-risk individuals, weight control programs, or offering a training program of strengthening and proprioceptive activities to those individuals involved in high-risk sports.

And future studies to investigate other important factors may be a good idea, too. The role of race, obesity, anatomy, nutrition, and preventive ankle bracing are just a few factors that remain to be evaluated.

Rheumatoid Arthritis Increases the Risk of Infection After Ankle Replacement

Surgeons know that replacing the ankle joint (a procedure called total ankle arthroplasty or TAA) is more successful for some patients than for others. This particular operation requires selecting patients carefully for the best outcomes.

There are all kinds of potential reasons why one patient would be a good candidate for an ankle joint replacement while another is rejected as a “poor” candidate. Factors such as age, sex (male versus female), body-mass index (BMI), and general health may make a difference. Some studies show results are compromised most often when the patient has rheumatoid arthritis.

In this study, the orthopedic surgeons were interested in narrowing down risk factors associated with complications following total ankle arthroplasty. They specifically focused just on wound infection of the incision used to open the ankle up. By doing a retrospective (looking back) chart review of 106 patients, they were able to see who had problems and why.

The authors collected, compared, and analyzed data recorded in the patients’ charts. For example, they looked at implant size, the use of medications, smoking (tobacco use) status, and type of sutures used to close the wound. They also separated the patients into three basic groups based on severity of complications. They compared the presence of each of these factors based on which group the patients were in.

The first group had no wound complications or only mild/minor problems with the healing incision. Group two had minor complications that could be easily treated with local care and possibly some oral (taken by mouth, usually in pill form) antibiotics. The most difficult and severe group (group number three) had major complications that meant having another operation.

As it turns out, the main difference between the groups with no complications or only mild complications and the group with major complications was the presence of diabetes mellitus. The biggest threat to healing without complications was the presence of rheumatoid arthritis (RA). In fact, patients with RA were 14 times more ikely to develop severe enough complications at the incision site to require another operation.

Why is rheumatoid arthritis such a big problem? It is an inflammatory condition that is often treated with medications that suppress (decrease) the immune system’s response. So any bacteria present at the surgical site aren’t always taken care of by the immune system. They can quickly mount an attack on the body. With limited immune capability, the body can’t fend off the growing bacteria and a full-blown infection breaks out.

The authors concluded that rheumatoid arthritis is not only a risk factor for infection inside the joint, it is also the number one risk factor for infection and complications at the wound (incision) site.

What can be done to prevent this from happening? Until we know how to work around the rheumatoid arthritis, surgeons are restricted from choosing a total ankle replacement for these patients.

This is especially true for anyone with rheumatoid arthritis who has poor circulation, is overweight (obese), and/or who smokes (uses tobacco products). Patients with any of these factors present at the time of the surgical evaluation are simply at too high a risk to consider for a total ankle arthroplasty.

The authors provide three caveats — the proverbial “yes, but” or “beware” of this study. First, it was a fairly small number of patients to base any firm recommendations off of. Second, they only evaluated patients with one type of ankle joint implant (DePuy Orthopaedics Agility Total Ankle System). The results might be different with another type. And third, follow-up was short-term (six months). The long-term survival of the joint and/or the start of a second infection later on was not evaluated.

A Rare Case of Synovial Osteochondromastosis Outside the Ankle Joint

Two podiatrists from the University of North Texas Health Science Center offer this case study of a rare ankle problem: extrasynovial synovial osteochondromatosis. Hootchy-what, you say? Let’s break that down a bit — extrasynovial means the problem has to do with synovial fluid being outside of a joint. Synovium is the fluid that keeps the joints lubricated and moving smoothly. It is a viscous (slippery) membrane that lines the cartilage (cartilage covers the bone).

Normally, the synovial fluid stays inside the joint. Any synovial fluid outside the joint is considered extrasynovial. We’ll come back to the significance of that in a moment. Now for osteochondromatosis: osteo refers to bone, chondro is the cartilage, and osis at the end of a word just tells us something is wrong. In this case, the synovium has started to proliferate or grow too much.

It clumps together with the cartilage forming small nodules that eventually harden. These tiny osteocartilaginous (bone and cartilage) bodies can stick to the synovium inside the joint. They can also move outside of the joint and become loose bodies floating around the various bones that form the ankle joint.

Sometimes the body breaks down and absorbs these tiny masses. In other cases, they get stuck between two bones or embedded in a tendon. The clinical picture is one of pain, loss of motion, and a joint that locks up with movement. In this case report, a 56-year-old woman had injured her left ankle and then noticed over time a bump growing along the anteromedial (front and inside) aspect of her ankle.

She eventually went to see the podiatrist (the authors of this case report). A patient history, physical exam, X-rays, and MRIs led to a diagnosis of chronic calcific ganglion. A ganglion is a cyst. A calcific ganglion means it has hardened. Surgery to remove the mass was followed by examination of the tissue in the pathology lab. It wasn’t until the pathologist analyzed the mass that the final diagnosis of extrasynovial synovial osteochondromatosis was made.

It wasn’t a ganglion cyst after all. The pathologist confirmed it was a combination of bone and cartilage. The surgeon found the hard mass outside of the ankle joint. It was free from any tendons nearby, which made it easier to remove. The patient was reevaluated nine months after surgery. She had no symptoms and there was no sign that the mass was coming back.

In this case, it can be said that All’s well that ends well. But the authors note that sometimes these osteochondral masses can grow back. They can even become malignant. That only happens about five per cent of the time but it’s something to watch out for. No one knows why this transformation from benign mass to malignant tumor (chondrosarcoma) occurs. There isn’t a way to predict who might develop a malignancy. That’s why the masses are removed and then observed closely afterwards.

Since synovial osteochondromatosis outside the synovium is such a rare condition, the authors felt it was important to publish their experience and observations with this case. Others may benefit from knowing that even with X-rays and MRIs, the final diagnosis isn’t always known until the tissue has been removed and examined by a pathologist. Because of the risk of malignancy, follow-up is very important.

New Treatment on the Horizon for Ankle Arthritis

Little by little orthopedic surgeons are finding better ways to treat ankle arthritis besides just fusing the joint. In this report, the use of a new technique called distraction arthroplasty for ankle arthritis is presented. It is one more step in the direction of preserving joint motion, especially in young patients.

Distraction arthroplasty is done by using an external frame with rods that stretch the ankle apart. The frame looks like a circular cage around the ankle and lower leg. A thin wire is placed through the joint and acts as a guide wire until the device is fully in place. Then the wire is removed.

The patient ends up with a cage that has two rings (one at the top, one at the bottom) and two rods in between the top and bottom rings. The rods are lengthened a little bit at a time pulling the joint apart. The joint only separates a tiny amount (up to three millimeters which is about one tenth of an inch).

What’s the theory behind how this works? Scientists working in the lab have found that chondrocytes (cartilage cells) damaged by trauma can actually recover or produce new cells.
By distracting or separating the joint, pressure is changed in the joint. The patient is allowed to walk on the leg and put weight on the foot. Being on and off the foot creates an intermittent (comes and goes) hydrostatic (fluid) pressure. Chondrocytes seem to respond to this effect and form new, healthy cells.

Who would have thought that stretching a joint while at the same time putting weight on the leg would improve cartilage? But that’s what’s happening. There’s actually a bit more to the procedure. Before applying the distraction device, the surgeon must clean out the joint, repair any damage done to the ligaments or other soft tissues, and restore normal ankle joint alignment.

There’s no sense in stimulating new chondrocytes that are just going to get chewed up and destroyed. Abnormal joint alignment and deformities that aren’t corrected cause uneven load bearing surfaces in the joint. Without correction of these problems, the new cartilage will get worn down same as before.

The natural questions to ask are: how well does this work? How long does it take? And who can benefit from this procedure? There aren’t a lot of published studies to help answer these questions. What is known so far is based on small studies with only 20 to 24 patients.

Pain is reduced and function improved in the majority of patients. The results seem to hold for up to two years. Long-term results (beyond two years) from most studies done just aren’t available yet. There are some patients who end up with additional surgeries and complications like infection. Quite a few patients have continued pain and discomfort.

Patients may not see any improvement at first. But after six months’ time, the positive benefits of the procedure become more evident. When compared with patients who just have the cleaning out procedure called debridement, the distraction patients do much better.

The authors say that it’s possible the deformity correction would have been enough to yield the positive results attributed to the distraction arthoplasty. It’s really hard to tell without two separate groups — one treated with deformity correction alone and the other with deformity correction and distraction arthroplasty.

That brings us to the question of who can benefit from the distraction arthroplasty procedure? Right now, it looks like younger patients who still have a fairly mobile ankle joint are better candidates than older adults with a stiff joint.

For anyone with ankle arthritis, the options are debridement, deformity correction, fusion, joint replacement, and now distraction arthroplasty. It’s not always clear which approach to take. More studies comparing treatment results among the various options are needed. Identifying which treatment works best for patients will take some time but will be worth the wait.

Orthobiologics for the Foot and Ankle

Orthobiologics — what in the world is that? Orthobiologics refers to growth factors and proteins used to help bone and soft tissues heal. It’s a fairly new area of study and development. These biologic agents are applied during surgery with the goal of boosting the body’s natural healing process.

Right now, there are three major orthobiologic products available for use during surgery. These include: 1) platelet-rich plasma (PRP), 2) bone morphogenetic proteins (BMPs), and 3) platelet-derived growth factor (PDGF).

In this review article, surgeons from the Department of Orthopedics at the University of Medicine and Dentistry in New Jersey (UMDNJ) discuss each one of these growth factors. The specific focus is on the use of growth factors in foot and ankle surgery. A summary of what’s been published is included for each product.

Let’s take a look at the first one mentioned: platelet-rich plasma. The patient donates his or her own blood for this procedure. The blood is separated in order to collect the platelets. Platelets travel around the body in the blood at all times. They are always ready to be available. When a cut or bleeding injury occurs, the platelets act like superglue and quickly form blood clots to stop the bleeding.

Platelets are full of various growth factors. Growth factors are important in wound healing because they are like the Maitre d’ (the man in charge at a restaurant). They signal to the waiters (other cells needed for inflammation, healing, and tissue recovery) when and where to go (the site in need of attention). Each stage of soft-tissue and bone healing requires different kinds of cells to complete the process.

Surgeons have found more and more uses for platelet-rich plasma. It started with mouth and jaw surgery and now extends to include bone healing in spine fusions, fracture repair, surgery to lengthen an uneven leg or arm, and tendon healing.

It makes sense that this same product could be used with ankle fusions. And especially when the patient is at high-risk for infection, delayed wound healing, or other complications after surgery. Studies show that platelet-rich plasma also works well for ankle fractures that aren’t healing well, for ankle joint replacements, surgery to correct foot deformities, and repair of Achilles tendon ruptures.

The platelet product can be painted on bone, sprayed on the surface of ankle implants used in joint replacements, or injected into healing tendons. The results are all the same: faster fusion or healing time. In the case of tendon repair, joint range of motion, function, and return to full activities improve much faster as well.

The next orthobiologic product reviewed is bone morphogenetic proteins (BMPs). These proteins specifically target bone growth. Scientists have discovered more than 20 BMPs so far. They have even managed to genetically engineer two bone growth factors for use with fractures and fusions.

Each of the 20 natural BMPs seems to have a slightly different job to do when it comes to turning stem cells into cartilage or bone cells. BMPs persuade the bone to create new bone cells in order to heal fracture sites or fill in bone defects. What are the results so far of studies with this new treatment?

Many of the studies done have been on lab animals (rats and rabbits). Only a few have been carried out on patients with ankle and foot problems. In both animals and humans, BMPs increase the area of new bone formed at fracture sites or where infection has eaten away at the bone leaving a defect (hole).

Scientists have even found a way to sustain the release of BMPs over time to create even more healing and bone fill-in. Use with high-risk patients who have poor bone healing from diabetes, high-energy injury, or who are immunosuppressed (immune system isn’t working well) is under further study.

And finally, the third group of orthobiologics: platelet-derived growth factor (PDGF). You may be wondering how is this different from the first group we talked about: platelet-rich plasma? Platelet-derived growth factor is actually one of the specific platelet growth factors that make up part of the platelet-rich plasma.

It just happens that researchers have been able to take this one specific platelet growth factor and study it more closely for use in bone fractures. The clinical application of platelet-derived growth factor has been mostly with rats. But the findings so far suggest that it could be used to enhance bone healing in patients with poor bone healing of the foot and ankle.

The authors conclude that orthobiologics are here to stay and may become a routine part of surgery. But before that can happen, research is needed to make sure orthobiologics is safe and effective. Part of the work of scientists will be to find out which patients are the best candidates for this treatment as well as who doesn’t need them.

With more orthobiologics being discovered and new ones being synthesized (manmade), the uses of these products will continue to expand over time. Their role is evident and important in enhancing healing and preventing infections and other complications. All of those effects will also improve patient satisfaction and reduce costs associated with surgeries for musculoskeletal problems.

Surgeons Find They Can Treat Two Ankle Problems at the Same Time

Many people sprain an ankle sometime in their lives. Lateral ankle sprains are the most common — that means the injury affects the outside of the ankle away from the other leg. Most of them recover nicely with a little ice, rest, and antiinflammatory medications like ibuprofen. Some need additional conservative care with a brace or support of some kind. A little physical therapy helps regain ankle motion, strength, and proprioception (fine tuning joint awareness).

But in a smaller subset of patients who suffer an acute ankle sprain, the ankle continues to hurt and gives out from underneath them. That instability occurs because one or more of the ligaments holding the joint steady has been torn. This can be very limiting and disabling. When nothing helps and the patient doesn’t get better, the question comes up: does this person need surgery? What would be the benefit?

Of course we know the patient wants a pain free ankle that moves perfectly fine again. Is that what they get? In this report, orthopedic surgeons follow 37 patients who had a severe ankle sprain. They also all had what’s called osteochondral lesion of the talus (OLT). The talus is a bone that sits just above the calcaneus (heel bone).

The term osteochondral tell us that the joint cartilage (chondral) and bone (oste) just underneath the cartilage have been damaged. With some of the more severe osteochondral lesions (OCLs), there is a piece of cartilage with the bone attached that is loose in the joint causing further problems. Anytime there’s a problem inside the joint, it’s referred to as an intraarticular lesion.

The problem with a severe ankle sprain that leads to an osteochondral lesion and joint instability is that these are two separate problems requiring different surgical techniques and different rehab approaches. Can they both be treated at the same time? The patients in this study were operated on in one procedure that had two steps. First, the surgeon used an arthroscope to look inside the joint and find any damage to the joint. Osteochondral lesions were removed and the joint surface was smoothed down.

Once that was taken care of, the surgeon repaired any damage done to the ligaments. If the tissue was too damaged to repair, then a piece of tendon from another muscle was taken and used as a graft to replace the torn ligament. Details of the operative techniques used on the 37 patients were provided. A particular method of repair called the Brostrom procedure was modified slightly and used by the surgeon.

Everyone in the study went through the same rehab program under the supervision of a physical therapist. At first the patients were in a cast to protect the ankle. But once the cast was removed and they were given a splint to wear, then the therapist could start gentle range-of-motion exercises with them. This portion of the rehab program occurred about three weeks after surgery.

Six weeks after surgery, the patients were able to use a removable walker boot and gradually put full weight on that ankle. Pool therapy was used before beginning land exercises and high-impact athletic activities. Most of the patients were able to return to normal activities by the end of four months. Those who had larger osteochondral lesions required additional time (up to six months) of rehab and recovery.

All tests and measures as well as X-rays used to evaluate the results showed good ankle stability in all patients. There were some early signs of ankle arthritis in about one-third of the group. Comparing results for patients with ankle sprain versus those who had both ligament damage and osteochondral lesions (OCLs), results were better when there wasn’t an OCL.

Scores on tests of ankle function were better for patients treated for lateral ankle stability without an OCL. Several different scoring systems were used (e.g., the Martin Score, the SANE scale, the Berndt and Harty Scale). By using more than one test, they were able to make sure the differences weren’t because of the kind of testing that was done and were really from the condition of the ankle.

The significance of this study lies in the treatment of both osteochondral lesions and ankle instability at the same time. For osteochondral lesions, ankle motion is needed right away to help develop smooth healing of the cartilage. But movement too early in the recovery phase could cause the healing ligament to tear.

Instead of waiting six weeks to put weight on the repaired ligament (usual treatment), the authors allowed motion at three weeks. This compromise made it possible to encourage cartilage recovery without endangering the healing ligament.

They were able to compare the results of this group to another group of patients they had treated in a different study. The patients in the previous study had osteochondral lesions without ligament injury. Patients in this current study with osteochondral lesions and ankle instability who had three weeks of immobilization in a cast had the same overall results as those in the other study with only osteochondral damage and no ligament damage.

The authors concluded that it is possible to perform both parts of the necessary surgery (removal and repair of osteochondral lesions as well as ligamentous repair or reconstruction) for chronic lateral ankle stability in one operation. Rehab can be modified to accomodate both types of injuries and their different surgical procedures without affecting the final results.

Have You Ever Heard of the Maisonneuve Injury?

For every orthopedic injury, surgeons must know the mechanism (how it occurred), details about the anatomy (part affected) and pathology (exactly what’s wrong), and how to treat it. Treatment must be evidence-based meaning studies have shown what works best to give patients optimum results.

The authors of this review article on Maisonneuve injuries of the ankle provide all of that information plus more: potential complications, goals of treatment, management strategies, and the results referred to as functional outcomes of 61 cases reported from four published studies.

You probably haven’t heard of Maisonneuve injuries. The name comes from the French physician who first reported this problem. Basically, the term refers t a spiral fracture of the upper one-third of the fibula. The fibula is one of two bones in the lower leg. It is the smaller bone situated on the outside or lateral side of the leg. The tibia is the other (larger) bone in the lower leg.

But there’s more to the injury than just the fracture. The force of the injury pushes the ankle into a flat-footed position with intense stretch pressure along the inside of the foot and ankle. The lower leg is externally (outwardly) rotated with the foot planted on the ground.

Associated injuries can also include fractures of the malleolus (bump on either side of the ankle that we usually point to and call our ankle bone) and tears or ruptures of the surrounding ankle ligaments or joint capsule.

In severe Maisonneuve injuries, the connective tissue between the two bones (tibia and fibula) is completely torn. This is called a syndesmotic disruption. Without this strong, fibrous interconnecting ligament, one bone can shift up or down in relation to the other causing a difference in leg length from one leg to the other.

The real dilemma with Maisonneuve injuries is that they aren’t painful so they can go undetected. The injuries in the lower ankle are more painful and get all the attention. No one thinks to X-ray the upper end of the fibula. People of all ages can experience a Maisonneuve injury as a result of slipping on ice, tripping and falling, falling from a height, car accidents, or sporting events.

Treatment isn’t standard because the injuries can vary widely in severity and involvement of the surrounding soft tissue structures. Most of the time, surgery is required because the injury is so severe. Without reconstructive surgery, the ankle remains unstable and at risk for further injury. Reduction of the fracture and fixation of the syndesmotic tear is essential in order to restore normal function and biomechanics of the leg.

Reduction means the surgeon puts the fractured ends of the bone back together. Plates and screws may be needed to hold the bones in place until they knit back together. Fixation of the syndesmosis is also accomplished with similar hardware called syndesmotic screws. The screws can be left in place or taken out according to the surgeon’s preferences and the patient’s wishes.

Surgery may not be needed for less severe Maisonneuve ankle injuries. The patient is placed in a cast for six weeks. This approach is acceptable when there are no soft tissue injuries of ligaments, syndesmosis, or joint capsule. In all cases, the goal is to restore normal ankle alignment and movement.

How do patients fare after treatment for Maisonneuve injuries? According to the authors of this article who reviewed all of the studies published on this injury — the majority of patients (88 per cent) have good-to-excellent results. Pain is eliminated and motion and function return to normal levels during daily activities. Functional outcomes are equal to before the injury within six months of treatment.

The authors would like to see more studies on this topic to look at two things: long-term results and results for each treatment approach. The hope is to find better ways to diagnose and treat this complex injury without significant delays that can negatively affect outcomes.

Keeping Up With the Latest in Foot and Ankle Surgery

In an effort to help orthopedic surgeons keep up with the latest research, the authors of this specialty update present a summary of evidence related to foot and ankle surgery. More than a dozen of the most common problems are presented including ankle fractures, calcaneal (heel bone) fractures, chronic ankle instability, ankle joint replacement, ankle fusion, diabetes-related problems, tendon problems, bunions, impingement problems, foot deformities, and amputations.

By reviewing all studies published in the last year on foot and ankle surgeries and summarizing presentations made at orthopedic meetings, the information presented hits the high points of what’s new. Surgeons reading this summary can then decide if they need to delve deeper into the literature for themselves.

When it comes to trauma resulting in ankle fractures, MRIs and arthroscopy now make it possible to see that the joint surface is often damaged with more severe ankle fractures. Surgeons must be on the look out for lesions of the articular surface of the joint. Sometimes the force is enough to break off bits of cartilage and bone leaving them inside the joint as a loose body. The surgeon must look for, find, and remove these fragments.

Severe ankle fractures may require open reduction and internal fixation (ORIF). An open incision is made; the fracture site is realigned; and metal plates, pins, and/or screws are used to stabilize (hold) everything together. This type of fixation works well with few complications. Problems occur most often in patients with diabetes and poor circulation. Surgeons are advised to keep a close eye on these patients during the post-operative period to prevent infections and the need for amputation.

And a final note on ankle fractures in particular. Surgeons often debate the need to cast or immobilize the ankle after surgery versus having the patient move the ankle early in order to keep joint mobile. So far, it looks like early motion is better but has some risks. Early motion helps prevent blood clots but seems to increase the risk of wound infection. The surgeon should strive for early mobility but make the decision based on each patient’s individual characteristics and risk factors.

As for calcaneal (heel bone) fractures, there’s enough evidence now to show that these patients end up with painful arthritis and foot deformities. Can these be prevented? Are they the result of the type of treatment (surgery vs. nonoperative care) provided in the first place? All evidence points to a better end-result when open reduction and internal fixation (ORIF) is later followed by fusion of the joint.

Efforts are being made to place screws percutaneously (through the skin without an open incision) for the fixation of calcaneal fractures. Using titanium screws instead of metal plates seems to work well and reduces the risk of wound infection.

Severe ankle pain following repeated ankle sprains or caused by traumatic arthritis that develops years after ankle injuries may require an arthrodesis (ankle fusion) or even a total ankle arthroplasty (ankle joint replacement). Ankle instability (the ankle gives way often while standing or walking) despite all efforts at rehabilitation is an indication that fusion or joint replacement might be the next step.

Patients are often encouraged to have an ankle fusion first with later conversion to joint replacement. Fusion stabilizes the ankle but has a poor track record. The lack of ankle motion limits activities and transfers load to the midfoot and hindfoot joints. Increased motion at these adjacent joints helps compensate for the loss of ankle motion but can create degenerative damage and arthritis.

Improved surgical techniques and joint replacement implants at least makes the conversion from fusion to joint replacement a possibility now. The authors discuss computer-assisted surgery and specific placement of screws in patterns that have been proven ideal for ankle fusion.

That brings us to a different type of problem: diabetes and charcot foot deformities (named after the physician who first described it). Because too much sugar in the system destroys nerve tissue, people with diabetes often end up with loss of sensation, reduced joint integrity, and collapse of the midfoot. The severe flat foot looks like the curved bottom of a rocking chair and is referred to as a rocker bottom foot deformity or charcot joint. Surgery to stabilize, reconstruct, or sometimes fuse the joint may be needed. The authors also review tecniques for surgical correction.

A different group of problems treated by orthopedic specialists involve the tendons. Surgery to repair tendon ruptures affecting the Achilles and anterior tibialis tendons is discussed. There’s a new Achillon suture system available now to repair ruptured Achilles using a minimally invasive (very small incision) technique. Some surgeons have tried reinforcing the tendon repair with additional tissue from the calf muscle but there’s no evidence that this improves the results or prevents a second rupture later.

The latest in treatment of tendinopathy (any tendon disease such as tendinitis or tendinosis) is also presented. When standard conservative (nonoperative) care of tendon problems doesn’t help, extracorporeal shock wave therapy seems to have a healing effect on tenocytes (tendon cells). Surgeons will want to keep an eye out for reported results of future studies in this area.

Researchers investigating treatment for hallux valgus (bunions) is focused on finding the best surgical technique and a way to measure the results reliably. Different types of osteotomies (surgery using a piece of bone to reshape the toe angle) are discussed with criticisms and results reported from various studies. One new tool available to assist surgeons when performing an osteotomy on the big toe is the Opening Wedge Low Profile Plate and Screw
. Angle correction is improved using a spacer of this type.

These are just the highlights of the many topics and updates provided in this review article. The article is filled with summaries of individual studies and meta-analyses for the dozen or more conditions covered. The use of endoscopy and fluoroscopy has changed what surgeons now know about ankle and foot injuries from the inside out. As a result, surgical techniques have changed and overall results (motion and function) have improved as well.

With these advanced imaging tools, surgeons are slowly eliminating the need for open incisions. The shift to minimally invasive procedures has also reduced post-operative complications and problems. There are fewer wound infections and a better chance of full recovery without second (revision) surgeries or the need for amputation. Joint-sparing surgeries are also changing the prognosis for foot deformities from paralysis or trauma.