News Category: Ankle

An arthroscopy is a procedure that allows a doctor to see inside a joint without major surgery. Using a small incision, the surgeon inserts a long, thin instrument with a camera on the end. Arthroscopies were often used for larger joints, like knees, but the ankle was often considered to be too small and complicated a joint for this procedure. This idea was changed in 1972 when researcher Watanabe and colleagues published the results of 28 ankle arthroscopies. Over the years since then, the procedure has been refined and is now regularly used to diagnose and treat problems of the ankle.

Endoscopic surgery uses the arthroscopic process but, using a few more very small incisions, surgeons can insert surgical instruments. By observing the inside of the joint with the camera, the surgeons perform the surgery without opening up the joint. The advantage to this type of surgery is that recovery time is shorter for the patient and the patient can return to his or her previous level of activity earlier than with traditional surgery.

Because of the anatomy of the ankle, certain problems are easier to see with arthroscopy and treat with arthroscopic surgery than others. For example, the back of the ankle is harder to access and treat because of the location. It is possible, however, by adapting the technique and positioning the patient’s foot in such a way that the surgeon can access it from different angles.

Anterior arthroscopy (from the front) of the ankle should be done to look for soft tissue or bone damage, to see if there is anything loose in the ankle, and to check for any osteochondral defects, or damage to the bone or cartilage. But, it’s not limited to these problems. It can also be done to help repair some types of fractures. There are some situations where an arthroscopy of the ankle shouldn’t be done, though. These include if there is an infection in the ankle or if there is severe degeneration. Other situations that are recommended but may be done in certain circumstances are if there is some degeneration in the ankle with limited range of motion, if the joint spaces are narrow, vascular disease (arterial), or edema (swelling in the tissue).

Not all doctors agree that arthroscopy of the ankle is a worthwhile diagnostic tool. Some estimate that arthroscopies only help about 26 percent to 43 percent of patients. If, after arthroscopy, the diagnosis is still not certain, then further testing must be done, including x-rays. Doctors can also detect some osteochondral defects by using magnetic resonance imaging (MRIs) or computed tomography (CT) scans.

When performing arthroscopy and surgery on the ankle, there is the distraction or the dorsiflexion approach. When the patient is lying on the operating table, his or her foot can be placed in such a way that the foot is pointed away from the body, increasing the angle of the ankle. That is distraction. Or, the foot can be pushed up, so the toe is point up towards the ceiling, closer to the patient’s head, reducing the angle of the ankle. This is called dorsiflexion. Using dorsiflexion to perform arthroscopic surgery often is better than distraction because distraction pulls the ankle tight, while dorsiflexion opens up and relaxes the area. However, since distraction is sometimes better, using arthroscopy, the patient’s foot can easily be arranged to lie in the correct position.

As with all surgeries, arthroscopic surgery of the ankle does have its complications. These include damage to the nerves and blood vessels, infection, and a long-term chronic pain syndrome called reflex sympathetic dystrophy. How many complications occur depends on the study. There have been reports of between 9 percent to 17 percent. Up to half of complications appear to be affecting the nerves. It’s suggested that using the distraction approach may be responsible for many of the complications.

With patients who have osteochondral defects, these are usually caused by a trauma (injury) to the ankle – this occurs in about 93 percent of lateral cases (along the side of the ankle) and 61 percent of medial cases (towards the middle). Patients with osteochondral defects usually have deep, off-and-on ankle pain that occurs during or after activity. There may be swelling and, at times, they may not be able to move their ankle as usual, although this isn’t always the case.

To diagnose osteochondral defects, x-rays of the patient standing and bearing weight on the ankle should be taken. This may be followed by a CT scan or MRI. Once the diagnosis is made, it must be classified according to its severity. Stage I is a small compression fracture; stage II is an incomplete break; stage III is a complete break; and stage IV is a complete break with a piece of bone broken off.

Treatment varies from doctor to doctor. Usually, if the patient isn’t experiencing too many symptoms or much discomfort, treatment is non-surgical at first. This is often done over six months and includes resting the ankle, applying ice, and perhaps bracing the ankle. If the ankle is causing pain, then surgery may be needed to remove the broken pieces of bone and removing unstable cartilage. This is where arthroscopy comes in. There is a 45 percent success rate for patients who are treated non-surgically while those who had surgery appear to have a success rate of around 86 percent.

Another ankle problem is called an anterior ankle impingement, which means the soft tissues in the front of the ankle have become pinched somehow. This is usually when the toes are pointed up towards the head of the body, closing the angle of the joint. This can be caused by injuring the ankle, traction, or chronic ankle instability from ankle sprains. Patients with anterior ankle impingement usually have pain around the ankle joint, swelling after activity and some limited motion in the ankle, although that’s not always present. If the doctor is examining the ankle, he or she can cause pain by pressing on the bone in the front of the ankle.

Anterior ankle impingement is another condition that can be treated non-surgically or surgically. If the problem is detected early enough, treatment may be injecting into the ankle and/or providing an orthotic that lifts the heel of the foot a bit. Surgery is done arthroscopically to shave away the tissue that is trapped, reducing the pain. Studies have shown that patients who had arthroscopic surgery recovered quicker than those who had regular “open” surgeries, although the outcome was relatively similar.

If the problem is in the back of the ankle, the hindfoot, then treatment is more complicated. Since the year 2000, surgeons have used a two-sided approach to look into that part of the ankle and to do surgery. This type of surgery may be needed if there are osteochondral defects , traumas, or any other similar problem with the back of the ankle. Surgeons can also treat problems with the Achilles tendon or the calf muscle if needed.

Like with anterior ankle impingement, patients may have posterior ankle impingement, where the pain is in the hindfoot when the toes point down, opening the angle of the foot. This can be treated with arthroscopic surgery with success. In one study of 146 endoscopic hindfoot procedures on 136 patients, researchers found the surgery was successful in most patients, with only two patients experiencing minor complications.

The authors of this article concluded that there has been considerable improvement over the past 30 years in arthroscopic ankle surgery.

One ankle sprain can change the course of your life. When does that happen? When one injury leads to another and another until you have a condition called chronic ankle instability (CAI). Every day in the United States, 23,000 people sprain their ankles. More than two-thirds of those folks will end up with CAI.

What happens with CAI? Why does it happen? And what can be done to prevent this from occurring? Those are the questions scientists are actively seeking to answer. Right now, there are several theories to help explain the mechanism behind chronic sprains.

Mechanical factors, such as the change in tissue tension around the ankle when a ligament is sprained, have always been part of the picture. But this is only one factor. Another is the loss of normal sensorimotor responses.

This refers to the ankle joint’s ability to receive and interpret neurologic information about sensation and movement. This is the neurologic side of ankle injury and instability. A decreased awareness of the foot and ankle position (especially with changes in the ground or surface we are walking on) contributes to repeated ankle sprains.

Swelling or edema associated with the injury reduces sensation needed to provide dynamic joint stability. Changes in the joint can also affect communication between the ankle joint and surrounding soft tissues such as muscles. This phenomenon is referred to as arthrogenic muscle inhibition. Arthrogenic means the effect on muscles is generated or starts in the joint first.

In this study, activity-dependent plasticity as it effects ankle stability/instability is the topic. Plasticity refers to the ability of the nervous system to change or modify function. The question is: when the ankle joint is injured, are there changes in the way the nervous system (spinal cord and brain) respond?

The experiment involved two groups of college-aged young adults. One group had a history of more than one ankle sprain in the past 12 months. The second (control) group had no history of ankle sprain and no problems with their feet or ankles.

Using a university research laboratory, they measured motoneuron pool excitability. The motoneuron pool in the spinal cord is the central controller of muscle activation. Excitability of the motoneuron pool comes from descending messages (from the brain) and ascending messages. Ascending messages come from the motor and sensory nerves in the joint and muscles bringing information to the spinal cord and up to the brain.

The Hoffman or H-reflex is used to measure the excitability of the motor neuron pool. In this study, H-reflex was used to look at the effect of CAI on the motoneuron pool excitability of the soleus muscle. The soleus muscle is the smaller of two calf muscles (gastrocnemius and soleus). It has an important role in ankle function. The soleus muscle helps provide postural stability when a person is standing. And postural stability is important in preventing repeated ankle sprains.

Everyone in the study filled out several surveys to assess function, functional limitations, and areas of disability. A special recording device was used to measure the H-reflex of the soleus muscle on the side of the injured ankle.

Electrodes placed over the soleus muscle recorded electric impulses and H-reflex responses when the nerve to the soleus (posterior tibial nerve) was stimulated. Testing was done with the subjects standing on both legs (double-legged stance) and when standing on one leg (single-legged stance).

They found a significant difference in motoneuron excitability between the two groups. The group with chronic ankle instability had more depression (less excitability) of the motoneuron pool. This means less input to the muscle to tell it to contract.

The biggest difference was seen when going from a double- to single-legged stance (standing position). The healthy group was able to modulate (change) nerve signals when changing position or surface stability (going from a stable to unstable surface). The injured group had much slower changes in reflex response and postural control.

This evidence that there may be a neurologic component to CAI will direct us in better understanding how the central nervous system adapts to joint injury. Physical therapists may be able to use this information to develop ways to prevent recurrent or repeated ankle sprains. For example, it may be possible to improve motoneuron excitability with training.

Other studies have already shown it’s possible to increase H-reflex responses following a program of dynamic resistance training. Further studies are needed now to find other ways to improve rehab for patients with CAI.

In the sports world, an ankle sprain is big news. Such injuries account for many days missed in training and in competition. An acute ankle sprain that isn’t treated properly can result in chronic weakness, pain, and instability. In such cases, recurring sprains are common and can lead to disability and the end of a promising career.

But what is proper care for this type of ligamentous injury? In this article, orthopedic surgeons from the United Kingdom describe a classification system to grade acute lateral ankle sprain. A lateral ankle sprain describes a ligamentous sprain along the outside of the ankle. Three grades are included based on degree of injury and severity of symptoms.

Grade I reflects the fact that the anterior talofibular ligament (ATFL) is stretched. Some of the fibers are torn but not ruptured. There is mild swelling and tenderness but no loss of ankle motion. Grade II means there is a moderate injury to the lateral ligaments. Usually, there’s a partial tear of the calcaneofibular ligament (CFL) and a full-tear (rupture) of the ATFL. Swelling, pain, and loss of motion are common.

Grade III is divided into three parts or subgroups: III, IIIA, and IIIB. Grade III sprains are severe but on a continuum from bad to worse. Grade III is a complete rupture of the ATFL and CFL. There is diffuse swelling, bruising, and tenderness along the front and outside of the ankle. With a Grade IIIA injury, there is at least a 10-degree loss of ankle motion. Swelling is measured as being more than two centimeters. X-rays of joint gapping when under stress are negative.

Grade IIIB injuries present with more than a 10-degree loss of motion, more than two centimeters of edema, and more than three millimeters distance between the joints when compared on X-rays to the normal (uninjured) ankle.

There are many contributing factors to chronic ankle instability. These could be mechanical such as ligamentous laxity (looseness) or degenerative changes that occur over time. They could be functional including loss of joint proprioception (sense of joint position), muscular imbalance due to weakness, and problems with motor control.

Ankle rehab has a major role in restoring normal joint function. The patient’s ankle may be taped or supported in an Air-cast, or lace-up support. Or the injured athlete can be put in a cast for a few weeks to allow for healing and prevent reinjury before ankle proprioception can be restored. Most high-performance athletes would like to avoid delays in getting back to play. They may not want to spend any amount of time immobilized. But if they can’t put weight on the foot, some type of rigid support may be necessary.

From there, they attend a 10 to 12 week long rehab period. During this time, a physical therapist helps them regain proprioceptive sense, motion, and strength. Early in the recovery phase, the principles of rest, ice, compression, and elevation (R.I.C.E.) are followed closely.

Once the athlete has progressed past the acute phase, then specific training can begin for balance, postural control, and proprioception drills with the ultimate goal of getting back into the game. This phase is referred to as functional training. With this type of management, patients return to sports and/or work faster with fewer symptoms. They report higher levels of personal satisfaction with their results.

Conservative care isn’t always effective. A study of overall results from many trials has not been able to show clear support for one method of nonoperative care over another. In the end, chronic pain, the ankle giving way, and recurrent sprains may lead to a more aggressive approach.

Surgery may be needed to repair the damage and restore ankle stability. There are many different possible surgical techniques for this problem. The authors provide a drawing and description of the most common anatomic repairs. These include the Broström repair, Gould modification, and Karlsson modification. These are ways to reattach and reinforce the ligament. The torn ends of the tendon may be sewn to the bone and/or to the nearby connective tissue.

If repair isn’t enough and a reconstruction of the ankle is needed, the Watson-Jones, Evans, or Chrisman-Snook procedures may be used. The authors provide illustrations of these techniques. The main reason reconstruction is done instead of repair is because the tendons have ruptured and frayed. The ragged ends may have retracted too far to pull back far enough to reattach them.

There have been several short- to long-term studies done on each of these surgical techniques. The results of studies reporting long-term outcomes are summarize for each one. The results are good-to-excellent for all but the Evans technique. Only one-third of the patients treated with this reconstructive method had a positive result.

There were more complications with the Chrisman-Snook method of repair than any other surgical approach. A significant number of patients reported wound complications, nerve injuries, a sensation that the repair was too tight, or weakness and instability.

Sometimes more involved techniques are needed to reconstruct the ankle. The surgeon may have to create a periosteal (bone) flap or use tendon grafts from elsewhere to reinforce the torn tendon. Tendon material taken from some other part of the foot and/or ankle must be strong enough to function as a graft. Grafts are held in place with screws or inserted through holes drilled in the bone. The graft is wrapped around or threaded through the bone to get just the right amount of tension. The goal is to preserve ankle biomechanics as much as possible.

Current management suggests that the surgeon perform an arthroscopic examination of the joint. Once the location and extent of damage is assessed, then the best management plan can be established. If necessary, the ankle can be repaired or reconstructed at the same time. The authors do not recommend the Evans procedure in high-demand athletes. Loss of normal ankle and hindfoot biomechanics can put them at risk for failure of the repair over time.

Many physically active people sprain their ankles. But not very many are sent to physical therapy. Some of those injuries occur over and over. The result can be persistent pain, weakness, and joint instability.

In this study, researchers asked the following questions. Do grade I (mild) and grade II (moderate) ankle sprains recover naturally (on their own)? Is more than standard advice of protection, rest, ice, compression, and elevation (PRICE) needed?

Fifty (50) people with acute ankle sprain (occurred in the last 72 hours) were studied for one month. All were first seen at an emergency department and discharged home with a PRICE program. While at the hospital, a senior physical therapy student assessed each one for this study.

Range-of-motion (ROM), strength, swelling, and bruising were measured and recorded. ROM and strength of the uninjured ankle/foot was measured first. A special handheld tool called a goniometer was used to measure motion of the ankle. The therapist performed a manual test of strength by resisting the patients’ motions by hand. Those measurements were used as a normal value for comparison to the injured ankle.

Everyone was given a way to protect the joint using an elastic ace wrap. Instructions were given to rest, use ice off and on for 48 hours, and elevate the leg to reduce swelling. Gentle ROM exercises were prescribed along with over-the-counter medications to alleviate pain and reduce swelling.

Four days later, patients were retested by the physical therapy student. A more sophisticated method of measuring motion and strength with a Biodex isokinetic dynamometer was used. Once again, both sides were measured and recorded.

In addition, the therapist looked at ankle function in daily activities, sports, and recreation. The Foot and Ankle Outcome Score (FAOS) was the self-reported survey used to assess function. These same tests were completed a final time 30 days after the first visit to the emergency department.

Some patients did not come back for the follow-up tests. In the end, the results of 28 patients were analyzed. Everyone was able to gradually resume most (but not all) of their previous activities. Mild pain and swelling with mild loss of motion left some patients unable or unwilling to participate in sports and recreational activities.

Everyone did get better as time went by. But at the end of one month, weakness of the plantar flexor muscles (used to rise up on toes or point the toes) and loss of ankle motion were still present.

This study showed that on the outside, people with mild-to-moderate ankle sprains seem to recover. But a closer look showed some significant deficits in motion and strength. It’s these undetectable differences that could lead to future reinjury and recurrent ankle sprains.

And it’s possible that even a small amount of long-term swelling can result in a loss of normal neuromuscular function. After an acute ankle sprain, the ankle joint doesn’t have normal proprioception (sense of joint position). Even a small loss of proprioception can affect athletic performance.

Likewise, pain can keep a person from moving through the normal, full arc of motion needed for daily and sports activities. Fear of pain and an unwillingness to move the joint can reduce function. This is true even when there is enough motion and strength present for full function.

The authors make two summary observations from the results of this study. First, measuring ankle motion with a standard handheld goniometer used by physical therapists may not be sensitive enough to detect the full measure of ankle impairment. Likewise, the use of manual muscle testing for ankle injuries is not as accurate as using a dynamometer system.

Second, standard care after a Grade I or II acute ankle sprain may not be enough to ensure full recovery and return to full function. The authors suggest management of acute ankle sprains with physical therapy may be a good idea. This could improve results within the first 30 days.

More studies are needed to prove this and to see if patients recover fully with standard care when given more than 30 days. Results of natural recovery may be different after six to eight weeks.

Ankle sprains are very common among athletes and sports participants. What’s the best way to prevent an ankle sprain? Is it high top shoes? Wearing a brace of some sort? Taping the ankle? In this report, sports medicine experts review type of ankle injury and goals of treatment. Prevention of both primary (first-time) ankle sprains and reinjury is also discussed.

Treatment is based on an accurate diagnosis. Physicians begin by taking a history and performing an exam. It’s important to know what type of ankle sprain is present when creating a plan of care.

There are two major types of ankle sprains: low and high. Low ankle sprains are the focus of this article. Low ankle sprains involve damage to any of the short ligaments that hold the bones of the ankle together and stabilize the ankle.

A high ankle sprain involves the ligaments above the ankle joint. This is called a syndesmosis injury. In an ankle syndesmosis injury, at least one of the ligaments connecting the bottom ends of the tibia and fibula bones (the lower leg bones) is sprained. Recovering from even mild injuries of this type takes at least twice as long as from a typical ankle sprain. A second article on high ankle sprains will be published later.

Low ankle sprains can occur on either side of the ankle. But most often, it’s the ligaments along the lateral (outside of the ankle) that are affected. This is because the mechanism of injury is usually plantar flexion (ankle and toes pointed downward) and inversion (toes pointed inward).

Certain ligaments are more likely to be torn or ruptured with lateral ankle sprains. This is because of the angle and orientation of the ligaments as they hold the bones together. For example, the anterior talofibular ligament (ATFL) is strained when the foot and ankle are in a position of plantar flexion, internal rotation, and inversion. Excess load or force in this position increases the risk of sprain.

There are some known risk factors for primary and recurring ankle sprains. Some are modifiable (can be changed to reduce the risk). Others are nonmodifiable risk factors. A high arch and wide foot are examples of nonmodifiable risk factors.

A previous history of ankle sprain is an important nonmodifiable risk factor. Though the injury itself is a nonmodifiable risk factor, the damage done can be changed. Poor balance, decreased strength, and poor proprioception (joint sense of position) are modifiable risk factors that may contribute to recurring ankle sprains. If the athlete did not complete a rehab program after the first sprain, there can be incomplete soft tissue healing and mechanical instability.

Treatment for an acute low ankle sprain begins with nonsteroidal anti-inflammatory drugs (NSAIDs) to control inflammation. Rest, ice, compression, and elevation (RICE) are important at first.

A physical therapist guides the patient through a rehab program of motion, proprioception, and strengthening exercises. Movement and mobility while supporting the ankle with a brace (or some other type of removable, external support) are equally important. This is called functional therapy. Later in the rehab program, sport-specific exercises are added.

Studies show that ankle sprains can be prevented with a program of strengthening and balance work. While it’s clear that a program to restore proprioception after the first injury is essential in preventing a second sprain, there’s no evidence yet that this type of training can prevent a primary (first-time) ankle sprain. More studies are needed in this area.

Stretching and wearing any particular type of shoe (e.g., high top versus low top shoes, shoes with inflatable air chambers) has not proven effective in preventing ankle sprains. The use of splints or external braces is effective and less costly than taping.

But these preventive measures may not be helpful for athletes who have sprained the same ankle more than three times. Fortunately, chronic injuries of this type are less common than the acute phase of ankle sprain. Ankle instability from repeated sprains may require reconstructive surgery.

It’s not clear what is the best treatment for tendinopathy. That’s the conclusion of researchers reviewing all the published studies on the topic. Tendinopathy refers to a painful tendon condition caused by overuse. Although it feels like it, it’s not the same as tendonitis. There’s pain but no actual inflammation.

Treatment has traditionally focused on providing anti-inflammatory measures. This has included nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, and physical therapy modalities. Stretching and strengthening exercises have always been a part of the standard treatment approach.

More recently, shock wave therapy, low-level laser therapy, sclerotherapy, and growth factors and stem cell treatment have been added. The results of all treatment methods were compared by performing a literature review. The authors summarized the results of 177 studies. They did not evaluate the quality of the work done.

For the most part, it appears that NSAIDs and cortisone injections offer short-term relief. There just isn’t a long-term benefit of these treatments. Results using heat and light modalities seem inconsistent. But this may be more likely to occur because of how the studies were conducted. Without consistent methods and measures, it’s difficult to compare one study to another.

The most effective treatment may be eccentric lengthening exercises, sclerotherapy, and nitric oxide patches. Eccentric exercises are done by placing the affected muscle in a shortened position then lengthening the muscle against resistance.

Sclerotherapy is the injection of a chemical to produce scarring in the blood vessels. The idea is to close down tiny blood vessels and destroy nerve fibers that form in the damaged area. Nitric oxide has some potential for tendon healing. A patch placed over the skin delivers an enzyme that acts as a chemical messenger to provide pain relief.

Newer treatments such as growth factors and stem cells look promising. But these approaches haven’t been studied enough to know what’s most effective. For now, it looks like a short course of NSAIDs and physical therapy with eccentric contraction exercises is a good way to get started. If eccentric exercises don’t help, then alternate treatment can be explored.

Large multi-center studies with control subjects comparing each treatment type are needed. Using controls means results for patients treated are compared with control groups who do not receive treatment. Many of today’s current studies did not include controls.

Midfoot arthrosis can be the result of several problems so the treatment varies significantly from patient to patient. The causes include trauma, inflammatory arthropathy, and idiopathic arthritis. Because midfoot pain can severely limit a patient’s lifestyle, treatment is often necessary whether it is surgical or nonsurgical.

For patients who have osteoarthritis of the midfoot, they may first try conservative management, such as arch supports, indepth shoes, full-length carbon foot plate, ankle foot orthoses, or casts. If surgery is needed, this could be resection arthroplasty, interpositional arthroplasty, arthrodesis in situ, arthrodesis combined with osteotomy, or arthroscopic arthrodesis.

Surgery, of course, does have the potential of complications, which include wound healing problems, infections, nonunion of the bone, neuroma and arthritic changes in adjacent structures.

Researchers have tried to understand the causes of midfoot primary osteoarthritis. One study measured the length of patients’ first and second metatarsals (toes). The researchers discovered that the average length of the first metatarsal in the patients with arthritis was 77 percent of the length of the second metatarsal. The control group, however, had a first metatarsal length that was 82 percent of the second. This finding led the researchers to suggest that the metatarsal length may play a role in the mechanical function of the foot.

Inflammatory arthritis of the midfoot affects patients with rheumatoid arthritis (RA) and although there is much research on end-stage RA of the foot, not much has been reported on early identification and effective conservative management. In one study, researchers tried identify if early gait patterns could indicate the onset of arthritis. They did find that patients with early RA in the foot tended to have higher pressures about the forefoot and metatarsals, particularly the second metatarsal head. Other researchers have used motion analysis to define gait differences.

In order to reduce the pain of RA in the midfoot, conservative treatment involves palliative, noncorrective orthoses, but specialized footwear is not usually used consistently enough by the patients to make a difference. The authors of this article wrote, “Traditionally, footwear has been designed by clinicians in order to correct malalignment or improve pain with little input given by the patient. Unfortunately, this footwear often draws unwanted attention to the patient’s foot, making the patient feel more self-conscious and may lead to worsened compliance.”

When dealing with patients with post-traumatic arthritis of the midfoot, the authors state that the treatment of choice is usually arthrodesis. Attempts at applying high compressive and shear forces to the medial and middle columns of the foot have not been successful for the most part.

Treatment of basal fourth and fifth metatarsal arthritis has no defined or well-established method of treatment. The authors note that there are concerns about fusing these joints because this could result in nonunion, chronic overload of the rigid lateral midfoot, and possible development of stress fractures.

Researchers have attempted treating with stand-alone medial and central column fusion but no valid study findings have yet been produced. Because a big concern is to preserve the motion and avoid overload because of the fusion or the potential of stress fractures, some researchers have tried an interposition arthroplasty. Of 12 patients, nine were satisfied with the surgery but full comparison of pain and function scores were not available because of the lack of preoperative scoring. Finally, some surgeons have been working with ceramic interpositional arthroplasty, which has been successful in hand surgery.

In conclusion, the authors wrote that the gold standard for treatment of midfoot arthritis remains arthrodesis, however, the procedure can speed up development of arthrosis in the neighboring structures. Reports of success from interpositional arthroplasty of the fourth and fifth metatarsal joints is encouraging, as are the excellent results with ceramic interpositional arthroplasty.

Over the last 40 years, ankle joint replacements have gone through three generations of implant design and materials. In this article, a group of orthopedic surgeons review the history of total ankle arthroplasty (TAA) and bring us up to date on this treatment approach for ankle arthritis.

Early designs were stable but the implants often loosened up or sank down into the bone. The first TAAs had a high failure rate and were removed from the market. Since then, many improvements have been made. Today’s implants allow the patient to keep ligaments needed for stability and avoid removing so much bone.

Porous-coated titanium or chromium alloy materials allow for bone ingrowth around the implant. It’s possible to hold the implant in place without cement. Various designs are in clinical trials or being considered by the FDA for use with the public. Short-term and medium-term results are available but long-term (10 to 15 years or more) studies of the newer implants are not yet possible.

Patient selection and surgeon experience seem to be two important keys to success. Although patient age doesn’t seem to be a factor, the ratio of patient weight-to-implant size does make a difference. And patients with changes in soft tissue alignment and altered joint mechanics may not be good candidates for TAA.

Complications are three times more likely in cases where surgeons are doing their first 10 cases. Poor wound healing and bone fractures are common problems that decline with increased surgeon experience.

Care must be used to avoid putting too much tension on the soft tissues with self-retaining retractors during the procedure. Sutures that are too tight or a foot positioned improperly are examples of technical errors made that can be corrected with practice. Choosing the wrong size implant can also create many postoperative problems.

There’s still much we don’t know about ankle implants. Studies are needed to compare outcomes using different implant designs. Results of the same prosthesis but by different surgeons should be compared. Changes in design and implant materials will continue to improve bone ingrowth and prevent wear-related problems.

Ankle sprains are fairly common, especially among athletes of all kinds. In this case report, a lateral ankle sprain (along the outside of the ankle) was accompanied by nerve damage. The patient was a 25-year-old professional dancer. The sural (sensory) nerve to the lower leg was affected.

Symptoms included numbness and tingling in the heel and along the lateral (outside edge) of the foot. There was pain and mild swelling around the lateral ankle bone. The patient could not put his full weight on that foot. He could not perform his regular dance activities.

Specific testing performed by the physician resulted in a diagnosis of lateral ankle sprain with sural nerve injury. Treatment was planned that took into consideration the added problem of a nerve injury. Anti-inflammatory medication and limited icing of the ankle were prescribed. The patient was also given a home-exercise program.

The dancer was able to return to full activity after one-month. He did not wear a brace right after the injury in order to avoid putting any pressure on the nerve. But an ankle brace was worn during dance performances for the first two weeks to prevent re-injury.

Nerve damage is uncommon in foot and ankle injuries among athletes. When they do occur, it’s important that the physician makes a correct diagnosis. If clinical testing is not conclusive, then nerve conduction tests can be done to confirm the diagnosis.

The authors report a positive outcome and attribute it to a correct diagnosis and prompt, accurate treatment. Ice was limited to avoid thermal injury to the nerve. Taping and bracing weren’t allowed to avoid compressing the nerve. Anti-inflammatory drugs and limited activity also helped the inflamed nerve calm down and heal without further aggravation.

Having diabetes can complicate the healing of a fracture. This is especially true with an ankle fracture when the diabetes has resulted in loss of blood and nerve supply to the foot. Delayed fracture healing and impaired wound healing can cause major complications for the patient.

The surgical management of ankle fractures in diabetic patients is the focus of this report. Surgery for patients with diabetes is avoided whenever possible because the rate of complications is almost 50 per cent. If the patient is elderly and inactive, then conservative care (even with a nonunion as the final result) may be best.

Surgery is advised when the fracture is displaced. Surgeons are aware of the high rate of problems common in diabetic patients with ankle fractures. Special techniques have been developed to help prevent these problems.

Sometimes the surgery has to be staged. This means it is done in a series of steps. For example, the bones may be reduced (put back in place and lined up) first. Then soft tissue trauma causing swelling must be treated before further surgery can be done. External fixation with a metal rod along the outside of the leg and pins through the bones may be needed.

The authors discuss a wide variety of fixation methods. The use of wires, pins, standard and locking plates, and self-threading screws is presented. Many X-rays taken before and after surgery are used to explain these approaches. Special problems such as osteopenia (low bone mass) or osteoporosis (brittle bones) are taken into consideration.

The authors remind surgeons that treatment for ankle fractures in this group of adults takes much longer than in a similar patient without diabetes. Cast immobilization, as part of the nonoperative care plan can take two to three times longer than for a nondiabetic patient. Weight-bearing isn’t allowed until fracture healing is seen on X-rays.

A multidisciplinary team approach works best. Goals include maintaining good blood-glucose levels, providing oxygen supply to the healing limb, and minimizing problems that could cause limb-threatening complications.

There is limited data on the types of injuries that occur among ballet dancers. Likewise, the number of injuries each year is not widely reported. In this study, physical therapists conducted screening exams on ballet students. Later, they reviewed the records for each dancer. They measured the rate of injuries and compared risk factors between injured and noninjured dancers.

All dancers were between the ages of 12 and 18. They were all students at a preprofessional ballet boarding school. Information was collected on strength, core stability, flexibility, and motion. Posture was also evaluated, making note of foot position, standing leg turnout, and knee hyperextension. Spinal problems such as scoliosis (curvature of the spine) or excess lordosis (swayback) or kyphosis (humpback curve) were noted.

The authors saw monthly and annual trends in injury patterns. These were linked with sudden increases in training. Changes in training occurred at the start of school, right before performances, and during ballet exams. The rate of injury was calculated between 32 and 51 per cent. This is much lower than the 67 to 95 per cent among professional dancers.

There weren’t very many differences between the two groups. Dancers who didn’t have enough ankle plantar flexion (toe pointing position) were more likely to have an injury. Foot pronation (flatfeet) increased the risk of injury. And more dancers in the injured group had a previous history of low back pain.

The authors did not recommend preseason screening as a way to prevent injuries. This practice has questionable value and requires time, money, and trained staff. More work and study are needed to find an easy, cost-effective injury prevention and management program for ballet dancers.

Ankle sprains are the most common ankle injuries in the adult population. In fact, it is estimated that at least one million such injuries occur every year in the United States.

Most people recover quickly and easily from ankle sprains. But a small number go on to develop long-term, chronic ankle pain. In this article, orthopedic surgeons specializing in foot and ankle problems help identify some of the more common causes of chronic ankle pain.

The authors advise using an anatomical approach. This will help doctors diagnose and classify problems and plan the best treatment. The ankle is divided into four sections. These are medial and posteromedial, posterior, lateral, and anterior. Pain in each of these areas can be caused by specific lesions.

Pain on the medial and posteromedial area (inside of the ankle) can be caused by tendonitis or nerve compression. The two tendons involved most often include the posterior tibial tendon (PTT) and the flexor hallucis longus (FHL). Tendonitis can lead to ligament damage and foot and ankle deformity.

Tarsal tunnel syndrome (TTS) can cause pain in the medial and posteromedial ankle when the tibial nerve is pinched or pressed. TTS can be the result of trauma, fracture, tumors, cysts, and other soft tissue problems. The most common symptoms of TTS are burning pain and numbness on the bottom of the foot.

Anterior (front of the ankle) pain occurs most often after significant ankle trauma. Bone fragments or loose pieces of tissue inside the joint cause pain from impingement (pinching) of structures during movement. Arthritis with bone spurs and cysts can also narrow the joint space. This results in similar symptoms from impingement.

And finally, pain along the lateral side (outside of the ankle) can occur with tendon subluxations or tears. Subluxation refers to slipping of the tendon out of the groove in the bone where it normally slides during motion.

Treatment for any of these ankle conditions is conservative. The management tools may include anti-inflammatory drugs, physical therapy, change in activities, and rest. Heel lifts, splints, bracing, and injections are also used.

If none of these help, then surgery may be needed. There are over 50 possible operations that can be used in the management of chronic ankle pain. Tendon transfers, ligament repairs, or ankle joint replacement are common methods used to reconstruct and stabilize the ankle.

In this study, the Orthofix retrograde locking nail system was used for ankle fusion. Specifically, the tibiotalocalcaneal joints were fused. This means the ankle and subtalar joints are both fused. This type of fusion is called an arthrodesis.

The authors describe the surgical steps used to perform this procedure. The union rate was calculated when using this system. They compared cases with and without debridement of the joints. Different methods of debridement were also compared. Debridement is cleansing of the joint to remove any unnecessary or loose cartilage.

Fifty patients were followed for at least 12 months. Besides union rate, time required to fuse and function were recorded. Patient satisfaction was also measured. X-rays were taken to confirm fusion results.

The authors reported all ankle joints were successfully fused. All but two of the subtalar joints were also fused. Fusion occurred after 12 weeks. Complete healing for some patients took over a year. There were some complications but all were easily managed. Most of the patients needed a corrective shoe.

The results of this study show that a retrograde nailing system is successful in fusing the tibiotalocalcaneal joints. It provides a stiffer fusion and greater stability than screws or plates. Debridement of the subtalar joint was not necessary with this locking nail system. Debridement of the ankle was a reliable method to aid fusion.

Either open or percutaneous debridement can be used. Percutaneous refers to a needle-puncture of the skin instead of an open incision. The authors suggest percutaneous debridement of the ankle works well to preserve the soft tissues. The more invasive open debridement can be avoided with this nail design.

As some people age and develop severe arthritis in the ankle, quality of life can be affected because they have difficulty with mobility and performing every day activities. Traditionally, this type of problem has been treated with arthrodesis, or fusing the bones together. This can be effective but also can cause other problems, such as arthritis developing in the neighboring joints and it can also make it difficult for the patient to walk, because of the decreased range of motion of the ankle.

Some doctors and researchers prefer to use and suggest the use of total ankle athroplasties, or ankle replacements. However, there is concern about the effectiveness of the replacement and the long-term viability of the replacement. While earlier studies do seem promising, the authors of this study point out that the authors of most of the studies had some sort of relationship with the implants.

In this study, the authors reviewed patients who had received either the fusion or the replacement to examine if patients who had received fusions were likely to need fusion of neighboring joints in the future.

Using a database of 4705 patients who underwent first ankle fusion and 480 who had undergone first replacement over a 10-year period, the researchers noted that the average age for fusion was 55 years (range from 18 to 95) and replacement was 59 years (range from 19 to 88). The groups were fairly equally divided between males and females. The reasons for the fusion and replacement were, respectively, degenerative joint disease: 48 percent and 57.5 percent, rheumatoid arthritis: 7 percent and 10.5 percent, osteonecrosis: 3 percent and 1 percent, uncomplicated diabetes: 6.5 percent and 6 percent, and complicated diabetes: 4 percent and 0 percent.

Even though the patients who had received the fusions were younger, on average, than those who had the replacement, the fusion group patients had a significantly higher rate of complicated diabetes. This group also had a a signficantly higher proportion of African Americans or Hispanics. Among the replacement group, the patients had a higher median income.

When the researchers evaluated the rate of complications, they found that short-term complications in both groups included pulmonary embolism (clot in the lungs), infection, and the need for a revision surgery. Patients who had replacements had a higher rate of needing major revisions and had a higher rate of being readmitted to the hospital because of an infection in the ankle. A very small percentage of the patients in the ankle fusion group only included a below-the-knee amputation, acute infection in the bone, and chronic infection in the bone.

Long-term complications were subtalar fusion (fusion of the other joint in the ankle) in 2.8 percent of the ankle fusion joint and in 0.7 percent in the replacement group.

The authors write that 23 percent of the patients who had received a replacement had to undergo a revision surgery within 5 years of the original surgery. Only 11 percent of the fusion group patients had to have a revision surgery in that same period.

The weaknesses of the study, as pointed out by the authors, include the possible difficulty in an adequate comparison of the two groups regarding the indications for surgery; those who had the fusion were more likely to have ankle instability, bone loss, and/or ankle deformity than did those in the replacement group. As well, the data that was available in the database did not allow the researchers to go beyond the usual demographics and surgery results. They were not able to assess functional outcome of the patients after undergoing the surgeries.

The authors conclude ankle replacement appears to have a higher rate of major revision surgery as compared with the ankle fusion. However, ankle fusion does result in a higher rate of neighboring joint fusion as compared with the ankle replacement.

Total ankle replacement (TAR) is still a fairly new treatment option for severe ankle pain and arthritis. Prior to ankle joint replacement, the standard treatment has been ankle fusion called arthrodesis.

How do the results of these two operations compare? The authors of this report reviewed 49 studies conducted over a 15-year period of time. Ten of the studies included patients receiving a TAR. The remaining 39 reports were on the results of ankle fusion.

As part of the review, the researchers also included abstracts from major orthopedic meetings held between 2003 and 2004. Pooling the data from all these studies allows comparisons when direct studies aren’t available.

This is helpful when there aren’t enough studies to answer the question of which operation gives the best result. It also avoids basing information on individual patient stories or personal experiences of the surgeon.

Results were measured by pain levels, joint motion, and ankle function. Implant survival was also recorded. Implant loosening or subsidence was counted as a failure for TAR patients. Subsidence refers to a sinking or shifting of the implant down into the bone. Nonunion or false joint called pseudoarthrosis was considered a failure for fusion.

Overall there was no significant difference in results between the two groups. About one-third of the patients in either group reported an excellent result. More patients in the TAR group had a poor result compared to the fusion group. The majority of patients in both groups rated their results as fair to good.

There were no studies that compared TAR to fusion directly. The pooled data from many studies is an acceptable way to compare treatment options. A direct study with matched patients is still needed. It would eliminate differences that occur from study to study.

The management of ankle osteoarthritis (OA) in young adults is a challenge. The two most common treatment approaches are ankle fusion and total joint replacement. But a long life expectancy and high activity levels bring both of these options under question.

In this article, surgeons from Switzerland bring forward a third possible option: realignment surgery. This type of ankle reconstruction works best in young patients with a partially preserved joint surface.

In this study, the authors show how realigment surgery decreased pain and improved ankle range of motion. After taking X-rays and measuring all angles, the type of surgery needed was planned for each patient. As a result, patients had better walking ability and could do more in terms of general activity.

Osteotomy and soft tissue release and balancing were used to restore the joint space and leg length evenly. During an osteotomy, the surgeon removes a pie-shaped wedge of bone. The remaining bone is realigned toward a more neutral position.

There are different types of osteotomies. The surgeon assesses each patient to determine the best reconstruction surgery to perform. Realignment surgery puts the joints of the ankle back into place. This allows for more normal motion. Pain is decreased and walking ability is improved.

The follow-up was too short to report on long-term outcomes. There were some patients who needed a second surgery. All patients in this study will be followed further and a report published with results later.

Ankle fractures are very common and orthopedic surgeons see many in their practices. The fractures are classified into one of two categories, according to how they are broken; one is called the supination-external rotation (SER-2) plus a deltoid ligament rupture or medial malleolar fracture, the two together are called a bimalleolar fracture (SER-4). Both types of SER-4 fractures respond better to surgery than to casting alone. For this study, the researchers wanted to compare the outcomes of the surgery for these two types of fractures.

Four hundred fifty six patients were followed for this study. All underwent similar surgeries and followed similar post-surgery rehabilitation. The researchers followed up with the patients at months 3, 6, and 12 after surgery with physical examinations, x-rays, and discussions about complications.

Results showed that 61 percent of the patients had a bimalleolar fracture, the remainder, a lateral malleolar fracture. The group was fairly even between men (53 percent) and women. the average age was 42.5 percent, with a range between 18 and 89 years. Bimalleolar fractures were more common in the over 60-years group (24 percent) compared with 6 percent under 60, and they were more common in women. The average age of patients with the fractures was 47.3 years. With the other fracture, the average age was 38.7 years. Thirteen percent of all the patients had diabetes.

The results showed that there were 26 complications (26 patients) in the group, with 21 of the patients asking to have the hardware removed because it was causing symptoms. The authors did not find any connection between patients with diabetes and the surgical outcome, but they point out that an earlier study did find a higher rate of complications, as well as hospital length stay among diabetic patients.

The authors conclude that the bimalleolar ankle fracture occurs more often in older people and functional outcome in this group is not as good with the lateral malleolar fracture.

Injuries of the ankle can involve bone, soft tissues, or both. A specific ankle injury called the syndesmotic injury is the topic of this review article. The syndesmosis is made up of four ligaments and a band of connective tissue. This band is called the interosseous membrane. It is located between the two bones of the lower leg.

Two orthopedic surgeons from the University of Southern California sum up the latest findings in the diagnosis and treatment of ankle syndesmotic injuries. X-rays are important, including the lateral view (from the side). This will help avoid missing certain types of fractures linked with syndesmotic injuries.

But X-rays don’t always show a syndesmotic injury. The surgeon must also conduct two stress tests: the squeeze test and the external rotation test. Both tests are described in detail. Other imaging tests may also be needed. MRIs are very helpful in showing syndesmotic injuries.

The goal of treatment is to restore the normal alignment of the bones. This will give the ligaments time to heal. Surgery is needed when there is a bone fracture and torn syndesmosis. Nonoperative care may be all that’s needed when the syndesmosis is sprained. The R.I.C.E. principle is used: rest, ice, compression, and elevation.

The authors discuss various ways to surgically repair a syndesmotic injury. Types of screws, number of screws, and placement are presented. X-rays and drawings are provided to show the correct placement of a syndesmotic screw. It is advised that patients keep the weight off the foot for at least six weeks. The screws can be taken out in most patients after 12 weeks.

The authors conclude that finding and treating syndesmotic injuries is important. Failure to identify such injuries leads to an unstable ankle and decreased function. The diagnosis of syndesmotic injuries is not always simple. But with a good history, careful clinical exam, and proper testing, most syndesmotic injuries can be found early.

Ankle sprains are a common problem among athletes. Many athletes who sprain their ankles one time, resprain it again. Ankle taping is one treatment method used to prevent reinjury.The researchers in this study asked two questions. Does ankle taping work? If so, why does it work?

Thirty people with recent ankle sprains signed up to participate in this study. Each one was tested using a hopping test and a balance test. These two tests were given under three conditions: 1) with real tape, 2) with placebo (pretend) tape, and 3) with no tape (control).

The subjects were told that both types of taping worked equally well but for different reasons. The real taping method was called mechanical tape. The placebo tape was referred to as proprioceptive tape. Everyone wore a blindfold when the tape was put on. And a cloth skirt was put around the lower leg so they could not see the tape or the ankle.

The two tests used are known to be reliable and valid measures of ankle stability. The researchers found no difference in performance from one trial to the next. The only thing that changed was the peoples’ sense of confidence in the treatment. Everyone felt better wearing the tape. Both types of taping worked equally well.

Although taping didn’t improve performance, it didn’t make it worse either. The authors suggest continued taping is still a good idea. It may prevent injury and it doesn’t impair function. Taping does not appear to improve function.

Testing after medical treatment is one way to measure the effectiveness of the treatment. In this study, a new tool to evaluate the results of treatment for patients with an Achilles’ tendon rupture is presented. The test is called the Achilles Tendon Total Rupture Score (ATRS).

The ATRS is a self-administered test that can be used after any type of treatment. It measures functional results on a patient-by-patient basis. This new patient-reported tool measures the outcome based on symptoms and physical activity. The hope is that it can be used to guide treatment and allow for comparisons between studies using different treatment approaches.

There were a series of steps in the process of developing this new tool. First, the authors searched for other studies to see if a similar type of test was already available. Then a group of experts including physical therapists and orthopedic surgeons came up with items for the testing tool. The tool was named the ATRS.

Over 100 patients with Achilles’ tendon rupture were given the ATRS to complete. Participants were asked for any comments about the questions asked. They were allowed to offer any ideas for improving the questionnaire. Several items were removed from the ATRS based on the patients’ feedback.

The ATRS was then tested on another group of patients with Achilles’ tendon rupture. Using statistical analysis, the authors were able to show that the ATRS is a reliable and valid tool.

The final test had 10 questions that were quick and easy to answer for the patient and easy to score for the clinician. The ATRS does measure the effect of treatment on Achilles’ tendon ruptures. Therapists and surgeons can use this tool to find out how patients are limited by their symptoms during various physical activities before and after treatment.