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ankles

1. Epidemiology Each day about one inversion injury of the ankle occurs for every 10,000 people. Seven to ten percent of all admissions to hospital emergency departments are attributed to ankle sprains. 20% of acute ankle sprains will develop into chronic ankle instability.

2. Syndesmosis Testing in High ankle sprains S yndesmosis tenderness Hopkins squeeze test (Hopkin's)  External rotation stress test   Cotton stress test Fibular translation test

3. Radiographic evaluation

4. CT and MRI for syndesmotic injuries CT: P ost-operatively to assess reduction of syndesmosis after fixation M ore sensitive than radiographs for detecting minor degrees of syndesmotic injury MRI Normal radiographs with clinical suspicion of syndesmotic injury L ambda sign described as being highly sensitive and specific for detecting syndesmotic injury 

5. Ankle Sprain Nonoperative Treatment RICE in Grade I, II, and III injuries Grade I and II : 1 week of weight-bearing immobilization in a walking boot, aircast or walking cast G rade III :10 days of casting and NWB High ankle sprain: NWB cast for 2 to 3 weeks Early movement and r ehabilitation should begin with motion exercises and progresses to strengthening of peroneal muscles, proprioception when pain and welling subsides. In high ankle sprain physical therapy program using a brace that limits external rotation.

6. Syndesmotic Injury Surgical Management S yndesmosis fixation with screw or suture button S yndesmotic ankle sprain with instability on stress radiographs Syndesmotic injury refractory to conservative treatment S yndesmotic injury with associated fracture that remains unstable after fixation of fracture Screw often requires removal after 6 weeks F iberwire suture with two buttons tensioned around the syndesmosis and does not require remo val Some studies show earlier return to activity when compared to screw fixation

7. Chronic ankle instability

8. Functional Instability risk factors : Functional Instability risk factors : C ongenital hindfootvarus Proprioceptive deficit L axity-related osteochondral talar dome lesions P eroneal tendon dislocation and/or fissure A nterior or posterior impingement A ll should be treated at the same time as lateral laxity

9. Patient History Frequent episodes of giving way, rolling the ankle, or tripping Sensation of instability Pain that is present between episodes of instability suggests possible additional pathology.

10. Talar Tilt

11. Dynamic Telos Xrays

12. Radiology MRI is important to evaluate the patient for concomitant injuries because some reports demonstrate that up to 96.9%of patients with ankle instability have additional pathologies

13. Surgical Techniques Anatomic repair or reconstruction Direct repair of the injured ligament and anatomical reconstruction with use of a graft Indicated for patients with sufficient ligament remnants amendable to sutures, whereas reconstruction is indicated for those with insufficient or attenuated ligament remnants. N on-anatomic reconstructions with tenodesis effect

14. Anatomic Repair or Reconstruction Non anatomic reconstruction Brostrom Watson Jones Brostrom Gould Chrisman-Snook Roy Camille Colville Blanchet E vans Dequennoy Karlsson

15. Direct repair using the native ligament remnant with or without reinforcement of local tissue is generally considered to be the first-line operative treatment of ATFL Contraindications: L ongstanding ankle instability with insufficient ligamentous tissue. Previous failed stabilization procedures . High body mass index. Generalized ligamentous laxity.

16. Positioning and approach S upine, with a support holding the limb in internal rotation. The approach is centered with respect to the lateral malleolus, curving forward then upward .

17. Broström Procedure

18. Gould Modification T his procedure was reinforced to reinforce Broström reinsertion. The superior distal extensor retinaculum bundle is fixed transosseously or by anchors to the anterior par tof the fibular malleolus, thereby reinforcing the anterior capsule and anterior tibiofibular ligament. The technique can be performed arthroscopically (arthroscopic Broström -Gould procedure)

19. Roy-Camille Technique

20. Blanchet Technique L igamentous tension restoration. The scar tissue of the LTFA is exposed and excised, simultaneously creating an anterior joint opening in front of the malleolus. The resection is carried out until reaching the "healthy ligament" near the talus, while preserving a few millimeters of tissue, even scar tissue, for suturing. E xploration to identify any associated lesions and to check for any incarceration of residual ATFL. The ligament can then be sutured to the remaining stump on the lateral edge of the talus, with the foot positioned in dorsal flexion and valgus Often it is necessary to reinforce this suture using a portion of the fibular tendon sheath. If needed, a final reinforcement with the frondiform ligament is described in the initial technique.

21. Duquennoy Technique Removal as a single unit, the anterior periosteum, the LTFA attached to it, and the joint capsule, simultaneously performing a pre-malleolar arthrotomy. This approach allows for the exploration of cartilage, particularly in the search for osteochondral lesions of the talar dome. Healthy ligament tissue is identified on the deep side of the disinserted tissue, and U-shaped sutures are passed through this healthy tissue. The reinsertion is supported by four to five transosseous sutures previously drilled by a Kirschner wire from the lateral face of the malleolus to its anterior edge, near the articular cartilage. The U-shaped sutures are passed through the bone tunnels before being tightened, with the foot at a right angle, enabling visualization of the anterior ligament tension. Currently, reinsertion has been facilitated by using anchors placed at the level of the lateral malleolus instead of transosseous tunnels.

22. Karlsson Technique

23. Non anatomic Reconstructions

24. Watson Jones Technique

25. Chrisman-Snook P rocedure

26. Colville Procedure

27. Evans Procedure

28. Ankle Arthroscopy Several intra-articular conditions are associated with chronic ankle instability, including osteochondral lesions of the talus, impingement, loose bodies, painful ossicles, adhesions, chondromalacia, and osteophytes. These conditions in themselves may produce ankle pain; left untreated, they may lead to less than favorable results after ligamentous stabilization. They found that 93% of patients had associated lesions requiring intervention but reported 96% good to excellent results.

29. Take off messages Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligamentreconstruction are the two recommended options. Non-anatomic reconstructions using the peroneus brevis should be abandoned. Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available. 

30. Suture Anchors vs Direct Repair Biomechanical studies have similarly revealed no significant differences in tensile strength and stiffness between direct repair techniques and suture anchor stabilization

31. Suture Tape Augmentation A ttempts to improve the strength of the construct were sought, and the concept of a suture tape augmentation was initiated. C ould possibly lead to overconstraint . Several authors have found no significant difference in suture anchor lateral ligament repair with and without suture tape augmentation. Still no clear evidence.