Clinical diagnosis, arthrography, stress examination and surgical findings after inversion trauma of the ankle

In a series of 921 patients with acute inversion trauma of the ankle joint, the diagnostic features of lateral ligamentous ruptures were evaluated. Patients with proven lateral ligamentous rupture (150 patients in this series) were submitted to a prospective trial to compare three methods of treatment. In the 50 patients operated upon, the results of clinical diagnosis, stress radiography, and ankle arthrography were compared with surgical findings. Clinical diagnosis proved to be of very little value. The positive signs of ankle arthrography showed a reliability of 96% in predicting ligamentous rupture. Inversion stress radiography under full anesthesia showed a reliability of 92%, but the same investigation under local anesthesia, however, was only 68%.     

Clinical diagnosis,arthrography, stress examination and surgical findings after inversion trauma of the ankle

Summary In a series of 921 patients with acute inversion trauma of the ankle joint, the diagnostic features of lateral ligamentous ruptures were evaluated. Patients with proven lateral ligamentous rupture (150 patients in this series) were submitted to a prospective trial to compare three methods of treatment. In the 50 patients operated upon, the results of clinical diagnosis, stress radiography, and ankle arthrography were compared with surgical findings. Clinical diagnosis proved to be of very little value. The positive signs of ankle arthrography showed a reliability of 96% in predicting ligamentous rupture. Inversion stress radiography under full anesthesia showed a reliability of 92%, but the same investigation under local anesthesia, however, was only 68%.

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Zusammenfassung In einer Serie von 921 Patienten mit einem akuten Inversionstrauma des oberen Sprunggelenkes werden die diagnostischen Merkmale der lateralen Ligamentrupturen erforscht. Von diesen Patienten mit einer bewiesenen Ligamentruptur wurden 150 einer prospektiven Studie unterzogen, um drei Behandlungsmethoden zu vergeichen. Bei 50 operierten Patienten konnten die Resultate der klinischen Diagnose, gehaltenen Röntgenaufnahmen und Arthrographien des oberen Sprunggelenkes mit den chirurgischen Befunden verglichen werden. Es hat sich herausgestellt, daß die klinische Diagnose nicht sehr wertvoll ist. Mit Hilfe der Arthrographie des oberen Sprunggelenkes konnte in 96% der Fälle eine Ligamentruptur zuverlässig vorhergesagt werden. Eine gehaltene Röntgenaufnahme in Narkose ergab eine Zuverlässigkeit in 92% der Fälle, jedoch eine gleiche Untersuchung in Lokalanästhesie nur in 68% der Fälle.

     

Zur Diagnostik der lateralen Kapsel-Bandläsion des oberen Sprunggelenkes

Report about twelve patients with ruptures of the lateral ligament of the ankle joint, who were treated surgically. Before surgery positioned x-rays in anterior-posterior and lateral view were done. After anesthesia had been given, x-rays in a.p.-view were repeated, while it was attempted to “open up” the joint. In eight patients the a. p. and lateral x-rays, which were done before anesthesia, showed a lesion of the lateral ligament. In the remaining four patients the a. p. x-rays prior to anesthesia revealed nothing abnormal. In these patients pictures were taken with the same technic under anesthesia. It could be demonstrated, that the joint opened up. Strikingly the lateral x-rays in these patients confirmed a lesion of the lateral ligament even without anesthesia. On the basis of our study we prefer x-rays taken in lateral view, if a lesion of the lateral ligament of the ankle joint is suspected.     

Subtalar arthrography in recurrent instability of the ankle.

Subtalar arthrography was done in 37 feet of 35 patients in whom recurrent instability of the ankle was diagnosed. There were 16 male and 19 female patients, with a mean age of 29.1 years (range, 11-56 years). The mean interval between the injury and arthrography was 4 years 3 months (range, 6 months-22 years). Anteroposterior, lateral, and oblique radiographs were obtained for all patients. Any leakage during arthrography into the ankle, tendon sheaths, or sinus tarsi was recorded. An oblique view of the microrecess along the interosseous ligament and an anteroposterior view of the lateral recess just under the end of the fibula were examined. At surgery, 13 feet had combined injuries of the anterior talofibular and calcaneofibular ligaments, and 24 feet had isolated injury of the anterior talofibular ligament. The findings of the two groups were significantly different when examined for leakage into the ankle, leakage into the peroneal tendon sheath, and the presence of the lateral recess. Presence of contrast medium in at least two of these three positive arthrographic findings showed 92.3% sensitivity and 87.5% specificity in making the diagnosis of calcaneofibular ligament injury. Subtalar arthrography is valuable in making the diagnosis of calcaneofibular ligament injury in recurrent instability of the ankle.     

Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle

The medial deltoid ligament is the primary stabilizing structure in the ankle joint following lateral malleolar fracture. However, medial deltoid ligament ruptures are difficult to diagnose using current imaging modalities. We hypothesized that ultrasonography can be used to accurately allow early clinical assessment of ankle fracture stability, thereby negating the need to perform plain film stress views of the acutely injured ankle. This prospective study included 12 patients (age range, 18-72) with supination external rotation fractures requiring operative fixation. Following induction of anesthesia, ultrasonography examination was performed, followed by an arthrogram under fluoroscopic screening. Radiographs, ultrasonography, and arthrographic findings were compared. There was 100% correlation between ultrasonography and arthrogram findings. Ultrasonography accurately diagnosed medial deltoid rupture with a sensitivity of 100% and specificity of 100%. Plain film radiographs of the ankle had a sensitivity of 57.1% and a specificity of 60%. The difference between these was significant (χ(2)=.0091). This study demonstrates diagnostic ultrasonography to be an accurate diagnostic modality in assessing medial deltoid ligament integrity in patients with supination external rotation fractures. It offers the same sensitivity and specificity as arthrography without the need for additional invasive procedures. Its relative ease of use and lack of ionizing radiation make it a potentially useful tool, particularly in a busy trauma service.     

Indications for surgery in ruptures of ankle joint ligaments (author's transl)

X-ray films of the forced extreme joint position are required for diagnosis of lateral ligamentous injuries of the ankle joint. These x-ray films must be taken in forced extreme joint position in two planes (a.p. and lateral planes) by means of a special holding device simulating the mechanism of trauma by supination, inversion and adduction of the ankle joint by plantar flexion of the foot. If there is a 5 degree difference in talar tilt angle or a 5 mm difference in talar subluxation, an operation is indicated to prevent post-traumatic weak ankle and early arthrosis following chronic instability.     

Stress test and anatomical study of the lateral collateral ligaments of the ankle

Many authors have discussed on the instability of the ankle joint. We have therefore investigated the variety, courses and the functions of the lateral collateral ligament by dissecting 16 freshly amputated limbs. It was composed of 4 ligaments, i.e., the anterior talofibular, the posterior talofibular, the calcaneofibular and the lateral talocalcaneal ligaments. These ligaments have various courses and influence the stability of the ankle joint in various manners. Transection of the anterior talofibular ligament alone caused inversion and forward instability, and transection of calcaneofibular ligament alone caused adduction instability of the ankle and subtalar joint, but posterior talofibular and the lateral talocalcaneal ligament and other ligaments, however, played an important role in the stability of the ankle joint, so that injuries of the anterior talofibular ligament or the calcaneofibular ligament caused varying degrees of instability in this joint. Conclusion: To evaluate this injury the following methods of taking X-ray pictures are indispensable, namely, stress inversion, stress anterior drawer, and stress adduction radiography.     

Diagnosis of ligament rupture of the ankle joint: Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma

We prospectively enrolled 160 consecutive patients with inversion trauma of the ankle in a diagnostic protocol that included physical examination within 2 days and at 5 days after trauma, arthrography, stress radiography, and ultrasonography. 135 patients had pathological lateral ligament laxity on the later physical examination or lateral ligament rupture diagnosed on arthrography and they were operated on. 122 of these patients had ligament ruptures.

At clinical follow-up after a minimum of half a year, all of the patients who were not operated on had stable joints without signs of previous ligament ruptures.

Delayed physical examination at 5 days after the injury led to the highest overall sensitivity (96%) and specificity (84%) for the detection of a ligament rupture. Additional diagnostic procedures, at a considerable cost, yielded little additional information.     

Lateral ankle stabilization. Modified Lee and Chrisman-Snook

Chronic lateral ankle instability is not always a severe disability, but surgical reconstruction may be necessary in patients with instability or when conservative measures fail. Although recent articles by Ahlgren and Larsson and Bergsten et al provide evidence of satisfactory results with late ligamentous repair of chronic ankle instability via imbrication, lateral ankle stabilization procedures that use tenodesing of fasciodesing techniques continue to provide good results. Prolonged disability after acute lateral ankle ligament disruption has been reported in 20% of patients. With long-term instability, uneven stress distribution with recurrent sprains can lead to osteoarthritis. Various methods for evaluation of the chronically unstable ankle include inversion stress testing, anterior drawer sign, arthrography, and tenography. All of these methods are controversial with false negative results, unreliability, and variations in measurements and interpretation being cited. With this in mind, radiographic instability must be correlated with mechanical and clinical instability. Once all of these findings are correlated the physician can determine the appropriate procedure that will provide the patient with long-term stability. Although more recent studies have addressed repair of chronic instability with ligamentous reinforcement or imbrication, these procedures remain controversial in lieu of Freeman's deafferentiation theory with loss of proprioception. There is also mechanical instability of the subtalar joint, which may also require stabilization. Use of the modified Lee and the Chrisman-Snook techniques as described have provided good results.     

Instability of the subtalar joint

Instability of the subtalar joint can follow inversion stress injuries to the lateral ankle and hindfoot. Ligaments involved in the injury include the calcaneofibular, lateral talocalcaneal, cervical, interosseous talocalcaneal, or a combination. Although the problem most often occurs in conjunction with lateral ankle instability, it may be an isolated problem and it is not corrected equally well by the various lateral ankle ligament reconstructions. Techniques available for diagnosis include routine stress radiographs of the ankle, which also include the subtalar joint, specific subtalar stress radiographs, stress tomograms, fluoroscopy, or subtalar arthrograms. Once diagnosed, subtalar instability symptoms can be treated by either nonoperative or operative means.     

Die Diagnostik der Bandverletzungen im Bereich des oberen Sprunggelenkes

On the basis of history and clinical findings it is attempted to stage a trauma of the ankle joint according to the genetic classification of Lauge-Hansen. This procedure is understood as a prophylactic measure against overlooking combined ligamentous lesions. Tears of the lateral collateral ligaments of the ankle are proven by stress roentgenograms taken in varus tilt position; they are performed by a specially developed method. Additionally stress roentgenograms are taken, when the talus is moved forwards (“anterior drawer sign”). Lesions of the deltoid ligament are shown by talar tilt in valgus position. Isolated tears of the anterior tibiofibular ligament can be visualized only by arthrography. If stress roentgenograms cannot confirm the clinical diagnosis, an arthrography is necessary.     

Involvement of the inner malleolus and deltoid ligament in supination trauma of the ankle joint

Additional ligament ruptures or fractures of the medial side of the ankle joint accompanying the lateral ligament rupture are rare. These injuries are more often in traumas with pronation-eversion movements of the foot. In cases of lateral ligaments ruptures we only found in 2.8% and in 5.9% additional medial injuries. This is confirmed by different biomechanical experiments. Experimentally the delta ligament rupture could mostly be caused by pronation-eversion movements or by forced plantar flexion of the foot. The diagnosis of bony lesions of the medial malleolus might be easy by X-ray, but ligament lesions of the medial ankle joint can be diagnosed easily too be using the stress X-ray controlling the medial talar tilt as a sign of medial instability. Because the necessity of surgical treatment is less important than of the lateral ligaments we recommend this procedure in cases of bilateral instability or if dislocation is obvious.     

Comparative results of conservative treatments for isolated anterior talofibular ligament (ATFL) injury and injury to both the ATFL and calcaneofibular ligament of the ankle as assessed by subtalar arthrography

Background There have been no reports describing the results of conservative treatment of acute lateral ligament injury of the ankle in detail in terms of the severity of the injury, and the results of conservative treatment for injury with severe instability are still controversial. The purpose of this study was to assess the results of nonoperative treatment of acute lateral ligament injury according to its severity. Methods Fifty-five consecutive acute lateral ankle ligament injuries in 54 patients who were treated nonoperatively were followed up as a prospective study. Twenty-seven were male patients and 27 were female patients; the average age was 23.9 years (12–55 years). The patients were divided into two groups according to the extent of the ligament injury: patients with an isolated injury of the anterior talofibular ligament and those with combined injuries of the anterior talofibular ligament and the calcaneofibular ligament. In addition to the routine examinations for inversion ankle sprain, subtalar arthrography was mainly used to assess the condition of the calcaneofibular ligament. The arthrography was performed an average of 3.5 days after the injury (0–5 days). Results Fifty-five ankles of patients who were treated nonoperatively according to the same protocol were included in this study, and were followed up for an average of 5.0 years (37–86 months). At the time of the final follow-up, 22 of 25 (88%) ankles with an isolated injury to the anterior talofibular ligament were asymptomatic; in contrast, only 9 of 30 (30%) ankles with combined injuries of the anterior talofibular and calcaneofibular ligament were asymptomatic. The average American Orthopaedic Foot and Ankle Society score of the isolated injuries was 97.8 points, in contrast to 92.4 points for the combined injuries. Conclusions The results of nonoperative treatment with 1 week immobilization followed by a functional brace were excellent in patients with an isolated injury of the anterior talofibular ligament, but were unsatisfactory in those with combined injuries of the anterior talofibular and calcaneofibular ligaments.     

Analysis of ankle-hindfoot stability in multiple planes: an in vitro study

BACKGROUND: It is necessary to have an understanding of ankle and hindfoot motion and stability to accurately diagnosis and treat ankle-hindfoot disorders. METHODS: We devised an ankle ligament testing apparatus to more critically determine ankle stability in all planes with a constant rotational force applied (inversion, eversion, internal rotation, external rotation) throughout the range of sagittal plane motion in 13 cadaver specimens. Three-dimensional kinematics were determined with a magnetic tracking device. RESULTS: With inversion force applied, calcaneal-tibial inversion was greatest in maximal plantarflexion (mean 22.1 +/- 6.0 degrees) and gradually decreased with dorsiflexion, which indicated that the ankle had the most inversion instability in plantarflexion. With eversion force applied, calcaneal-tibial eversion gradually increased with increasing dorsiflexion to 12.7 +/- 7.4 degrees indicating that the most eversion instability was in dorsiflexion. With internal rotation force applied, calcaneal-tibial internal rotation from plantarflexion to neutral ankle position increased. With external rotation force application, external rotation from neutral to maximal dorsiflexion increased. CONCLUSIONS: Ankle laxity was not constant but varied depending on the plantarflexion-dorsiflexion position and the direction of the applied force. The degree of ankle laxity was greater with inversion and internal rotation torque. Variation in laxity between specimens was observed, consistent with previous reports. These data indicate that the ankle is less stable in plantarflexion when inversion and internal rotation forces are applied. This may explain why the lateral ankle ligaments are most prone to injury in this position. The ankle was less stable in dorsiflexion when eversion and external rotation forces were applied. This is consistent with the observation that deltoid ligament injuries occur in the neutral to dorsiflexion position. The study demonstrates the importance of examining patients with suspected ankle ligament injuries in several ankle positions. The ankle testing device has potential application for in vivo testing of patients with suspected ankle ligament instability.     

微创锚钉治疗陈旧踝关节外侧副韧带损伤

目的探讨微创锚钉治疗陈旧踝关节外侧副韧带损伤的临床效果。方法采用微创锚钉治疗30例陈旧踝关节外侧副韧带损伤患者。术后给予支具固定踝关节并进行相关功能锻炼。观察伤口愈合情况,采用AOFAS评分、距骨倾斜角度及距骨移动距离评价疗效。结果伤口均一期愈合。患者均获得随访,时间6~12个月。术后6个月踝关节功能恢复良好,AOFAS评分、距骨倾斜角度及距骨移动距离与术前比较差异均有统计学意义(P<0.001)。结论微创锚钉治疗陈旧踝关节外侧副韧带损伤具有创伤小、高效恢复踝关节稳定及正常功能的效果。     

Carbon fiber replacement of the ligaments of the shoulder girdle and the treatment of lateral instability of the ankle joint

A normal active human being will not accept chronic instability or persistent luxation of any joint. Many attempts have been made to stabilize a damaged joint with autogeneic and allogeneic materials and by various surgical techniques. In animal and clinical trials, carbon fibers are reported to be a promising material for ligament replacement in chronic joint instability. The authors are investigating carbon fibers not only for repair of chronic instability of knee joints but also for chronic luxations and subluxations of the sternoclavicular, acromioclavicular, and ankle joints. For long-term stability of the new ligament, carbon fibers must be implanted in cancellous bone channels. Ingrowth of connective tissue and newly formed bone produces a secure ligament anchorage. A temporary tension band wire loop immobilizes the sternoclavicular or acromioclavicular joint. The ankle ligament replacements are immobilized with a weight-bearing plaster boot for six weeks postoperation. The use of carbon fibers as a ligament replacement in the sternoclavicular, acromioclavicular, and ankle joints produces favorable functions and stability. Reconstruction of the normal ligament insertions of a joint is essential, particularly with respect to supination and free range of movement. Of 56 cases with lateral chronic instability of the ankle, 51 with a mean average postoperative follow-up period of two years, 49 had subjectively good results. Stable joints were demonstrable in 48 cases; supination was limited in four cases.     

Acute and chronic lateral ankle instability in the athlete

Ankle sprain injuries are the most common injury sustained during sporting activities. Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body's center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability, resulting in chronic ankle instability. Treatment of acute ankle sprains generally can be successfully managed with a short period of immobilization that is followed by functional rehabilitation. Patients with chronic ankle instability who fail functional rehabilitation are best treated with a Brostrom-Gould anatomic repair or, in those patients with poor tissue quality or undergoing revision surgery, an anatomic reconstruction.     

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. METHODS: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. RESULTS: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. CONCLUSIONS: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.     

Arthroscopic Treatment of Anterolateral Impingement of the Ankle

Anterolateral ankle impingement is due to entrapment of pathological tissues in the anterolateral aspect of the joint. The aim of this study was to evaluate the results of arthroscopic diagnosis and treatment of anterolateral ankle impingement. Twenty patients with anterolateral ankle impingement who had arthroscopic debridement were included in this prospective study, including 16 men and 4 women with a mean age of 35.8 years. Synovial hypertrophy was found in 13 patients, impinging distal fascicle of the anterior inferior tibiofibular ligament in 2 patients, torn anterior inferior tibiofibular ligament in 3 patients, and fibrofatty scar tissue in 2 patients. Seven patients had associated talar cartilage damage. Four patients had additional inversion injuries after the arthroscopic procedures. Final results were excellent in 11 patients, good in 6 patients, fair in 2 patients, and poor in 1 patient. One of the 7 patients with cartilage damage had excellent results, 5 patients had good results, and the remaining patient had fair results. Two of the 3 patients with complete tear of the anterior inferior tibiofibular ligament had fair results, and the other had a poor result. One of the 4 patients with additional inversion injuries had good results, 2 had fair results, and 1 had a poor result. In conclusion, ankle arthroscopy is useful in the diagnosis and treatment of anterolateral ankle impingement. Factors that negatively affect final outcome are associated chondral lesions of the talus, associated syndesmotic lesions, and new inversion injuries after the arthroscopic procedure.     

Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的生物力学比较

目的:测试Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的术后稳定性,为临床治疗方法的选择及预后的判断提供依据。方法:2008年7月至2009年6月,采集18具冰冻下肢标本,男10例,女8例,平均年龄(39.3±11.2)岁,随机分为3组:正常对照组(A组),Evans术式组(B组)和Chrisman-Snook术式组(C组),每组6只标本。解冻后在B、C组中切断距腓前韧带和跟腓韧带,造成外侧副韧带Ⅱ度损伤,并采用Evans术式和Chrisman-Snook术式重建外侧副韧带,进行生物力学测试,观察胫距关节和距下关节侧方应力加载下的位移情况。结果:①胫距关节侧方应力试验显示B组对外侧副韧带损伤修复后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。②距下关节侧方应力试验显示B组术后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。结论:踝关节外侧副韧带损伤造成踝关节不稳,在其修复术式中Chrisman-Snook术式比Evans术式在重建踝关节术后初期稳定性上优于Evans术式,Chrisman-Snook术式更符合生物力学原理。