CENTRO DI TRAUMATOLOGIA DELLO SPORT CHIRURGIA ARTROSCOPICA UNITA OPERATIVA DI RIABILITAZIONE SPORTIVA
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1 CENTRO DI TRAUMATOLOGIA DELLO SPORT CHIRURGIA ARTROSCOPICA UNITA OPERATIVA DI RIABILITAZIONE SPORTIVA IRCCS GALEAZZI - MILANO Responsabili: M. DENTI - H. SCHÖNHUBER - P. VOLPI Responsabile: G. MELEGATI Equipe: C. BAIT F.BRAMBILLA M. GALLI - R. POZZONI Equipe: M. BANDI C. TOMMASI - D.TORNESE
2 TREATMENT OPTIONS OF THE OSTEOARTHRITIC ANKLE IN ATHLETS P. Volpi M. Galli
3 INTRODUCTION About 15% of the world s adult population is affected by joint pain and disability that result from osteoarthritis Many of these cases involve ankle osteoarthritis
4 INTRODUCTION OSTEOARTHRITIC ANKLE 70% post-traumatic traumatic osteoarthritis Primary osteoarthritis Systemic arthritis (rheumatoid arthritis and other)
5 INTRODUCTION OSTEOARTHRITIC ANKLE Arthritis-predisposing traumatic ankle injuries are: Malleolar fractures Tibial plafond fracture Talus fracture Osteochondral damages of the talar dome Ligament lesions
6 INTRODUCTION OSTEOARTHRITIC ANKLE Ligament common sports lesions are the most injuries and recreational susteined in activities and account for about 25% of the injuries that occur in running and jumping sports The incidence of degenerative arthritis after chronic lateral ankle instability ranges from 13% to 78% ( Hintermann B. - After arthroscopic findings,, 2002)
7 LIGAMENT LESIONS OF THE ANKLE NATURAL HISTORY LIGAMENT LESION RECURRENT SPRAINS IMPINGEMENT (BONY OR SOFT-TISSUE) TISSUE) ANKLE INSTABILITY OSTEOCHONDRAL DEMAGE CHRONIC ANKLE
8 LIGAMENT LESIONS OF THE ANKLE ANATOMIC TECHNIQUES Primary suture (acute ankle) Ligament retention Ligament reinsertion NON ANATOMIC TECHNIQUES Autografts (Peroneal tendon, Achilles tendon) Allografts Artificial grafts
9 LIGAMENT LESIONS OF THE ANKLE In chronic ligament lesions the location of the related osteochondral defects is often in the medial aspect of the tibia 83% in chronic ligament lesions _ Volpi Taga and Shino,, 1993
10 ANKLE OSTEOARTHRITIS Ankle osteoarthritis in atheletes can show different problems such as: Articular pain Swelling Limited range of motion Locking Deep pain on weight bearing Stiffness
11 ANKLE OSTEOARTHRITIS The different types of ankle osteoarthritis in athletes are: Osteochondral lesions of the talus Anterior bony or soft-tissue tissue impingement Posterior impingement syndrome Loose body
12 OSTEOCHONDRAL LESIONS OF THE TALUS Chronic sprains can lead to articular surface damage In these patients pain during weight bearing is present The pain is probably the result of edge loading by the tibia on the cartilage rim of the defect and the subchondral bone MRI is used for better defining the exact size and location of the lesion and is valuable for preoperative planning therefore more
13 OSTEOCHONDRAL LESIONS OF THE TALUS NON-OPERATIVE OPERATIVE TREATMENT Restriction of sporting activities In case of giving way cast immobilisation for at least 3 weeks The aim is to give the bruised talus rest so that oedema can resolve or for partly detached fragment to become re-attached to the surrounding bone
14 OSTEOCHONDRAL LESIONS OF THE TALUS SURGICAL TREATMENT BONE MARROW STIMULATION After debridement, we create multiple connections with the subchondral bone by micro-fractures The aim is to stimulate the formation of new blood vessels and so a fibrin clot Arthroscopy
15 OSTEOCHONDRAL LESIONS OF THE TALUS SURGICAL TREATMENT RETROGRADE DRILLING This technique is reserved for primary osteochondral defects where there is an almost intact cartilage The aim is to induce subchondral bone revascularisation Arthroscopy
16 OSTEOCHONDRAL LESIONS OF THE TALUS SURGICAL TREATMENT AUTOLOGOUS CHONDROCYTE IMPLANTATION ACI aims to regenerate tissue with hyaline-like like cartilage Two steps Arthrotomy is preferred
17 OSTEOCHONDRAL LESIONS OF THE TALUS SURGICAL TREATMENT OSTEOCHONDRAL TRANSPLANTATION Allografts or autografts (OATS) The aim is to reproduce the mechanical, structural and biomechanical properties of the original hyaline articular cartilage Open approach or arthroscopic procedure
18 OSTEOCHONDRAL LESIONS OF THE TALUS SURGICAL TREATMENT FIXATION Large fragment can be fixed by Herbert screw, Kirschner wire or absorbable pin or screw Arthroscopic or open technique
19 ANTERIOR BONY IMPINGEMENT The characteristic locations are the medial aspect of the talar neck and lateral to mid-line of anterior distal tibia The aetiology of spur formation could be due to excessive stretching of the anterior capsule, resulting microtrauma, scar tissue and then ossification Arthroscopic excision of spurs decrease pain and improve the ankle s range of motion
20 ANTERIOR SOFT TISSUE IMPINGEMENT This is the most common pathology after recurrent ankle inversion The anterolateral tissue, including the Anterior talofibular ligament and capsule, can elongate and hypertrophy creating chronic pain Arthroscopic excision of scare tissue is recommended
21 POSTERIOR IMPINGEMENT SYNDROME BONY PATHOLOGY Irritation or fracture of the os trigonum or enlarged talar tubercle that can occur from a hyper-plantar plantar-flexion injury and can lead to chronic pain when kicking Initial conservative treatment with rest and prevention of plantar-flexion with brace, but if symptoms continue a surgical treatment by open or arthroscopic excision is necessary
22 POSTERIOR IMPINGEMENT SYNDROME SOFT TISSUE PATHOLOGY Stenosing tenosynovitis of the flexor hallucis longus Hypertrophy of the posterior capsule Enlargement of the posterior inter-malleolar ligament These chronic changes in the posterior ankle in athletes can lead to pain that must be eliminated by surgical treatment
23 LOOSE BODY In osteoarthritic ankle is often possible to find loose bodies that cause articular pain with locking and limited range of motion Arthroscopic removal is indicated
24 CONCLUSIONS There are many types of osteoarthritic ankle in athletes that sport traumatologist have to know Prevention in different sports should therefore be aimed at preventing ankle sprains Surgical treatment of ankle instability is recommended Arthroscopic surgery can resolve many of these chronic problems and also affords a quicker return to play if it s possible
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