Anatomy The ankle joint comprises the the true ankle joint (upper ankle joint) and the subtalar joint (lower ankle joint). The latter is rarely affected by injuries and therefore discusses in association with ankle osteoarthritis. The upper ankle joint (UAJ) is the connection between the ground-contacting foot with the talus as lower portion of the joint and the tibia carrying the body weight which forms the upper joint surface together with the inner malleolus. Laterally lying we can see the fibula. This construction enables a sliding movement = flexion and extension and thus the power when walking or jumping. Stable ligaments prevent lateral tilting. At the inner malleoulus the broad and stable delta ligament, at the outer malleolus three considerably thinner ligaments from which the anterior- and medial collateral ligament are often partly or even completely ruptured when twisting one s ankle (supination trauma, distorsion). Ligament Injuries Strain of ligaments and joint capsule, sprain (grade I) Treatment: ice, compressions, elevated resting, full loading possible after few days. Partial rupture (grade II) Treatment: as grade I, additionally walking on crutches necessary for some days and wearing of a stabilizing ankle brace (e.g. Aircast or Malleo-Tri-Step) for 2-4 weeks. Physiotherapy is recommended for improvement of coordination and muscular stabilization as prevention against new injuries. Ligament rupture (grade III). Treatment: as grade II, but with the joint being splinted for up to 6 weeks. With severe instability even operative ligament suture. Chronic instability of lateral collateral ligament after repeated distortion. If physiotherapy, broadened heels and elastic bandages do not bring improvement, operative ligament surgery should be considered. When having a sufficiently stable and worn-out scar, it can be doubled and sutured again to tighten it (surgery according to Broström). Advantage: anatomic reconstruction. In case of a rupture of two ligaments or severe instability, strengthening of the ligaments has to be carried out by using additional material e.g. periosteum (periosteal flap surgery), tendons from the foot or recently also tendons from the knee. Advantage: very good stabilizing effect. Disadvantage: complex surgery, difficult anatomic positioning. Complications of such operations: - Infections (less than 1%) - Slight movement restrictions (1-2%) - Sensory disturbances at the outer side of the foot - Insufficient stabilization Syndesmosis rupture: Rupture of the tight ligament connection between lateral malleolus and shinbone. With proven rupture (by MRI), fixation with screw and walking on crutches for 6 weeks is necessary. 96
Tendon Injuries Subluxation of the peroneal tendon: normally lying behind the lateral malleolus, the tendon forcefully snaps out of its position. Therapy: operative protection by partially tightening soft tissue or relocation of a lateral malleolus lamella. Ellenbogen Foot Tibialis posterior tendon tears: weakness or rupture of the flexor tendon behind the medial malleolus with increasingly painful pes valgus. If conservative therapy approaches are not successful, reconstruction of the tendon often combined with correction of the heel bone against the pes valgus deformity are necessary. Ankle Fracture Medial malleolar fracture (second most common bone fracture). Treatment: smaller stable fractures can be treated conservatively with orthesis or plaster. Bigger fractures at the inner- or outer malleolus are regarded as serious joint injuries and have to be treated surgically; otherwise, there is danger of early degeneration of the joint (arthrosis). Arthroscopic Ankle Surgery General Information There are numerous sports injuries and deteriorative illnesses at the ankle joint. Indication for surgery is mostly made on the basis of pain, swelling, movement restriction, instability, jams or blood in the joint. meniscoid lesion access for arthroscope working access Fig. 1: Scheme of ankle arthroscopy: automated milling machine on left side, optics with attached camera on right side (Dyonics, McGinty 91) 97
Arthroscopic Ankle Surgeries Consequential damages after dislocations with stress pain, instability or blockages through loose joint bodies are the most common causes. Furthermore inflammations of the synovial membrane, adhesions and scarrings with movement restrictions (arthrofibrosis) and limitations to mobility as a result of entrapped scar tissue (meniscoid syndrome) can be treated successfully. Protruding osteophytes at the front side of tibia and talus are especially with ball players and dancers a common cause for pain, swelling and movement restriction. Arthroscopic removal of these osteophytes is a promising and wellproven treatment option. When suffering from joint cartilage damage, a cartilage treatment similar to the one at the knee joint can be carried out. In most cases, the damaged cartilage is carefully removed, smoothed and the underlying bone brushed up in order to stimulate fibrocartilage regeneration. In rare cases treatment includes transplantation of donor cartilage. Major Ankle Surgeries Deep cartilage defects with underlying bone defects are called Osteochondritis dissecans (OD). They occur mostly at the inner side of the talus which is very difficult to reach, and causes are severe distortions, chronic instabilities or circulatory disorders of the bone. They are divided into four grades: Grade I: Bone oedema, circulatory disorder without changes in the bone structure, intact cartilage layer. Treatment: rest, use of crutches, circulation stimulating measures (hyperbaric oxygen therapy HBOT or iloprost injections, see chapter foot, p. 89). In case of persisting progression, the affected area can be drilled from the rear side under arthroscopic control. Grade II: beginning demarcation, displacement of a mostly oval-shaped cartilage bone fragment, in most cases still intact cartilage layer, but sometimes partly frayed. This lesion is potentially instable and reaches grade III soon without treatment. Thus, either early and consequent conservative treatment with rest for a longer period or surgical treatment is necessary. Grade III: the cartilage bone fragment has detached completely from the talus bone but still lies in its mouse bed. This condition does not heal by itself. For therapy please refer to stage IV. Grade IV: The cartilage bone fragment has broken off the bone and as loose joint body causes additional damages by interfering with the joint. There is only one option: surgical treatment. In favorable cases refixation of the fragment, otherwise simple removal of the fragment and stimulation of self-healing (mostly possible without removal of inner malleolus, but then with reduced chances of fast healing). Another promising method is cartilage bone transplantation: a healthy cylinder-shaped piece of cartilage bone is taken from the knee and transplanted into the defect area of the talus. Here, the inner 98
malleolus has to be removed in order to reach the affected area; it is affixed with screws afterwards. Advantage: load stable condition within 5-6 weeks. Complete surgery possible in one session. Public health insurance companies cover the costs of this operation method. Ellenbogen Foot Disadvantage: Transplant has to be extracted from the knee. Alternative possibility: autologous chondrocyte transplantation (ACT) = cultivation and transplantation of the body s own cartilage cells (see chapter arthrosis, p. 36). Advantage: high-tech procedure with best chances for development of new loadstable hyaline cartilage. No additional injury at the donor site. By using recent technologies of spheroid ACT even detachment of the inner malleolus can be avoided. Disadvantage: expensive (public insurance companies cover the costs only to a limited extent; mostly clinics are allowed only a limited number of ACT-operations. Surgically challenging. This method is only appropriate for flat defects; otherwise the bone defect has to be filled up when removing the cells. Normally, two surgical steps are needed (first cell extraction for cultivation and later transplantation). In some cases however, after verification of the diagnosis and indication, approval of cost transfer has to be obtained from the health insurance company first before cell removal and transplantation afterwards can be carried out. Here, bureaucracy makes 3 surgical steps inevitable. 99
Besides the information given, please also note the following: Prior to operation Do not put your joint under unnecessary strain; this might extend your recovery period after the operation. If necessary train walking on crutches. Arrange treatment dates with your physiotherapist or masseur, beginning about 1-2 days after the operation. For further information about a planned operation please refer to chapter anesthesia from page 18. Aftercare With most ankle joint surgery patients an extended program for postoperative care is arranged. Special details of aftercare are mentioned in the operation record. Generally applies: Do not put full weight on the foot the first days after surgery and rest your foot in an elevated position. Until completed wound healing (5-10 days) support your foot by walking on crutches. Cool the joint with dry ice-pack several times a day for approx. 15 min. Movement and Drainage After rest of 2-3 hours get up and walk a few steps. By activating the lower leg musculature you can help preventing thrombosis best. In case that the small drainage bottle becomes filled, please do not worry and leave it alone. Under no circumstances empty the bottle, nothing will happen. Dressing Change and Aftercare The day after surgery please visit us for change of dressing. The next change after 2-3 days can be carried out from your referring specialist or family doctor. Taking a shower is possible after 1 week; removal of stitches is done approx. 14 days after surgery. Full loading is permitted after 5-10 days in most cases. Please carefully read the chapter Aftercare of your operation record which serves as information for you and for other physicians as well as physiotherapists dealing with the case. We kindly ask you to arrange a follow-up examination after 3 weeks and in some cases again after 3 months. 100