Operative management of ankle and foot injuries

Dr. Rukmanikanthan Shanmugam, Consultant Orthopaedic surgeon. Prince Court Medical Centre When to do operative management

▪ Most condition would have an option of either non operative or operative. ▪ Best option:  fractures  mass / growth ▪ Failed non operative:  most other injuries Trauma

▪ Severity of trauma  Injury may be trivial in pathological fractures ▪ May have visible signs:  Bruising  Wounds  Point tenderness  Deformity  swelling

Ottawa Rules

▪ Ankle X-ray:  Bone tenderness along distal 6cm of post edge of tibia or tip of medial malleolus  Bone tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus  Inability to bear weight for 4 steps ▪ Foot X-ray:  Bone tenderness at the base of fifth metatarsal  Bone tenderness at navicular bone  Inability to bear weight for 4 steps Ankle sprain

▪ Sprain vs strain:  Sprain – injury to ligaments  Strain – injury to muscles and tendons ▪ Follows trauma:  Usually following a forced inversion injury to the ankle  Sudden onset of pain  May or may not have bruising depending of severity  Usually associated with tenderness and swelling Ankle Sprain Ankle Sprain Management

▪ Initial:  Rest – immobilization (cast, slab, brace, etc.)  Ice – Pain relieve (intermittent cold compression)  Compression (bandaging etc to reduce swelling)  Elevation (to reduce swelling) ▪ Early functional exercises:  When pain and swelling subsides  Start range of motion and strengthening exercise  Proprioceptive training ▪ Gradual return to usual activity with or without bracing ▪ Prone for re-injury (especially if rehabilitation is incomplete) ▪ Majority do not need surgical intervention ▪ If symptoms persists then MRI and KIV surgery ATFL and Extensor retinaculum

Fibula origin of ATFL Augmentation with artificial ligament

▪ Artificial ligament augments the repair ▪ Can also be used to augment CFL ▪ In very badly degenerated ligaments or revision cases, may need autograft ▪ Peroneal subluxation:  Usually due to trauma – tear of Superior peroneal retinaculum  Can be contributed by low lying muscle belly of Peroneus brevis

Degenerative

▪ Bony degeneration e.g. Osteoarthritis, Osteochondral injuries ▪ Soft tissue degeneration e.g. posterior tibialis tendon dysfunction (PTTD), Achilles tendinopathy etc ▪ Ankle OA:  Primary OA is very rare  Secondary causes:  Post traumatic  fractures  Osteochondral injuries  Injury leading to instability  Post infection  Synovial chondromatosis  Management based on extent and symptoms:  Activity modification  Analgesics / orthotics  Intraarticular injections  Debridement  Osteotomies  Arthrodiasthesis  Ankle replacements  Ankle fusion

Osteochondral injuries / defect

▪ Damage to articular cartilage with or without bone involvement:  Usually traumatic in nature  Can be due to infection, chondrolysis  Unable to regenerate Osteochondral injuries / defect

▪ Management:  Debridement  Debridement with microfracture  Debridement with grafting:  Synthetic  Biological  Mosaicplasty Degenerative / Attrition damage PTTD Accessory navicular bone

Summary

▪ Usually a trial of non operative management is still recommended for most injuries ▪ Surgery has inherent s risks and complication which must be taken into consideration ▪ Operative management may be the primary option for certain conditions THANK YOU

Kanthan Email : [email protected] Tel : 016-3360791