CENTRO DI TRAUMATOLOGIA DELLO SPORT CENTRO DI TRAUMATOLOGIA DELLO SPORT CHIRURGIA ARTROSCOPICACHIRURGIA ARTROSCOPICA

UNITAUNITA OPERATIVA DI RIABILITAZIONE OPERATIVA DI RIABILITAZIONE SPORTIVASPORTIVA

IRCCS IRCCS GALEAZZI GALEAZZI -- MILANOMILANO

Responsabili: Responsabili: M. DENTI M. DENTI -- H.H. SCHSCHNHUBER NHUBER -- P. VOLPIP. VOLPI

Equipe: Equipe: C. BAIT C. BAIT F.BRAMBILLA F.BRAMBILLA M. GALLI M. GALLI -- R. POZZONIR. POZZONI

Responsabile:Responsabile:G. MELEGATIG. MELEGATI

Equipe: Equipe: M. BANDI M. BANDI C. TOMMASI C. TOMMASI -- D.TORNESED.TORNESE

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TREATMENT OPTIONS OF THE TREATMENT OPTIONS OF THE

OSTEOARTHRITIC ANKLE IN OSTEOARTHRITIC ANKLE IN

ATHLETSATHLETS

P. Volpi P. Volpi M. GalliM. Galli

INTRODUCTIONINTRODUCTION

AboutAbout 15% of the 15% of the worldworlds s adultadult

populationpopulation isis affectedaffected byby jointjoint

painpain and and disabilitydisability thatthat resultresult

fromfrom osteoarthritisosteoarthritis

ManyMany of of thesethese casescases involveinvolve

ankleankle osteoarthritisosteoarthritis

70% 70% postpost--traumatictraumatic osteoarthritisosteoarthritis

Primary Primary osteoarthritisosteoarthritis

Systemic arthritis (rheumatoid Systemic arthritis (rheumatoid arthritisarthritis and and otherother))

INTRODUCTIONINTRODUCTIONOSTEOARTHRITIC ANKLEOSTEOARTHRITIC ANKLE

MalleolarMalleolar fracturesfractures

TibialTibial plafond plafond fracturefracture

TalusTalus fracturefracture

Osteochondral Osteochondral damagesdamages of of the the talartalar domedome

LigamentLigament lesionslesions

ArthritisArthritis--predisposingpredisposing traumatictraumatic ankleankle injuriesinjuries are:are:

INTRODUCTIONINTRODUCTIONOSTEOARTHRITIC ANKLEOSTEOARTHRITIC ANKLE

LigamentLigament lesionslesions are the are the mostmostcommon common injuriesinjuries susteinedsusteined in in sportssports and and recreationalrecreational activitiesactivitiesand account and account forfor aboutabout 25% of the 25% of the injuriesinjuries thatthat occuroccur in in runningrunning and and jumpingjumping sportssports

The The incidenceincidence of degenerative of degenerative arthritisarthritis after after chronicchronic laterallateral ankleankleinstabilityinstability rangesranges fromfrom 13% 13% toto78% 78% ( ( HintermannHintermann B. B. -- After After arthroscopicarthroscopicfindingsfindings, 2002), 2002)

INTRODUCTIONINTRODUCTIONOSTEOARTHRITIC ANKLEOSTEOARTHRITIC ANKLE

LIGAMENT LESIONS OF THE LIGAMENT LESIONS OF THE ANKLEANKLE

NATURAL HISTORY

LIGAMENT LESIONLIGAMENT LESION

IMPINGEMENTIMPINGEMENT(BONY OR SOFT(BONY OR SOFT--TISSUE)TISSUE)

OSTEOCHONDRAL DEMAGEOSTEOCHONDRAL DEMAGE

RECURRENT SPRAINSRECURRENT SPRAINS

ANKLE INSTABILITYANKLE INSTABILITY

CHRONIC ANKLECHRONIC ANKLE

LIGAMENT LESIONS OF THE LIGAMENT LESIONS OF THE ANKLEANKLE

PrimaryPrimary suture (acute suture (acute ankleankle)) LigamentLigament retentionretention LigamentLigament reinsertionreinsertion

Autografts (Peroneal tendon, Autografts (Peroneal tendon, AchillesAchilles tendontendon)) AllograftsAllografts Artificial Artificial graftsgrafts

ANATOMIC TECHNIQUESANATOMIC TECHNIQUES

NON ANATOMIC TECHNIQUESNON ANATOMIC TECHNIQUES

LIGAMENT LESIONS OF THE LIGAMENT LESIONS OF THE ANKLEANKLE

In In chronicchronic ligamentligament lesionslesions

the location of the the location of the relatedrelated

osteochondralosteochondral defectsdefects isis

oftenoften in the in the medialmedial aspectaspect of of

the tibiathe tibia

83% in 83% in chronicchronic ligamentligamentlesionslesions _ Volpi_ Volpi

TagaTaga and and ShinoShino, 1993, 1993

ANKLE OSTEOARTHRITISANKLE OSTEOARTHRITIS

AnkleAnkle osteoarthritisosteoarthritis in in atheletesatheletes can show can show differentdifferent problemsproblems suchsuch asas::

ArticularArticular painpain

SwellingSwelling

Limited Limited rangerange of of motionmotion

LockingLocking

Deep pain on weight Deep pain on weight bearingbearing

StiffnessStiffness

ANKLE OSTEOARTHRITISANKLE OSTEOARTHRITIS

The The differentdifferent typestypes of of ankleankle osteoarthritisosteoarthritisin in athletesathletes are:are:

OsteochondralOsteochondral lesionslesions of the of the talustalus

AnteriorAnterior bonybony or or softsoft--tissuetissue impingementimpingement

PosteriorPosterior impingementimpingement syndromesyndrome

LooseLoose bodybody

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

ChronicChronic sprainssprains can can leadlead toto articulararticular surfacesurface

damagedamage

In these patients In these patients painpain during weight during weight bearingbearing isis

presentpresent

The pain is probably the result of edge The pain is probably the result of edge loadingloading byby

the tibia on the the tibia on the cartilagecartilage rimrim of the of the defectdefect and the and the

subchondralsubchondral bonebone

MRI MRI isis usedused forfor betterbetter definingdefining the the exactexact sizesize and and

location of the location of the lesionlesion and and isis thereforetherefore more more

valuablevaluable forfor preoperativepreoperative planningplanning

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

NONNON--OPERATIVE TREATMENTOPERATIVE TREATMENT

RestrictionRestriction of of sportingsporting activitiesactivities

In case of In case of givinggiving way cast way cast

immobilisation for at immobilisation for at leastleast 3 3

weeksweeks

The aim is to give the bruised The aim is to give the bruised

talus rest so talus rest so thatthat oedemaoedema can can

resolveresolve or or forfor partlypartly detacheddetached

fragmentfragment toto becomebecome rere--attachedattached

toto the the surroundingsurrounding bonebone

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

SURGICAL TREATMENTSURGICAL TREATMENT

After After debridementdebridement, , wewe

create multiple create multiple connectionsconnections

withwith the the subchondralsubchondral bonebone

byby micromicro--fracturesfractures

The The aimaim isis toto stimulatestimulate the the

formationformation of new of new bloodblood

vesselsvessels and so a and so a fibrinfibrin clotclot

ArthroscopyArthroscopy

BONE MARROW STIMULATIONBONE MARROW STIMULATION

ThisThis techniquetechnique isis reservedreserved forfor primaryprimary

osteochondralosteochondral defectsdefects wherewhere therethere isis anan almostalmost

intactintact cartilagecartilage

The The aimaim isis toto induce induce subchondralsubchondral bonebone

revascularisationrevascularisation

ArthroscopyArthroscopy

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

SURGICAL TREATMENTSURGICAL TREATMENT

RETROGRADE DRILLINGRETROGRADE DRILLING

AUTOLOGOUS CHONDROCYTE IMPLANTATIONAUTOLOGOUS CHONDROCYTE IMPLANTATION

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

SURGICAL TREATMENTSURGICAL TREATMENT

ACI ACI aimsaims toto regenerateregenerate tissuetissue withwith

hyalinehyaline--likelike cartilagecartilage

TwoTwo stepssteps

ArthrotomyArthrotomy isis preferredpreferred

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

SURGICAL TREATMENTSURGICAL TREATMENT

AllograftsAllografts or or autograftsautografts (OATS)(OATS)

The aim is to reproduce the The aim is to reproduce the mechanicalmechanical, ,

structuralstructural and and biomechanicalbiomechanical propertiesproperties

of the of the originaloriginal hyalinehyaline articulararticular cartilagecartilage

Open Open approachapproach or or arthroscopicarthroscopic procedureprocedure

OSTEOCHONDRAL TRANSPLANTATIONOSTEOCHONDRAL TRANSPLANTATION

OSTEOCHONDRAL LESIONS OSTEOCHONDRAL LESIONS OF THE TALUSOF THE TALUS

SURGICAL TREATMENTSURGICAL TREATMENT

LargeLarge fragmentfragment can can bebe fixedfixed byby

HerbertHerbert screwscrew, , KirschnerKirschner wirewire or or

absorbableabsorbable pin or pin or screwscrew

ArthroscopicArthroscopic or open or open techniquetechnique

FIXATIONFIXATION

ANTERIOR BONY ANTERIOR BONY IMPINGEMENTIMPINGEMENT

The The characteristiccharacteristic locationslocations are the are the

medialmedial aspectaspect of the of the talartalar neckneck and and

laterallateral toto midmid--lineline of of anterioranterior distaldistal

tibiatibia

The The aetiologyaetiology of of spurspur formationformation couldcould

bebe due due toto excessiveexcessive stretchingstretching of the of the

anterioranterior capsule, capsule, resultingresulting

microtrauma, microtrauma, scarscar tissuetissue and and thenthen

ossificationossification

ArthroscopicArthroscopic excisionexcision of of spursspurs

decreasedecrease painpain and and improveimprove the the ankleankles s

rangerange of of motionmotion

ANTERIOR SOFT TISSUE ANTERIOR SOFT TISSUE IMPINGEMENT IMPINGEMENT

ThisThis isis the the mostmost common common pathologypathology

after after recurrentrecurrent ankleankle inversioninversion

The anterolateral tissue, including The anterolateral tissue, including

the Anterior talofibular the Anterior talofibular ligamentligament

and capsule, can and capsule, can elongateelongate and and

hypertrophyhypertrophy creatingcreating chronicchronic painpain

ArthroscopicArthroscopic excisionexcision of of scarescare tissuetissue isis recommendedrecommended

IrritationIrritation or or fracturefracture of the of the osos trigonumtrigonum or or

enlargedenlarged talartalar tubercletubercle thatthat can can occuroccur fromfrom a a

hyperhyper--plantarplantar--flexionflexion injuryinjury and can and can leadlead toto

chronicchronic painpain whenwhen kickingkicking

InitialInitial conservative treatment conservative treatment withwith restrest and and

preventionprevention of of plantarplantar--flexionflexion withwith brace, brace, butbut ifif

symptomssymptoms continue a continue a surgicalsurgical treatment treatment byby open open

or or arthroscopicarthroscopic excisionexcision isis necessarynecessary

POSTERIOR IMPINGEMENT POSTERIOR IMPINGEMENT SYNDROMESYNDROME

BONY PATHOLOGYBONY PATHOLOGY

POSTERIOR IMPINGEMENT POSTERIOR IMPINGEMENT SYNDROMESYNDROME

SOFT TISSUE PATHOLOGYSOFT TISSUE PATHOLOGY

StenosingStenosing tenosynovitistenosynovitis of the of the flexorflexor hallucishallucis longuslongus

HypertrophyHypertrophy of the of the posteriorposterior capsulecapsule

Enlargement of the posterior Enlargement of the posterior interinter--malleolarmalleolar ligamentligament

TheseThese chronicchronic changeschanges in the in the posteriorposterior ankleankle in in athletesathletes

can can leadlead toto painpain thatthat mustmust bebe eliminatedeliminated byby surgicalsurgical

treatment treatment

LOOSE BODY LOOSE BODY

In In osteoarthriticosteoarthritic ankleankle isis oftenoften

possiblepossible toto findfind looseloose bodiesbodies

thatthat cause cause articulararticular painpain withwith

lockinglocking and and limitedlimited rangerange of of

motionmotion

ArthroscopicArthroscopic removalremoval isis

indicatedindicated

CONCLUSIONS CONCLUSIONS

ThereThere are are manymany typestypes of of osteoarthriticosteoarthritic ankleankle in in

athletesathletes thatthat sport sport traumatologisttraumatologist havehave toto knowknow

PreventionPrevention in in differentdifferent sportssports shouldshould thereforetherefore bebe

aimedaimed at at preventingpreventing ankleankle sprainssprains

SurgicalSurgical treatment of treatment of ankleankle instabilityinstability isis

recommendedrecommended

Arthroscopic surgery can resolve many of these Arthroscopic surgery can resolve many of these

chronic chronic problemsproblems and and alsoalso affordsaffords a a quickerquicker return return toto

play play ifif itits s possiblepossible

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TREATMENT OPTIONS OF THE OSTEOARTHRITIC ANKLE IN ATHLETSINTRODUCTION