ADVANCES IN THE MANAGEMENT OF ANKLE INJURIES IN ATHLETES

James D. F. Calder

ADVANCES IN THE MANAGEMENT OF ANKLE INJURIES IN ATHLETESISBN - 978-1-78808-570-0©James Calder – james.calder@fortiusclinic.com

Production by Kumar Amarnath, Exeter Premedia - www.exeterpremedia.comPrinting and production arranged by Emma Vodden, Head of Editorial Publishing Services, The British Editorial Society of Bone & Joint Surgery, 22 Buckingham Street, London, WC2N 6ET, UK

Cover photo: The best environment for original thought is away from laboratories and operating theatres(Camel Estuary, North Cornwall, UK)

Rear cover photo: Same athlete; similar injuries; wildly different sports (Siobhan Modukpe – professional ballet dancer and elite rugby player)

Advances in the Management of Ankle Injuries In Athletes

James D. F. Calder

Advances in the Management of Ankle Injuries in Athletes

ACADEMISCH PROEFSCHRIFT

Ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam

op gezag van de Rector Magnificus

prof. dr. ir. K.I.J. Maex

ten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Agnietenkapel

op woensdag 5 juli 2017, te 12.00 uur

door James David Forbes Calder

geboren te Norwich, Verenigd Koninkrijk

PROMOTIE COMMISSIE:

Promotor:

Prof. dr. C. N. van Dijk AMC-UvA

Copromotor:

Dr. ir. L Blankevoort AMC-UvA

Overige leden:

Prof. dr. R.L. Diercks Rijksuniversiteit Groningen

Prof. dr. G.M.M.J. Kerkhoffs AMC-UvA

Prof. dr. M. Maas AMC-UvA

Prof. dr. F. Nollet AMC-UvA

Dr. J.L. Tol AMC-UvA

Faculteit der Geneeskunde

For Toby, Alice and Joanna (the bravest girl I know)

TABLE OF CONTENTS

INTRODUCTION

Chapter 1. General introduction 3 Purpose and aims 10

Part I ANKLE INJURIES

Chapter 2. Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilisation and time to return to sports. 25

Calder J, Bamford R, Petrie A, McCollum G Arthroscopy. 2016 Apr;32(4):634–42.

Chapter 3. The broken ‘Ring of Fire’ – A new radiological sign as predictor of syndesmosis injury? 43

Calder J, Mitchell A, Lomax A, Ballal M, Grice J, van Dijk CN, Lee J. Orth J Sports Med. 2017 (March) 5(3); 2325967117695064

Chapter 4. Return to sport following lateral ligament repair of the ankle in professional athlete. 55

White J, Calder J, McCollum G Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1124–9.

Part II ANKLE ARTHROSCOPY AND TALAR OSTEOCHONDRAL LESIONS

Chapter 5. Histological Evaluation of Calcaneal Tuberosity Cartilage - A Proposed Donor Site for osteochondral Autologous Transplant for Talar Dome Osteochondral Lesions 71

Calder J, Ballal M, Deol R, Pearce C, Hamilton P, Lutz M Foot Ankle Surg. 2015 Sep;21(3):193–7.

Chapter 6. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. 85

Calder J, Sexton S, Pearce C Am J Sports Med. 2010 Jan;38(1):120–4.

Part III THE PLANTARIS TENDON AND ACHILLES TENDINOPATHY

Chapter 7. Plantaris injuries in elite UK track and field athletes over a 4-year period: a retrospective cohort study 99

Pollock N, Dijkstra P, Calder J, Chakraverty R Knee Surg Sports Traumatol Arthrosc. 2016 Jul; 24(7):2287–92.

Chapter 8. Plantaris excision reduces pain in mid-portion Achilles tendinopathy even in the absence of plantaris tendinosis. 113

Calder J, Stephen J, van Dijk CN Orth J Sports Med. 2016 Dec 13; 4(12):2325967116673978

Chapter 9. Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. 125

Calder J, Freeman R, Pollock N Br J Sp Med. 2015 Dec;49(23):1532–1534.

Part IV VENOUS THROMBO-EMBOLISM RISKS IN FOOT, ANKLE AND ACHILLES TENDON DISORDERS

Chapter 10. Meta-analysis and suggested guidelines for prevention of venous thrombo-embolism (VTE) in foot and ankle surgery 139

Calder J, Freeman R, Domeij-Arverud E, van Dijk CN, Ackermann P

Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4), 1409–1420.

GENERAL DISCUSSION AND SUMMARY

Chapter 11. General discussion, conclusions and future research 165 English Summary 178 De nederlandse samenvatting 186

ADDENDUM Acknowledgements 198 Curriculum vitae 200 PhD portfolio 202

INTRODUCTION

1GENERAL INTRODUCTION

PURPOSE AND AIMS

| Chapter 14

GENERAL INTRODUCTION

This thesis investigates the mechanisms, diagnosis and also presents novel manage-ment strategies for some of the commonest sport-related injuries of the ankle and the Achilles tendon. It is estimated that every day one in 10,000 1,2 people sustain an ankle injury and ankle sprains are responsible for 7–10% 3 of attendances at emer-gency departments. They account for 40% of all sport-related injuries, are more common in basketball, soccer, running and ballet 4–6 and in a systematic review they were the most common injury in 24 of 70 sports.7 The ankle is involved in up to 53% of basketball injuries, 29% of soccer injuries and accounts for 12% of total time lost from soccer.8,9 The majority of ankle injuries occur in those under 35 years of age and is most common in those aged 15–19 years where one is six high school sport-related injuries involve the ankle.10,11

Ankle and Achilles tendon injuries are a particular problem in the professional athlete where there is an overall incidence of 9.35/10,000 elite exposures,12 rising to 0.9 per 1000 hours in volleyball 13 and they are the commonest injury in professional rugby accounting for more than half the absence due to injury.14 Although mid-por-tion Achilles tendinopathy may affect up to 9% of recreational runners it may end the career of up to 5% of professional athletes.15 Ensuring early, accurate diagnosis followed by appropriate management is paramount when treating professional ath-letes. There is always pressure from the club management, the medical team and the athlete to provide an estimation of the expected time to return to sport following ankle and Achilles tendon injuries but all too frequently accurate information is not readily available in the literature.

This thesis has concentrated on the investigation of ankle and Achilles tendon problems in the professional athlete. The scientific advantages of treating elite ath-letes include access to early clinical and radiographic assessment of the acute injury and also the ability to ensure that a structured and carefully supervised rehabilitation programme is undertaken. This group of individuals therefore lends itself very well to clinical studies for the following reasons:

a. They usually have isolated injuries requiring prompt treatment that are less likely to be affected by co-morbid conditions

b. Loss to follow-up is unlikely c. A standardised rehabilitation programme can be prescribed.

It is hoped that the lessons learned from treating the elite athlete in this thesis may be used to influence management of recreational athletes and thus encourage a cost-effective treatment strategy for the general public.

There are certain injuries that are commonly encountered in the elite athlete in which there is controversy regarding their optimal management. This thesis explores four of these areas:

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Part 1. Ankle ligament injuries - injury to the ankle syndesmosis and the ankle lateral ligament complex.

Part 2. Treatment of associated ankle injuries - arthroscopic treatment for poste-rior ankle impingement and the potential for novel treatments of larger osteochondral lesions of the talus.

Part 3. Minimally invasive treatment for mid-portion Achilles tendinopathy.Part 4. The need for thromboprophylaxis following isolated foot and ankle

injury or surgery.

Part 1 – Ankle ligament injuriesInjury to the syndesmosis may occur in 1–18% of all ankle sprains and the incidence may be higher in certain sports such as ice-hockey, skiing and soccer.16–24 Wright et al 22

demonstrated that syndesmosis injuries take twice as long to return to sports when com-pared to isolated lateral ligament sprains while Gerber et al 25 showed that involvement of the syndesmosis was the most predictive factor of chronic ankle dysfunction at 6 months post-injury. They may be associated with prolonged pain and have an unpredictable time away from sport 16 and chronically unstable injuries may lead to osteoarthritis.26

These injuries are therefore a significant problem to the athlete and they are often sub-tle in their presentation with minimal swelling and inconsistent degrees of pain. A high degree of suspicion is therefore required for an athlete presenting with “high ankle pain” as they are subtle in their presentation with minimal swelling and inconsistent degrees of pain meaning that they frequently missed or under-treated. The history of mechanism of injury may raise the possibility of syndesmosis involvement. Although external rotation of the ankle with a pronated foot may cause disruption of the syndesmosis ligaments,27–29 other mechanisms such as forced dorsi-flexion or inversion of the ankle have also been described.16, 30–32 The clinical and radiologic severity of injury to the syndesmosis associ-ated with these different mechanisms of injury is not well understood.

Early recognition and accurate assessment of the degree of injury is critical in order to initiate appropriate treatment and avoid a delay in return to sport. However, the clinical and radiologic findings are variable making it difficult to determine whether the injury is stable and may be managed non-operatively or if there is dynamic insta-bility of the syndesmosis requiring stabilisation.24 Currently, the most frequently used classification system (West Point Classification) 25 recommends non-operative treat-ment for grade 1 (stable) injuries and operative fixation of grade 3 (unstable) injuries. Grade 2 injuries are frequently encountered in the professional athlete and although it is recognised that some of these may be unstable there are no evidence-based guidelines on how best to assess and manage them.

These injuries are therefore frustrating for both the treating medical team and the athlete. This thesis investigates three areas of controversy - the clinical and radiologic features suggestive of an unstable syndesmosis injury; assessment of the factors affecting the time of return to sports following injury; specific features on magnetic resonance imaging (MRI) that may raise immediate suspicion of a syndesmosis injury and differentiate this it from a “simple ankle sprain”. Chapter 1 investigates 64 con-secutive professional athletes with a grade 2 syndesmosis injury in an attempt to

| Chapter 16

highlight firstly the clinical and radiological features that may differentiate stable from unstable injuries and secondly provide an indication of the likely time of return to sports. Chapter 2 investigates whether there is a “pathognomonic” sign present on MRI to differentiate a syndesmosis injury from other ankle pathology and whether certain features are more suggestive of syndesmosis instability.

Supination-inversion trauma is the most common ankle injury and may result in isolated acute lateral ligament disruption. Many of these “sprains” may be suc-cessfully managed non-operatively with a period of immobilisation and functional rehabilitation. However, some may be associated with osteochondral lesions (OCLs) and others may develop long-term symptoms resulting from chronic instability.33–37 Lynch and Renstrom reported that 10–30% of patients may have chronic symptoms such as persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weak-ness and frequent giving-way.38 For a commercial team the extended absence of a key player following a severe ankle injury may result in defeat and an economic loss. There is a greater load on the ankle joint of a professional athlete when compared to the general population and elite level sports may be an unfavourable prognostic factor for the development of residual symptoms.39 Verhagen40 demonstrated that residual instability is a predictor of repeat injury and a meta-analysis by Pijnenburg41

suggested better results with operative treatment for ruptures of the lateral liga-ments. Although a recent Cochrane Review 42 showed fewer complications and good functional results with non-operative treatment they reported that surgery did lead to greater objective stability and a faster return to sports. Therefore, there has been a trend towards considering early operative repair of acute lateral ligament rupture although this still remains controversial. Chapter 3 investigates the results of surgical repair for acute injuries in the professional athlete to determine whether it provides a predictable and timely return to play.

Part 2 – Treatment of associated ankle injuriesOsteochondral lesions (OCLs) may be associated with up to 50% of lateral ligament sprains 43 and van Dijk et al identified OCLs in 20/30 ankles undergoing arthroscopy prior to lateral ligament reconstruction.44 For symptomatic OCLs debridement and bone marrow stimulation (BMS) techniques such as microfracture are widely used to stimulate the release of mesenchymal stem cells (MSCs) and growth factors.45–52 This results in the formation of fibrocartilagenous repair tissue.53,54 Ferkel et al 55 reported 72% good or excellent results from BMS in 50 patients at a mean follow-up of 71 months and a systematic review by Zengerink et al 56 reported success in 85% of patients from 18 studies meeting inclusion criteria. In the longest follow-up study to date Van Bergen et al recently reported 74% of their patients as good or excellent according to the Berndt and Harty scale at 141 months (101 to 242).57

However, OCLs >15mm have a poor outcome following BMS techniques. Chuckpaiwong et al described good/excellent results in 100% of 73 patients with OCLs <15mm but 31/32 patients had a poor outcome with lesions >15mm.48 Choi et al reported 80% poor results in 25 patients with OCLs >15mm.58 Replacement strategies may therefore be considered for larger lesions. Autologous chondrocyte

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implantation, first described in the knee, requires the harvesting of native healthy articular cartilage following which the chondrocytes are isolated and cultured for 11–21 days before being implanted into the OCL either under a periosteal layer sutured to the surrounding cartilage or imbedded in a matrix (MACI).59 In the system-atic review by Zengerink et al 45 the success rate of 76% was reported in 59 patients with ACI and a recent meta-analysis by Niemeyer et al 60 reported a clinical success rate of 89.9% in 213 patients. The major limitations of the technique are the high costs and the necessity of a 2-stage procedure for implantation of the chondrocytes.

Osteochondral autologous transplantation (OATS) involves harvesting one or more cylindrical osteochondral grafts, usually from the periphery of the ipsilateral femoral condyle, and transplanting them into the prepared OCL defect.61–64 The aim is to provide structural support with similar mechanical and biological properties as the native hyaline cartilage. Although most studies on OATS are retrospective and case series, successful clinical outcomes have been documented. Hangody et al and Georgiannos et al 65, 66 both reported 93% good/excellent outcome, Flynn et al 67 reported significant improvement in clinical and radiologic outcome in 85 consecu-tive patients and the systematic review by Zengerink et al 45 reported success in 87% of patients. Return to sport was reported in 91% of patients by Mithoefer et al 68and 90% of professional athletes and 87% of recreational athletes returned to pre-injury level of sports at a mean follow-up of 5.9 years in the recent study by Fraser et al.69 Despite these encouraging results the histological features of the knee cartilage are different from the talus and there is concern about donor site morbidity with knee pain reported in 2% to 36% of cases.45, 69–71 This latter aspect is particularly worrying in the athlete and has led to the investigation of alternative donor sites such as the proximal tibio-fibular joint or even non-articular cartilage covered osteo-periosteal cylinders from the medial tibia or iliac crest.72–75

Histological studies have reported fibrocartilage covering the tuberosity on the anterior wall of the retrocalcaneal bursa 76,77 and some have identified hyaline-like car-tilage.78,79 It is therefore possible that this site could be an alternative local donor site for OATS and less liable to give iatrogenic symptoms. This has not previously been investigated – a histological study is conducted in Chapter 4 comparing the cartilage covering the posterior superior calcaneal tuberosity with that of the talus to see if it could be a suitable harvest site for OATS.

Posterior ankle impingement syndrome (PAIS) is another potential consequence of an ankle sprain or repetitive ankle plantar flexion during ballet and sports such as soccer, basketball and running.80–87 Pain may be due to bone impingement from an os trigo-num or prominent posterior trigonal process of the talus (Steida process).88–89 Soft tis-sue impingement may occur from thickening of the posterior intermalleolar ligament, oedema of the posterior capsular structures or pathology of the flexor hallucis longus (FHL) tendon.90–91 Image-guided injections may confirm the diagnosis and are poten-tially therapeutic.88 Traditional open surgical treatment for PAIS using either a medial or lateral approach has 75% good/excellent results reported in the literature.82 Van Dijk et al originally described the 2-portal posterior endoscopic approach for the treatment of PAIS

92 with an improvement in clinical outcome and reduced complications subsequently being reported over open surgery using this technique.87,93–95

| Chapter 18

Providing an accurate assessment of the expected return to sports is an import-ant aspect of management of professional soccer players with PAIS as is being able to predict the effectiveness of an image-guided injection to provide temporary improvement until the end of the season when there may be time for rehabilitation. This information is not known as the current literature reports on various athletes who are mostly recreational. Chapter 5 investigates 28 professional soccer players undergoing posterior ankle arthroscopy for PAIS and reports on the clinical results of surgery, the effect of whether the primary pathology was bony or soft tissue, the expected return to sport and the effect of previous image-guided injections and whether this effected the result of surgery.

Part 3 – Minimally invasive treatment for non-insertional Achilles tendinosisMid-portion Achilles tendinopathy is frequently encountered in recreational runners and professional athletes. The mainstay of treatment is non-operative with activity modification, correction of any underlying biomechanical disturbance 96,97 and chang-ing the elastic loading of the tendon with an eccentric exercises programme.98–101 Achilles tendinosis may be career-ending in up to 5% of professional athletes 102 and in an eight year follow-up study conservative measures failed in 29% of individuals.103 However, surgery does not guarantee return to sports with reported success rates for open procedures of between 75 and 100%.104–108 Complications from open surgery are not uncommon with Paavola et al reporting an overall complication rate of 11% and re-operation rate of 3% in a consecutive series of 432 patients.108 Minimally inva-sive techniques may reduce the risks associated with open surgery and stripping the paratenon from the ventral aspect of the Achilles tendon is thought to remove the neovascularisation and denervate the tendinopathic area. Endoscopic descriptions of this technique have shown promising results in small numbers of patients.109–111

Steenstra and van Dijk were the first to suggest involvement of the plantaris ten-don in medially located mid-portion Achilles pain.111 The plantaris originates from the posterolateral femoral condyle, descends between the gastrocnemius and soleus muscles and then lies along the medial border of the Achilles tendon. It is frequently described as a vestigial structure absent in 8–20% of individuals112–115 but more recent studies suggest it is present in 98–100% of specimens116,117 with a variable insertion into the calcaneus or the Achilles tendon.117–119

It has been postulated that the plantaris may contribute to the development of mid-portion Achilles tendinopathy. Lintz et al demonstrated increased stiffness in the plantaris compared to the Achilles tendon.120 Constant compression and/or sheering between the tri-articulate plantaris and the bi-articulate Achilles tendons is thought to provoke a localised inflammatory response leading to adherence to, or invagination into, the highly innervated peritendinous tissue.121–126 This painful frictional syndrome may result in inflammatory change around the Achilles tendon and potentially intratendinous pathology.122 It has been postulated by Sterkenburg and van Dijk that this area of inflammatory changes surrounding the midportion Achilles tendinopathy results from a neurogenic inflammation induced by the rela-

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tive avascular Achilles tendon.124 The plantaris tendon is incorporated in this inflamed peritendinous tissue which contains abundant neovascularisation and neo innerva-tion. The different dynamics between Achilles tendon and plantaris tendon result in a continuous irritation and pain from friction to this inflamed peritendinous tissue. The authors attribute the good results of stripping of the plantaris tendon and the anterior side of the Achilles tendon to the denervation of this area.124

It has recently been reported as a significant problem in professional athletes where the annual incidence of injury related to the plantaris tendon was 3.9–9.3% affecting 22% of all sprinters and 18% of endurance runners.123 Interestingly it affected the right side nearly four times as frequently in bend sprinters, supporting a biomechanical component to its development.127

Image guided high volume injections within the paratenon to strip the neovas-cularisation from the Achilles and break down adhesions aiming to separate the plantaris from the Achilles have been described with variable success.128–130 A small number of case series on the surgical sectioning of the plantaris and stripping of the ventral neovascularisation from the Achilles have been reported with promising results.121,131,132 Very little is known about the incidence of plantaris-related disorders in the elite athletic population or its effect on training. There are currently no studies published on the results of plantaris surgery in the professional athlete. The patho-physiology underlying plantaris-related Achilles tendon pain is poorly understood and only one paper has reported histological changes in the plantaris consistent with tendinosis.133 These three issues are addressed in chapters 6 to 8.

Chapter 6 investigates a cohort of elite track and field athletes under the supervi-sion of the British Athletic Medical Team. Over a four-year period, any occurrence of a plantaris-related injury was recorded with its treatment and ultimate outcome docu-mented. This sets a bench-mark for those medical teams looking after athletes. Chap-ter 7 explores the clinical results of plantaris excision using a mini-incision approach in a prospective series of 32 professional athletes who failed conservative treatment. The time of return to sports and the factors affecting ultimate outcome are presented and discussed.

Chapter 8 determines whether excised plantaris tendons from patients with mid-portion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes

Part 4 – The need for chemo-prophylaxis following isolated foot and ankle surgery or injury.Venous thrombo-embolism (VTE) is a significant risk following orthopaedic lower limb surgery or injury. The risk of VTE following hip or knee arthroplasty without prophylaxis is between 40% and 60% and the routine use of mechanical and chem-ical thrombo-prophylaxis reduces this risk.134–136 There is consensus for the use of such prophylaxis following elective hip and knee surgery with the implementation of guidelines such as those recommended by the National Institute of Clinical Evi-dence (NICE) and the American College of Chest Physicians (ACCP).137,138 However, the incidence of VTE following isolated foot and ankle procedures or Achilles ten-

| Chapter 110

don surgery has been studied less than in other areas of orthopaedics. Some studies suggest that the risk of VTE is 0.22–4%,139–141 others report no reduction in risk of VTE using chemoprophylaxis such as aspirin142 or low molecular weight heparin in these patients143–145 but recognise there is a small risk of complications such as bleed-ing, wound problems and heparin-induced thrombocytopaeinia.146–150 Therefore the need for routine chemoprophylaxis in patients undergoing isolated foot and ankle or Achilles tendon surgery (even those requiring cast immobilisation)137,138,151 remains controversial.152–154 This is especially important in the athletic population where the development of VTE and the subsequent need for anticoagulation may significantly affect their ability to return to sport.

The meta-analysis in chapter 9 investigates the incidence of VTE in patients with foot and ankle conditions, identifies the risk-factors that are important when con-sidering thromboprophylaxis and suggests guidelines to optimise the protection of such patients.

PURPOSE AND AIMS

The purpose of this PhD thesis is to investigate the mechanisms, diagnosis and also to present novel management strategies for some of the commonest sport-related inju-ries to the ankle and the Achilles tendon. It focusses on professional athletes in whom it is crucial to make an early and accurate diagnosis to ensure optimal treatment.

The overall aim of the thesis is to raise awareness of, and give some clarity to, injuries in which management is controversial. It also aims to provide an estimation of their expected time of return to sport – information that is lacking in the current literature. Part I investigates ankle ligament injuries that are highly prevalent in many different sports. Part 2 describes novel treatments for some of the consequences of those ankle ligament injuries and Part 3 the results from a minimally invasive proce-dure in professional sports for the treatment of Achilles tendinopathy. Part 4 presents the findings of when and how we should protect our athletes from VTE following injury or surgery to the ankle and Achilles tendon.

It is hoped that by identifying the optimal management strategy for these inju-ries in the controlled environment of elite athletes this knowledge may enhance the treatment for injuries sustained by those of us mere mortals who call ourselves a “recreational athlete”!

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51. Murawski CD, Foo LF, Kennedy JG (2010) A review of arthroscopic bone marrow stimulation techniques of the talus: the good, the bad, and the causes for concern. Cartilage 22:137–144.

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112. Freeman AJ, Jacobson NA, Fogg QA (2008) Anatomical variations of the plantaris muscle and a potential role in patellofemoral pain syndrome. Clin Anat 21:178–181

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part IANKLE INJURIES

2STABLE VERSUS UNSTABLE GRADE II HIGH

ANKLE SPRAINS: A PROSPECTIVE STUDY PREDICTING THE NEED FOR SURGICAL

STABILISATION AND TIME TO RETURN TO SPORTS

James D. F. Calder, Richard Bamford, Aviva Petrie, Graham McCollum

Journal of Arthroscopy 2016 Apr; 32(4):634-42

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ABSTRACT

Purpose: To investigate grade II syndesmosis injuries in athletes and identify factors important in differentiating stable from dynamically unstable ankle sprains and those associated with a longer time to return to sports.

Methods: Sixty-four athletes with an isolated syndesmosis injury (without fracture) were prospectively assessed, with a mean follow-up period of 37 months (range, 24 to 66 months). Those with an associated deltoid ligament injury or osteochondral lesion were included. Those whose injuries were considered stable (grade IIa) were treated conservatively with a boot and rehabilitation. Those whose injuries were clin-ically unstable underwent arthroscopy, and if instability was confirmed (grade IIb), the syndesmosis was stabilized. Clinical and magnetic resonance imaging assess-ments of injury to individual ligaments were recorded, along with time to return to play. A power analysis estimated that each group would need 28 patients.

Results: All athletes returned to the same level of professional sport. The 28 patients with grade IIa injuries returned at a mean of 45 days (range, 23 to 63 days) compared with 64 days (range, 27 to 104 days) for those with grade IIb injuries (p<0.0001). There was a highly significant relationship between clinical and magnetic resonance imaging assessments of ligament injury (anterior tibiofibular ligament [ATFL], ante-rior-inferior tibiofibular ligament [AITFL] and deltoid ligament, p<0.0001). Instability was 9.5 times as likely with a positive squeeze test and 11 times as likely with a del-toid injury. Combined injury to the anterior-inferior tibiofibular ligament and deltoid ligament was associated with a delay in return to sports. Concomitant injury to the ATFL indicated a different mechanism of injury to the syndesmosis is less likely to be unstable and is associated with an earlier return to sports.

Conclusions: A positive squeeze test and injury to the AITFL and deltoid ligament are important factors in differentiating stable from dynamically unstable grade II inju-ries and may be used to identify which athletes may benefit from early arthroscopic assessment and stabilization. They may also be important in predicting the time frame for athletes expected return to play.

Level of evidence II

Stable versus unstable grade II high ankle sprains | 27

2

INTRODUCTION

Syndesmosis injuries of the ankle are less common that acute lateral ligament inju-ries, but they are often difficult to diagnose accurately and are associated with a less predictable outcome and a prolonged recovery.1–3 Classifications such as the West Point Ankle Grading System have attempted to categorize the degree of injury and use this to recommend management.1 Grade I injuries with a sprain to the anterior- inferior tibiofibular ligament (AITFL) are stable and may be managed conservatively with a period of immobilization, reduced weight bearing, and gradual rehabilitation, whereas grade III injuries with complete disruption of the syndesmosis and dias-tasis require operative stabilization. Controversy in management arises in grade II injuries when there is a severe ligamentous injury (including rupture of the AITFL and injury to the intraosseous ligament [IOL]) without discernible diastasis but only subtle instability of the distal tibiofibular joint, which may be difficult to reproduce accurately even with stress testing under anaesthesia.4,5 This dynamic instability in professional athletes may require stabilization to prevent late adverse sequelae such as the recurrence of “high ankle pain,” anterolateral ankle soft-tissue impingement from an inflamed AITFL, and local synovitis or even the development of a chronically unstable distal syndesmosis.2,6–12

Because syndesmosis injuries may occur in 1% to 18% of all ankle sprains, this diagnostic problem is frequently encountered in the elite athlete, for whom there is the additional pressure for an early return to play and an accurate prediction of time lost through injury.2,6–8,10,12,13 Although there are a number of tests for syndesmotic injury, with extension of tenderness above the ankle and a positive squeeze test both correlating with a prolonged time to return to sports, it is unknown which combina-tion of clinical and radiologic tests predicts the severity of injury or identifies which athletes with a grade II syndesmosis injury may have dynamic instability requiring stabilization.14–20 Arthroscopy has proved to be more accurate than radiologic detec-tion of syndesmotic injury and may be used to assess the degree of diastasis, whereby greater than 2 mm is suggestive of dynamic instability.10,11,21–23

At present, there is no classification system that allows a clear definition of the degree of injury, guidance of treatment, or prediction of outcome. The purpose of this study was to investigate grade II syndesmosis injuries in athletes and identify fac-tors important in differentiating stable from dynamically unstable ankle sprains and those associated with a longer time to return to sports. The null hypothesis was that clinical and radiologic factors would be unable to predict the stability or the expected time to return to play in grade II syndesmosis injuries.

METHODS

Consecutive professional athletes with a significant soft-tissue ankle syndesmosis injury presenting to a tertiary referral sports orthopaedic clinic between January 2008 and December 2012 were examined, and data were collected prospectively. Local

| Chapter 228

ethical board approval was obtained for the study. All patients were initially assessed by the club medical team and then independently by J.D.C. and R.B. between 5 and 10 days after the injury. Only patients with significant symptoms of high ankle pain compatible with a grade II injury, clinical signs of a syndesmosis injury, and magnetic resonance imaging (MRI) evidence of complete rupture of the AITFL were included.1 Patients with an acute fracture of the ankle or Weber type C fracture of the fibula were excluded. The MRI scans were independently reported for the purpose of this study, and the reporting radiologist was blinded to the ultimate diagnosis when identifying the ligament. The type of sport, mechanism of injury, and clini-cal examination findings were recorded. All patients underwent an MRI scan and weight-bearing plain radiographs of the ankle at 5 to 10 days after injury. Athletes with clinical signs of potential instability of the syndesmosis were offered surgery (Fig 1). The clinical examination was standardized, and the findings were recorded on a sheet specifically designed for this study to ensure complete data collection (Fig 2). The examination consisted of palpation over individual ligaments and spe-cialist tests such as ankle external rotation and syndesmosis squeeze tests.

Fig. 1. Selection algorithm to decide on conservative management or arthroscopic assessment. (EUA, examination under anesthesia; MRI, magnetic resonance imaging; Mx, management; +ve, positive.)

MRI con�rmation of syndesmosis injury

Grade I or III injury

Excluded Yes No

+ve external rotation with +ve squeeze test••••

Ankle fracture or weber C �bula fracture ?

Grade II injury

West point classi�cation

Any of the following at 5-10 days post-injury:

Tenderness along anterior interosseousmembrane >6 cm proximal to ankle

Suspicion of widened syndesmosis on X-ray

NoStable grade IIa injury

Conservative Mx

YesUnstable grade IIb injury

EUA, arthroscopy +/–surgical �xation

Deltoid ligament injury on MRI

Stable versus unstable grade II high ankle sprains | 29

2

Patients with a clinically stable syndesmosis (grade IIa) were treated non-oper-atively and underwent placement of an Aircast XP Walker boot (DJO Global, San Diego, CA) while not bearing weight for 10 days, after which they were allowed to bear weight as long as pain free. The medical team was advised to leave the boot on for a minimum of 3 weeks and then to mobilize the ankle free of the boot as long as the ankle was pain free. Taping of the ankle syndesmosis was encouraged for a minimum of a further 6 weeks during the rehabilitation phase.

Patients with signs of an unstable syndesmosis (grade IIb) underwent examina-tion under anaesthesia and arthroscopic assessment of the ankle within 48 hours of this diagnosis. The indications for surgery included a positive squeeze test with a positive external rotation test, tenderness on palpation over the anterior interosseous membrane more than 6 cm proximal to the ankle joint, and injury to the medial del-toid or posterior-inferior tibiofibular ligament (PITFL) on MRI. Direct visualization of the syndesmosis allowed confirmation of rupture to the AITFL and assessment of the syndesmosis opening during external rotation stress testing. A 4.5-mm arthroscopic shaver (Smith & Nephew, Andover, MA) was used to debride the AITFL remnant and to probe the syndesmosis. The injury was deemed unstable if the 4.5-mm shaver blade could be passed into the distal syndesmosis or if the syndesmosis opened up more than 3mm on stress testing under direct vision using a 3-mm arthroscopy probe

Fig. 2 Sheet for recording of clinical and magnetic resonance imaging (MRI) details. (AITFL, anterior-inferior tibiofibular ligament; ATFL, anterior talofibular ligament; D.O.B., date of birth; IOL, intraosseous ligament; OCL, osteochondral lesion; o/e, on examination; PITFL, posterior-inferior tibiofibular ligament; +ve/-ve, positive/negative.)

Date

Name

D.O.B.

Date of Injury

Ligament injury and exam findings

Clinical findings(tenderness yes/no)

MRI findings(ligament injury yes/no)

Deltoid

AITFL

ATFL

PITFL

IOL (o/e length of tenderness above ankle joint in cms)

Associated Injury (e.g. OCL)

External Rotation Test +ve/-ve

Squeeze Test +ve/-ve

Arthroscopy (yes/no)

Date return to sport (team selection)

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(Smith & Nephew). Such cases were stabilized with a Tightrope device (Arthrex, Naples, FL); the stability was rechecked under direct vision with an arthroscope and the shaver blade, and the medial joint space was inspected to ensure that there was no infolding of the medial deltoid ligament, which could prevent accurate reduction of the ankle syndesmosis. The patients were mobilized in a boot for 4 weeks while non-weight bearing for 1 week, partially weight bearing for 1 week, and then fully weight bearing if pain free. Ankle exercises to regain range of motion were encour-aged from 10 days post- operatively; pool exercises and proprioceptive exercises were commenced from 3 weeks and impact activities from 5 weeks postoperatively.

Concomitant osteochondral lesions were treated arthroscopically. The time taken to return to full sporting activities was recorded along with any need for image-guided injections or residual symptoms. All patients were followed up for a mini-mum of 24 months after injury.

Statistical advice was sought from the Biostatistics Unit, University College London Eastman Dental Institute, London, England. A power analysis estimated that approxi-mately 28 patients would be needed in each group to detect - using a 2-sample t-test, with a significance level of 0.01 and a power of 90% - a difference of 15 days in time to return to sports, assuming an SD of 14 days in each group. However, because it was uncertain how many patients would be recruited prospectively, it was decided to stop recruitment when the smaller group had 28 patients. The 2-sample t test was performed on the time to return to sports. We performed logistic regression to assess the relation between clinical and MRI assessments of individual ligaments using Stata statistical soft-ware (release 13; StataCorp, College Station, TX), recognizing the paired nature of the measurements. A significance level of P<0.01 was used to avoid spuriously significant results from multiple testing. Logistic regression was performed to determine the odds ratio for independent predictors of the clinical and MRI factors associated with a longer time to return to sports and the need for surgery. Only those variables significant at the 5% level were included as covariates in the logistic regression. The Mann-Whitney U test was used for non-normally distributed data comparing the length of time immobilized and need for subsequent injection and the effect of chondral injury on time to return to sports. The data were analysed using SPSS software (IBM SPSS Statistics for Windows, version 22.0; IBM, Armonk, NY).

RESULTS

Sixty-four consecutive professional athletes with grade II syndesmosis injuries were assessed between 5 and 10 days after injury. These injuries were sustained during rugby in 32 patients, soccer in 25, cricket in 2, hockey in 2, netball in 2, and Amer-ican football in 1. Of the 64 injuries, 26 were assessed to be stable (grade IIa) and were treated conservatively with immobilization. In contrast, 38 of 64 injuries were deemed potentially unstable (grade IIb) and underwent arthroscopic assessment under general anaesthesia; the injuries in 2 of these patients were found to be stable at arthroscopy and were subsequently treated conservatively, leaving 36 patients requiring stabilization of the syndesmosis.

Stable versus unstable grade II high ankle sprains | 31

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Prediction of Ligament Injury and Dynamic InstabilityThe presence or absence of tenderness on palpation over the anterior tibiofibular ligament (ATFL), AITFL, and deltoid ligament showed a highly significant relation between clinical and MRI findings of ligament injury (P<0.0001) (Table 1). The pres-ence of a combined injury to the AITFL and deltoid ligament was highly predictive of a grade IIb injury; conversely, injury to the ATFL meant that the syndesmosis was less likely to be unstable (Table 2). Logistic regression of those factors significant in the χ2 tests was used to determine the independent predictors of instability and showed that a positive squeeze test was associated with an increase in severity of injury, with the odds ratio of requiring surgery being 9.5 times greater if the squeeze test was positive.

Table 1. Relationship Between Clinical Assessment and MRI Findings of Individual Ligament Injury Using Logistic Regression Analysis.

P Value OR (95% CI) Sensitivity Specificity Positive Predictive Value

Negative Predictive Value

Clinical and MRI assessment of ligaments

PITFL .03 3.4 (1.1-10.6)

48.2% 78.8% 65.0% 65.0%

Deltoid ligament

< .001 25.0 (6.4-97.2)

83.3% 83.3% 83.3% 83.3%

ATFL < .001 96.0 (11.8-782.4)

80.0% 96.0% 80.0% 96.0%

External rotation test and MRI assessment of ligament injury

PITFL – -1.00 100% 0.0% 56.3% –

Deltoid ligament

.02 7.0 (1.4-35.5)

93.3% 33.3% 58.3% 83.3%

ATFL – 1 0.0% 100.0% – 79.2%

IOL .006 20.1 (2.4-168.9)

96.9% 39.3% 64.6% 91.7%

Squeeze test and MRI assessment of ligament injury

PITFL .002 6.8 (2.1-22.4)

81.5% 60.6% 62.9% 80.0%

Deltoid ligament

< .001 10.0  (2.9-34.0)

83.3% 66.7% 71.4% 80.0%

ATFL – 1 0.0% 100.0% – 79.2%

IOL .006 20.1 (2.4-168.94)

96.9% 39.3% 64.6% 91.7%

ATFL, anterior talofibular ligament; CI, confidence interval; IOL, intraosseous ligament; MRI, magnetic resonance imaging; OR, odds ratio; PITFL, posterior-inferior tibiofibular ligament.

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Time to Return to SportsThe mean time to return to sports was 45 days (range, 23 to 63 days) for patients with grade IIa injuries compared with 65 days (range, 27 to 104 days) for those with grade IIb injuries (P<0.0001) (Fig. 3). Patients with injury to both the AITFL and del-toid ligament took longer to return to sports than those with an AITFL injury alone, and IOL injury on MRI and PITFL injury on MRI were both independently associated with a delay in return to sports (Table 3). Conversely injury to the ATFL was associ-ated with an earlier return to sports (P=0.037), with multiple regression of those fac-tors significant in the χ2 tests showing a return 13 days earlier for patients with ATFL injuries (P=0.006) (Table 4).

Delay in return to sports was also associated with a positive squeeze test (64 days vs 43 days, P<0.0001) and a positive external rotation test (61 days vs 43 days, P=0.001). Although both tests had comparable sensitivity in predicting instability (79% and 76%, respectively), the specificity of the squeeze test was 71%, with a pos-itive predictive value of 79% and negative predictive value of 68%, whereas for the external rotation test, the specificity was only 29%, with a positive predictive value of 61% and a negative predictive value of 50%.

There was a significantly longer time to return to sports on average in patients with injuries that required treatment with a concomitant chondral surgical procedure (P=0.002). The time to return to sports was also associated with the length of time

Table 2. Determination of Independent Variables Likely to Predict Surgery Using Univariate and Multivariate Logistic Regression.

Assessment of Ligament Injury-Univariate Logistic Regression: P Value Multivariate Logistic Regression

Clinical MRI

Clinical MRI OR (95% CI) P Value OR (95% CI) P Value

Individual ligament injury combined with AITFL and need for surgery

Deltoid ligament

< .001 < .001 1.98 (0.29-13.43)

.485 11.04 (1.56-78.37)

.016

ATFL .081 .081

PITFL .008 .002 0.82 (0.11-5.89)

.840 0.59 (0.09-4.00)

.592

Clinical tests and need for surgery

External rotation

.012 1.53 (0.18-13.08)

.700

Squeeze test

< .001 9.47 (1.69-53.00)

.011

AITFL, anterior-inferior tibiofibular ligament; ATFL, anterior talofibular ligament; CI confidence interval; MRI, magnetic resonance imaging; OR, odds ratio; PITFL, posterior-inferior tibiofibular ligament.

Stable versus unstable grade II high ankle sprains | 33

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Table 3. Univariate Analyses of Time to RTS by Ligament Injury and Specialist Tests.

Ligament Injury/Test Mean Time to RTS (SD), days

Difference in Mean Time to RTS (95% CI), days

P Value From 2-Sample t Test

No Injury Injury

ATFL on clinical assessment

58.2 (20.0) (n = 54)

43.7 (18.0) (n = 10)

-14.5 (-28.1 to 0.9)* .04

IOL on MRI assessment

45.8 (12.6) (n = 30)

64.9 (21.7) (n = 34)

19.1 (10.0 to 28.1) <.001

PITFL on clinical assessment

49.7 (18.6) (n = 43)

68.6 (17.9) (n = 21)

18.9 (9.1 to 28.7) <.001

Deltoid ligament on MRI assessment

45.2 (12.0) (n = 32)

66.7 (21.3) (n = 32)

21.5 (12.9 to 30.2) <.001

External rotation test 42.5 (9.1) (n = 13)

59.4 (21.0) (n = 51)

16.9 (4.9 to 28.8) <.001

Clinical squeeze test 44.1 (10.6) (n = 28)

65.1 (21.3) (n = 36)

21.1 (12.3 to 29.9) <.001

ATFL, anterior talofibular ligament; CI, confidence interval; IOL, intraosseous ligament; MRI, magnetic resonance imaging; PITFL, posterior-inferior tibiofibular ligament; RTS, return to sports; SD, standard deviation.

*A negative value for the ATFL variable indicates a shorter time to RTS.

120

100

80

60

RTS

40

20

No surgery SurgeryGroup

Fig. 3 Box-and-whisker plot of time to return to sports (RTS). The mean time to return to sports was 44.36 days in the non-surgically treated group versus 64.92 days in the surgically treated group, with a difference in mean values of 20.56 days (95% confidence interval, 12.29 to 28.83 days; P<0.001).

immobilized for every additional day of immobilization, the time to return to sports increased by 0.86 days on average. An ultrasound-guided injection was administered for anterolateral ankle impingement in 11 patients (3 in surgically treated group and 8 in non-surgically treated group) at a mean of 56 days (range, 36 to 71 days) after

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injury. Ultrasound confirmed soft-tissue synovitis surrounding the injured AITFL. No athlete required more than 1 injection, and no patient had subsequent impinge-ment symptoms at final follow-up. Early removal of the boot did not increase the likelihood of requiring an injection when this was assessed with the Mann-Whitney U test (P=0.205). A superficial wound infection overlying the lateral suture button developed in 2 patients, and this was resolved with a course of oral antibiotics. Three patients underwent removal of the suture button at 5, 8, and 14 months postopera-tively because of lateral skin irritation.

DISCUSSION

The most important finding of this study was that most patients with AITFL and deltoid ligament tenderness together with positive squeeze and external rotation tests were found to have an unstable syndesmosis at arthroscopy. Patients with concomitant injury to the ATFL are more likely to have a stable syndesmosis and should expect a quicker return to sports. Syndesmosis injuries are challenging to treat because they are often subtle in their presentation and because misdiagnosis, leading to poor management, may result in unacceptable disability to the athlete. The unpredictable nature of the recovery is frustrating to the injured athlete when predicting the return to play. Previous categorization into grade I injuries with a par-tial tear to the AITFL and a stable syndesmosis that will resolve with conservative management and grade III injuries with complete disruption of the syndesmosis requiring operative stabilization appears clear-cut.1 However, the intermediate grade

Table 4. Multivariate Linear Regression Analysis Results With Time to Return to Sports (in Days) as Dependent Variable.

Explanatory Variable Regression Coefficient 95% CI for Regression Coefficient

P Value

Immobilization time 0.86* 0.43 to 1.30 < .001

PITFL on clinical assessment

3.49 -4.41 to 11.39 .38

ATFL on clinical assessment

-13.35† -22.80 to -3.89 .006

Clinical squeeze test 9.44 1.45 to 17.44 .02

PITFL on MRI assessment

14.75 7.55 to 21.94 < .001

ATFL, anterior talofibular ligament; CI, confidence interval; MR1, magnetic resonance imaging; PITFL, posterior-inferior tibiofibular ligament.

*Immobilization by 1 additional day leads to a 0.86-day longer return to sports on average, after adjustment for the other variables in the equation.†A negative value for the ATFL variable indicates a shorter time to return to sports.

Stable versus unstable grade II high ankle sprains | 35

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II injuries have been poorly defined in any of the classifications available because they are more of a spectrum of tears with dynamic instability that is difficult to deter-mine.1,9,22 Successful treatment relies on maintaining the anatomic restoration of the syndesmosis throughout the duration of treatment until healing is complete. It is known that some grade II injuries may be dynamically unstable, and in the elite ath-lete, it may advisable to hold the reduction with a surgical fixation during rehabilita-tion while the ligaments heal to avoid later complications such as impingement from a chronically inflamed AITFL or chronic syndesmosis instability.2,21,22,24 Identifying which athletes may benefit from early stabilization or are at risk of the development of later symptoms from a subtle syndesmosis instability currently relies on an individ-ual interpretation of the severity of the injury through a combination of meticulous history taking, clinical examination findings, imaging, and personal assessment of the level of activity and expectations of the athlete.9,14,19,25

Arthroscopy certainly appears to be the gold-standard method to assess dynamic syndesmosis instability and has proved to be more accurate than radiologic detection of syndesmotic injury.10,22,23,26-28 Early arthroscopic assessment (with or without sta-bilization) has therefore been advocated in elite athletes with a severe syndesmosis injury when dynamic instability is suspected to avoid later symptoms and a delayed return to play.9,26-28 Greater than 2 mm of diastasis is suggestive of instability, but we chose 3 mm as the cut-off for differentiating a stable syndesmosis from a dynami-cally unstable syndesmosis because this may be clearly shown with an arthroscopic shaver or standard arthroscopic probe without having to use a specialist measuring device. We therefore believe that this is a practical and reproducible value to use.

This article has focused on identifying which clinical and MRI findings are most useful for differentiating a stable (grade IIa) from a dynamically unstable (grade IIb) injury. It has also attempted to estimate the expected time of return to sports and identify those clinical and MRI findings that consistently lead to a longer recovery crucial information for the athlete and the team.

Patients deemed to have a stable injury (isolated AITFL rupture, even with a pos-itive external rotation test) were treated conservatively, and all returned to sports at a mean time of 45 days. Tenderness over individual ligaments during clinical exam-ination 5 to 10 days after the initial injury correlated well with MRI confirmation of injury to these ligaments, and possibly more importantly, lack of tenderness was associated with normal MRI findings. This has previously been reported only in ATFL injuries during ankle sprains, and no previous authors have described this for other ligaments.29 We believe this is an important observation for medical teams assessing potential syndesmosis injuries, and we hope this may reduce unnecessary MRI scans while lowering the risk of underdiagnosing a potentially significant injury. Con-versely, a concomitant injury to the medial deltoid ligament, IOL, or PITFL was highly suggestive of a more severe injury with instability of the syndesmosis and in addition to a positive external rotation test, these athletes frequently had a positive squeeze test. Therefore, clinical evaluation of the integrity of the ligaments also appears effec-tive in determining which athletes may have a significant risk of dynamic instability. In addition, this study showed that a positive external rotation test is frequently found

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in a grade IIa injury whereas the most predictive combination suggestive of instabil-ity is a positive squeeze test and concomitant injury to the medial deltoid ligament.

Interestingly, the presence of an ATFL injury in this study reduced the likelihood of the syndesmosis being unstable and led to a quicker return to sports than in those athletes with a normal ATFL. Of the 12 athletes with injury to the ATFL, all had a positive external rotation test and 10 of 12 had a positive squeeze test but with only 1 of them requiring operative stabilization, highlighting the crossover in these tests with other injuries. We presume that the mechanism of injury is different for these patients when there is injury to the ATFL, it is primarily supination-inversion (the clas-sical lateral ligament sprain) with extension into the syndesmosis causing high ankle pain. Conversely, patients without an ATFL injury probably have a true syndesmotic disruption from the dorsiflexion-external rotation mechanism widely recognized as the main cause for syndesmosis injury.5,30,31 This conclusion is also supported by the literature that suggests that syndesmosis injuries have a longer recovery than isolated lateral ligament injuries.3

From a practical viewpoint, this study has shown that patients with injuries with rupture of the AITFL but a clinically stable syndesmosis (grade IIa) may be treated non-operatively in a boot followed by progressive mobilization according to symp-toms and may be expected to return to sports at a mean of 45 days. Those with clinical evidence of instability confirmed at arthroscopy (grade IIb) may undergo sta-bilization and progressive rehabilitation with an expected return to sports at a mean of 64 days after injury. Both groups appear to have a predictable return to their sport. The factors important in differentiating these injuries and a summary of manage-ment are shown in Figure 4.

It could also be argued that an arthroscopy was performed unnecessarily in 2 athletes who had clinical and MRI suspicion of instability but who were subsequently

Fig. 4 Algorithm of proposed management of grade II syndesmosis injuries after assessment at 5 to 10 days after injury. (ATFL, anterior talofibular ligament; IOL, intra- osseous ligament; PITFL, posterior-inferior tibiofibular ligament; +ve, positive; -ve, negative).

• Normal Deltoidligament

• (ATFL injury?)• -ve squeeze test

• +ve squeeze test• Advise probable return to

play @ 9 weeks

• Deltoid injuryand/or

• (+/–ve PITFL injury)

• +ve external rotation test• AITFL rupture +/– IOL injury

Grade IIa injurystable

Grade II syndesmosis injury

Grade IIb injury“dynamic” instability Consider arthoscopic

assessment +/– stabilization

• Advise probable returnto play @ 6 weeks

• (ATFL injury – earlierreturn & chondral injurylonger return)

Conservative managementand progressive

rehabilitation

Stable versus unstable grade II high ankle sprains | 37

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shown to have stable injuries that could be treated non-operatively. However, the risk of complications from arthroscopy is low, and there was merit in knowing that the injury was stable because this provided reassurance to the athlete and medical team with confidence that a non-operative rehabilitation program would lead to a successful return to sports in a time frame earlier than initially feared. Arthroscopic examination also allows excision of the AITFL remnant, which may swing down into the lateral gutter causing later impingement during rehabilitation even after stabili-zation, as well as documentation and treatment of acute chondral lesions, and these injuries were associated with the longest recovery time important information when planning the rehabilitation in an athlete.31 The longer time to recovery of sports par-ticipation associated with concomitant chondral injury probably reflects the slower rehabilitation instigated rather than the nature of the syndesmosis injury itself (ath-letes were advised to restrict their return to impact activities for a longer period after debridement and microfracture to an osteochondral lesion).

Three athletes underwent removal of a prominent lateral suture button because of skin irritation, and this incidence is comparable with that reported in other studies.32 This complication did not affect their return to play because padding was used to  protect the prominence until it could be removed at a convenient break in the season. Finally, 11 athletes still required an ultrasound-guided injection for anterolateral ankle soft- tissue impingement at about 8 weeks after injury. Although there were fewer such patients in the surgically treated group, this was not signifi-cant. This impingement may reflect the severe nature of the injury combined with the more aggressive rehabilitation used in elite athletes with pressure for an early return to play. We therefore consider it important to remove the redundant remnant of the AITFL when performing the arthroscopy to reduce the likelihood that this will cause impingement in the anterolateral gutter.31 It is also interesting to note that early removal of the boot did not appear to hasten the return to play (1 additional day in the boot led to a 0.89 reduction in the time to return to sports). This means that removing the boot earlier than advised did not improve the return-to-play time but did risk the development of anterolateral soft-tissue impingement requiring ultra-sound-guided injection.

LimitationsWe specifically excluded grade I syndesmosis sprains, and only patients with a com-plete AITFL rupture and significant symptoms and signs at 5 to 10 days after injury were included. In an ideal situation, we would have assessed all 64 athletes with an arthroscopy because it is certainly possible that some of those injuries judged to be clinically grade IIa injuries may have proved to be unstable if an arthroscopy had been performed and, despite this, were successfully treated non-operatively. Arthroscopic examination of all grade II injuries would have been difficult to jus-tify ethically, especially in light of our results, which suggest that those injuries that are deemed stable on clinical examination may be managed non-operatively and expected to have good results. Conversely, we also recognize that this study can be criticized for perhaps over-treating grade IIb syndesmosis injuries and having selec-

| Chapter 238

tion bias because there was no comparative group with identical injuries treated non-operatively against which the results could be judged. Although all patients were professional athletes and were able to resume their previous sporting activities at the same competitive level, we accept that a more cautious, prolonged conser-vative treatment with immobilization in a boot and subsequent taping could have yielded good results. However, it is recognized that athletes with this more severe grade of injury are at risk of continuing significant symptoms and a delayed return to sports after conservative management, and the treatment adopted here has resulted in a high success rate and timely return to competitive sports. We also acknowledge that it is possible that some unstable injuries were deemed stable but were success-fully treated conservatively.

CONCLUSIONS

A positive squeeze test and injury to the ATFL and deltoid ligament are important fac-tors in differentiating stable from dynamically unstable grade II injuries and may be used to identify which athletes may benefit from early arthroscopic assessment and stabilization. They may also be important in predicting the time frame for athletes expected return to play.

Stable versus unstable grade II high ankle sprains | 39

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2. Rammelt S, Zwipp H, Grass R. Injuries to the distal tibio- fibular syndesmosis: An evidence-based approach to acute and chronic lesions. Foot Ankle Clin 2008;13:611-633, vii-viii.

3. Wright RW, Barlie J, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med 2004;32:1941-1945.

4. Ogilvie-Harris DJ, Reed SC. Disruption of the ankle syndesmosis: Diagnosis and treatment by arthroscopic surgery. Arthroscopy 1994;10:561-568.

5. Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: Evaluation of the ligamentous structures, methods of fixation, and radio- graphic assessment. J Bone Joint Surg Am 1995;77:847-856.

6. Beumer A, Heijboer RP, Fontijne WP, Swierstra BA. Late reconstruction of the anterior distal tibiofibular syndesmosis: Good outcome in 9 patients. Acta Orthop Scand 2000;71:519-521.

7. Brown KW, Morrison WE, Schwetzer ME, Parellada JA, Nothnagel H. MRI findings associated with distal tibio- fibular syndesmosis injuries. AJR Am J Roentgenol 2004;182:131-136.

8. Harper MC. Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18.

9. McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN. Syndesmosis and deltoid injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 2013;21: 1328-1337.

10. Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: Value of MR imaging for diagnosis. Radiology 2003;227:155-161.

11. Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in the athlete: The role of arthroscopic surgery. Arthroscopy 1997;13:564-574.

12. Press CM, Gupta A, Hutchinson MR. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep 2009;8:228-233.

13. Jones MH, Amendola A. Syndesmosis sprains of the ankle: A systematic review. Clin Orthop Relat Res 2007;455:173-175.

14. Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: Reliability and return of function. J Orthop Sports Phys Ther 1998;27:276-284.

15. Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 2004;423:227-234.

16. Cesar de Cesar P, Muller E. Comparison of MRI to physical examination for syndesmotic injuries after lateral ankle sprain. Foot Ankle Int 2011;32:10-16.

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17. Mei Dan O, Kotz E, Barchilon V, Massarwe S, Nyska M, Mann G. A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: A preliminary study. Am J Sports Med 2009;37:1009-1016.

18. Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: An MRI study. Clin Orthop Relat Res 2005;436: 216-221.

19. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 2001;29:31-35.

20. Uys HD, Rijke AM. Clinical association of acute lateral ankle sprains with syndesmotic involvement: A stress radiography and MRI study. Am J Sports Med 2002;30:816-822.

21. Gardener MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 2006;27:788-792.

22. Wolf BR, Amendola A. Syndesmosis injuries in the athlete. When and how to operate. Curr Opin Orthop 2002;31:151-154.

23. Watson B, Lucas D, Simpson G, Berlet GC, Hyer CF. Arthroscopic evaluation of syndesmotic instability in a cadaveric model. Foot Ankle Int 2015;36:1362-1368.

24. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.

25. Pena FA, Coetzee JC. Ankle syndesmosis injuries. Foot Ankle Clin 2006;11:35-50.

26. Mak M, Gartner L, Pearce C. Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin 2013;18: 195-214.

27. Takao M, Ochi M, Naito K, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 2001;17: 836-843.

28. Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br 2003;85:324-329.

29. Van Dijk CN, Mol BW, Lim LS, Marti RK, Bossuyt PM. Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand 1996;67:566-570.

30. Zalavras C, Thordarson D. Ankle syndesmosis injury. J Am Acad Orthop Surg 2007;15:330-339.

31. Miyamoto W, Takao M, Matsushita T. Anterior fibrous bundle: A cause of residual pain and restrictive plantar flexion following ankle sprain. Knee Surg Sports Traumatol Arthrosc 2013;21:1385-1389.

32. Naqvi G, Shaqqat A, Awan N. Tightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications and technique modification. Injury 2012;43: 838-842.

Stable versus unstable grade II high ankle sprains | 41

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3THE BROKEN ‘RING OF FIRE’ – A NEW

RADIOLOGICAL SIGN AS PREDICTOR OF SYNDESMOSIS INJURY?

James D. F. Calder, Adam Mitchell, Adam Lomax, Moez Ballal, John Grice, C Niek van Dijk, Justin Lee

Orthopaedic Journal of Sports Medicine 2017 (March) 5(3) 2325967117695064

| Chapter 344

ABSTRACT

Background: We noticed that subcircumferential periosteal oedema above the ankle joint was frequently present on MRI with syndesmosis injuries but was not previously reported. Fluid height within the interosseous membrane has also not previously been shown to be associated with syndesmosis injury severity.

Purpose: Investigate whether a new sign on MRI and measurement of the length of fluid within the interosseous membrane above the ankle may be used to enable identification of a syndesmosis injury and allow differentiation from lateral ligament injury.

Methods: Three groups of patients were identified from a patient notes database and the MRI scans retrieved – those with an isolated syndesmosis injury (SI group), iso-lated lateral ligament injury (LLI group) and or no injury (NI group) who had an ankle MRI for another reason. The scans were anonymized and independently assessed by eight clinicians (surgeons and radiologists) who were blinded to the diagnosis. The maximum length of fluid above the ankle within the intraosseous membrane was measured for each patient. The presence or absence of distal anterior, lateral and posterior tibial periosteal oedema was recorded (Broken ‘Ring of Fire’).

Results: Measurement of the length of fluid above the ankle had excellent intra-ob-server reliability (ICC=0.97 [0.93-0.99]) but poor interobserver reliability. Fluid extended higher in both the LLI group (p=0.0043) and SI group (p=0.0058) than the NI group but there was no significant difference between the LLI and SI groups (p=0.3735) indicating that this measurement cannot differentiate between the inju-ries. The presence of the broken ‘Ring of Fire’ around the distal tibia was signifi-cantly more frequent in the SI group when compared to both LLI and NI groups (p<0.00001). The sensitivity of this sign is 49% but when present this sign has a 98% specificity for syndesmosis injury.

Conclusion: The presence of tibial subcircumferential periosteal oedema 4-6cm above the ankle joint (the ‘Ring of Fire’) is highly suggestive of a syndesmosis injury. This new radiological sign can assist with early identification of such injuries. The measurement of height of fluid above the ankle within the interosseous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involv-ing the syndesmosis.

Level of evidence III

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INTRODUCTION

Ankle syndesmosis injuries are a cause for delayed return to sport and are associ-ated with ankle pain and long term disability if the diagnosis is delayed or unrecog-nized.8,20,24 The mechanism of injury and the presence of high ankle pain may alert the treating clinician to the presence of a syndesmosis injury rather than a “simple“ lateral ligament sprain. 2,6,7,12,14,25,26 However, frequently the history of injury and the clinical signs may be confusing. Plain radiographs may show instability of the syn-desmosis in high-grade unstable injuries but the most frequent injuries encountered in sports are the more subtle syndesmosis injuries (referred to as sprains by some authors).4 Delay in appropriate treatment of these injuries may lead to long term adverse sequelae.3,10,13,17-19,23

Injury to the anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) and the interosseous ligament (IOL) may be accurately identified on MRI.9,12,15,21,22 However, previous injuries to these ligaments with thickening and fibrosis demon-strated on MRI with associated oedema proximally from the anterior talofibular liga-ment (ATFL) injury in a supination-inversion ankle injury may lead to uncertainty as to the presence of an acute syndesmosis injury requiring specific treatment. We had noticed during clinical practice in a tertiary referral sports injury centre the presence of subcircumferential oedema on MRI around the tibia 4-6cm above the ankle joint in patients with a syndesmosis injury. We had not observed this in patients with injury only to the ATFL. We had also observed significant oedema or extrusion of joint fluid along the interosseous membrane proximal to the ankle joint. We considered this subcircumferential oedema, which has not previously been described and which we termed the broken ‘Ring of Fire’ (RoF) may be a diagnostic sign for syndesmosis injury and measurement of the length of bleeding along the interosseous membrane may correlate with the presence of a syndesmosis injury and aid with the early rec-ognition of such injuries.

The aim of this study was to assess whether identifying the broken ‘Ring of Fire’ (RoF) or measuring the height of bleeding into the interosseous membrane are useful sign in the early detection of a syndesmosis injury and can help to differentiate such injuries from lateral ligament injuries isolated to the ATFL.

METHODS AND PATIENTS

MRI scans of patients with an isolated syndesmosis and isolated lateral ligament inju-ries were identified from a patient notes electronic database following confirmation that Research Ethics Committee approval was not required. All those with a syndes-mosis injury (SI group) had grade II injury according to the West Point Classification.8 Diagnosis of syndesmosis injury was made by a combination of clinical examination (by a foot and ankle orthopaedic consultant surgeon) and MRI scan using traditional methods of diagnosing syndesmosis injury; oedema and ligamentous disruption

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demonstrable on axial and coronal images. Those with an isolated lateral ligament injury (LLI group) had injury to the ATFL alone or ATFL and calcaneofibular liga-ment (CFL). A third group of patients were identified with no history of injury to the syndesmosis or lateral ligament complex (NI group). These patients underwent MRI scanning for unrelated conditions such as osteochondral lesion of the talus or Achilles tendon injury. Identifying features were removed from the scans, which were then randomly listed for review.

Imaging the ankle was performed in a number of centres. Although the imaging parameters were not completely standardized axial imaging included either a STIR (Short tau inversion recovery series), PDFS (proton density fat saturation) of a T2FS (T2 weighted fat saturated). The MRI scanners had a magnetic strength of 1.5Teslas. All of these sequences were able to identify oedema enabling the diagnosis of subcir-cumferential oedema with confidence.

Eight clinicians (Radiologists and Surgeons) were blinded to the diagnosis and independently reviewed all of the scans. Two were fellowship trained consultant orthopaedic surgeons, one musculoskeletal radiologist, two senior foot and ankle orthopaedic fellows and three senior orthopaedic residents. All were asked to assess the axial imaging for the presence or absence of subcircumferential oedema around the tibia in any of the slices between 4-6cm proximal to the ankle joint having been shown examples of the RoF (Figure 1). They were also asked to measure the height of fluid (representing oedema or joint fluid) above the ankle joint (Figure 2). The coronal view used to measure the fluid height was standardised to be in line with the centre of the syndesmosis on the AP/lateral plane. The height was re-measured on 12 scans on a separate occasion to assess intra-observer reliability.

Statistical advice was sought from the Department of Biostatistics, Eastman Insti-tute, University College London, UK and statistical analysis performed using SPSS software (IBM SPSS Statistics for Windows, version 22.0; IBM, Armonk, NY). A pilot

Fig. 1 Example of the broken Ring of Fire (arrowed in red). Axial T2 Fat Sat MRI image from patient in SI group.

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study was performed with 9 scans in each group and a subsequent power study concluded that a minimum of 18 patients would be required in each group with a power of 80% and alpha value 0.05.

The presence/absence of the RoF was analysed using the Chi-squared test as well as the sensitivity, specificity, and positive/negative predictive values. Reliabil-ity testing was performed on measurements of the height of fluid above the ankle using intra-class correlation coefficient (ICC) on the 12 scans that underwent repeat testing. This result was interpreted according to Ciccheti et al (Table 1).5 The Krus-kal-Wallis test was used to assess differences in the distributions of height with the nul hypothesis (H0) stating that there is no difference in the heights between the groups with an alpha level of 0.05 and a critical value of 5.99147. The Mann-Whitney U test for non-normally distributed data was used to assess differences between the distributions of each group with a significance level of p<0.05.

Fig. 2 Example of measurement of height of fluid within syndesmosis (red arrow and lines). Coronal T2 Fat Sat MRI image from patient in SI group.

Table 1 Qualitative ratings of agreement based on ICC values (from Ciccheti et al5).

ICC value Assessment of inter-rater reliability

<0.40 Poor

0.4-0.59 Fair

0.60-0.74 Good

0.75-1.0 Excellent

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RESULTS

A total of 98 suitable scans were identified and included in the study - 22 in the SI group, 31 in the LLI group and 45 in the NI group.

Assessment of the Ring of FireSubcircumferential oedema of the distal tibial periosteum was nominated the broken ‘Ring of Fire’ (Rof).

The results of the presence or absence of the RoF are summarized in Table 2. The RoF was present more frequently in those with a syndesmosis injury than without (P<0.001) and significantly more frequently than in those with a lateral ligament injury (p<0.001) (Table 3). Although the RoF had a sensitivity of predicting a syndes-mosis injury of 49% it had a false positive rate of 1.4% in the NI group and 2.8% in the LLI group. Overall it had a specificity of 87% with a negative predictive value of 98% and a positive predictive value of 88%.

Assessment of height of fluid in the interosseous membraneThe distribution of the height measurements is summarized in Table 4. Intra-observer reliability testing resulted in an ICC of 0.97 (95% confidence limits 0.93-0.99) rep-resenting excellent reliability in the re-testing measurement of height. However, for

Table 2 Contingency table for presence/absence of Ring of Fire.

True Positive True Negative Total

Ring of Fire Positive 86 12 98

Ring of Fire Negative 90 596 686

Total 176 608 784

Table 3 Chi squared results for Ring of Fire.

Groups assessed Chi Squared value P value

SI versus no SI 274.3732 <0.001

SI versus LLI 127.4412 <0.001

SI versus NI 189.0183 <0.001

Table 4 Measurement of height (millimetres) for groups.

Group Mean Standard Deviation

Median (interquartile range)

Maximum-Minimum Values

NI 13.65 4.84 13.10 (10.1–16.3) 3.2–34.1

LLI 16.72 6.21 16.20 (12.4–20.5) 2.6–32.6

SI 17.88 7.72 16.70 (12.8–22.5) 4.5–58.5

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inter-observer reliability the ICC was 0.49 (95% confidence limits 0.21-0.75) indicat-ing only fair reliability between observers (Table 5). The Kruskal-Wallis test demon-strated that H0 failed to exceed 5.99 and therefore the null hypothesis was accepted and there was no significant difference between all the groups. The data was checked for normality and there was a non-normal distribution with skew to the right. The Mann-Whitney U test demonstrated a significant difference in height between both the LLI and SI groups when individually compared with the NI group (p=0.0043 and p=0.0058 respectively) but no difference in height between the SI and LLI groups (p=0.3735).

DISCUSSION

The most important finding of this study is that the presence of the broken ‘Ring of Fire’ sign on MRI may alert the clinician to the possibility of a syndesmosis injury and it may be helpful in differentiating this high ankle sprain from the more common isolated lateral ligament injury. It may be considered as a diagnostic sign as it has a high specificity although its absence does not exclude a syndesmosis injury since it has a sensitivity of only 49%. This has similar sensitivities and specificities as the Segond fracture has to anterior cruciate disruption.10 We suggest that it only occurs when there has been sufficient trauma to disrupt part of the intraosseous membrane which leads to bleeding proximally and circumferentially around the tibia. We con-clude that this does not occur when the ATFL or CFL are injured in isolation. We recommend that scans are assessed for this sign 4-6cm proximal to the ankle joint to reduce the likelihood of a concomitant ankle capsular injury giving a false positive sign. We would suggest all ankle imaging extends to this level. It is noted that the maximum height of fluid extension into the syndesmosis in the NI and LLI groups was 34.1mm and 32.6mm respectively reinforcing our opinion that observation of the RoF should be sought above 4cm. When this new sign is identified on a scan its specificity should alert the clinician to the possibility of syndesmosis injury so that careful clinical assessment may be made as to the stability of the injury and appropri-ate management commenced.

Measurement of the height of oedema / extrusion of joint fluid within the syndes-mosis, although reproducible within observers appears open to individual interpre-tation and it does not appear to be reliable. This variation between observers means that it is not an accurate method of assessment for syndesmosis injury. Fluid extruded proximally within the interosseous membrane in both the LLI and SI groups which we presume is due to bleeding from the AITFL/ATFL injury or joint fluid from an

Table 5 Reliability testing for measurement of height of fluid in syndesmosis.

ICC value 95% Confidence Limits

Intra-observer reliability 0.97 0.93-0.99

Inter-observer reliability 0.49 0.21-0.75

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associated capsular tear. Although the maximum height was 34mm in the LLI group and 59mm in the SI group there does not appear to be a threshold above which this measurement is significant. In addition to the unacceptable variability between observers, measurement of this height cannot be used to differentiate a syndesmo-sis from isolated lateral ligament injury as no significant difference between these groups could be demonstrated.

The limitations of this study include its retrospective nature and that although the patient notes indicated the diagnosis of isolated grade II syndesmosis injury, only some patients underwent arthroscopic confirmation of this diagnosis. Although the observers were shown examples of the RoF sign and measurement of the fluid height was demonstrated it could be argued that further experience following feedback from this data could improve the inter-observer reliability. Naussbaum et al demon-strated the length of tenderness on palpation along the anterior aspect of the interos-seous membrane is associated with a longer recovery following syndesmosis injury.16 It would have also been interesting to have clinical follow-up data to see whether the height of fluid correlates with a poorer outcome.

CONCLUSIONS

The presence of subcircumferential periosteal oedema around the tibia 4-6cm above the ankle joint (the broken ‘Ring of Fire’) is highly suggestive of a syndesmosis injury. This new radiological sign can assist with early identification of such, especially in recurrent injuries. The measurement of height of fluid above the ankle within the interosseous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

WHAT IS KNOWN ABOUT THIS SUBJECT:

Ankle syndesmosis injuries are a cause for delayed return to sport and are associ-ated with ankle pain and long term disability if the diagnosis is delayed or unrecog-nized.8,20,24 The mechanism of injury and the presence of high ankle pain may alert the treating clinician to the presence of a syndesmosis injury rather than a “simple“ lateral ligament sprain.2,14,25,26 However, frequently the history of injury and the clin-ical signs may be confusing. Plain radiographs may show instability of the syndes-mosis in high-grade unstable injuries but the most frequent injuries encountered in sports are the more subtle syndesmosis injuries (referred to as sprains by some authors).4 Delay in appropriate treatment of these injuries may lead to long term adverse sequelae.3,10,13,17-19,23

Injury to the anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) and the interosseous ligament (IOL) may be accurately identified on MRI.15,22 How-ever, previous injuries to these ligaments with thickening and fibrosis demonstrated

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on MRI with associated oedema proximally from the anterior talofibular ligament (ATFL) injury in a supination-inversion ankle injury may lead to uncertainty as to the presence of an acute syndesmosis injury requiring specific treatment.

WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE

The most important finding of this study is that the presence of the broken “Ring of Fire” sign on MRI may alert the clinician to the possibility of a syndesmosis injury and it may be helpful in differentiating this high ankle sprain from the more common isolated lateral ligament injury. It may be considered as a diagnostic sign although its absence does not exclude a syndesmosis injury since it has a sensitivity of only 49%. This new radiological sign can assist with early identification of such injuries.

The measurement of height of fluid above the ankle within the interosseous mem-brane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

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REFERENCES

1. Beumer A, Heijboer RP, Fontijne WP, et al. Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand 2000; 71(5):519–21.

2. Beumer A, van Hemert WL, Niesing R et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 2004; 423:227–234.

3. Brown KW, Morrison WE, Schwetzer ME, Parellada A, Nothnagel H. MRI findings associated with distal tibiofibular syndesmosis injuries. Am J Roentgenol 2004; 182:131–136.

4. Calder JD, Bamford R, Petrie A, McCollum G. Stable Versus Unstable Grade II High Ankle Sprains: A Prospective Study Predicting the Need for Surgical Stabilization and Time to Return to Sports. Arthroscopy. 2016 Apr;32(4):634-42.

5. Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment. 1994;6(4):284–290.

6. Close JR. Some applications of the functional anatomy of the ankle joint. J Bone Joint Surg Am 1956; 38-A:761–78.

7. Ebraheim NA, Taser F, Shafiq Q et al. Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surg Radiol Anat 2006; 28:142–149.

8. Gerber JP, Williams GN, Scoville CR et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle 1998; 19:653–660.

9. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):944-56.

10. Hess T, Rupp S, Hopf T, Gleitz M, Liebler J. Lateral tibial avulsion fractures and disruptions to the anterior cruciate ligament. A clinical study of their incidence and correlation. Clin Orthop Relat Res. 1994;303:193–7.

11. Harper MC. Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22(1):15–8.

12. Hoefnagels EM, Waites MD, Wing ID et al. Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament. Foot Ankle Int 2007; 28:602–604.

13. McCollum GA, van den Bekerom MP, Kerkhoffs GM et al. Syndesmosis and deltoid injuries in the athlete. Knee Surg Sports Traumatol Arthroscopy. 2013 Jun; 21(6):1328-37.

14. Miyamoto W, Takao M, Matsushita T. Anterior fibrous bundle: a cause of residual pain and restrictive plantar flexion following ankle sprain. Knee Surg Sports Traumatol Arthroscopy 2013; 21(6):1385-1389.

15. Muhl C, Frank LR, Rand T. Tibiofibular syndesmosis: high resolution MRI using a local gradient coil. J Comput Assist Tomogr 1998; 22:938–944.

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16. Nussbaum ED, Hosea TM, Sieler SD et al. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 2001; 29:31–35.

17. Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, Ochi M. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 2003; 227:155–161.

18. Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in the athlete: the role of arthroscopic surgery. Arthroscopy 1997; 13:564–574.

19. Press CM, Gupta A, Hutchinson MR Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep 2009; 8:228–233.

20. Rammelt S, Zwipp H, Grass R. Injuries to the Distal Tibiofibular Syndesmosis, Foot Ankle Clin N Am 2008; 13:611-633.

21. Sarrafian SK (1993) Anatomy of the foot and ankle. Descriptive, topographic, functional, 2nd edn. Lippincott, Philadelphia, pp159–217.

22. Takao M, Ochi M, Oae K. Diagnosis of a tear of the distal tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br 2003; 85-B:324–329.

23. van den Bekerom MPJ, Raven EEJ. The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review. Knee Surg Sports Traumatol Arthosc 2007; 15:465–471.

24. Wright RW, Barlie J, Suprent DA et al. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med 2004; 32:1941–1945.

25. Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 1995; 77-A:847–856.

26. Zalavras C, Thordarson D. Ankle syndesmosis injury. J Am Acad Orthop Surg 2007; 15:330–339

4RETURN TO SPORT FOLLOWING ACUTE

LATERAL LIGAMENT REPAIR OF THE ANKLE IN PROFESSIONAL ATHLETES

W James White, James D. F. Calder, Graham A McCollum

Knee Surgery Sports Traumatology and Arthroscopy 2016 Apr; 24(4):1124-9.

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ABSTRACT

Background: Recent literature supports early reconstruction of severe acute lat-eral ligament injuries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Not previously reported, predicting the time to return to training and play is important to both athlete and club. We evaluate the effectiveness and complications of lateral ligament reconstruction in professional athletes.

Aim: We aim to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

Methods: A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

Results: The median return to training and sports for isolated injuries was 63 days (49–110) and 77 days (56–127), respectively. However, for concomitant injury results were 86 days (63–152) and 105 days (82–178). This delay was significant (p < 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p = 0.027, p < 0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

Conclusion: Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

Level of evidence III

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INTRODUCTION

The ankle is commonly injured in sporting activities occurring in up to 1 in 10,000 people a day 10 and is the most common injury in 24 of 70 sports,4 with an incidence of 9.35/10,000 elite athletic exposures.19 The majority of these injuries involve the anterior talo-fibular ligament (ATFL) and calcaneo-fibular ligament (CFL) with forced supination-inversion being the most common mechanism.

For the professional athlete, this may mean significant time away from play, chronic instability, pain and ankle dysfunction. Clinical examination and the degree of ana-tomical disruption allow grading of these injuries from I to III.8 Grade I is a stretching of the ATFL, grade II is partial rupture of the ATFL with mild instability, and grade III is complete rupture of the ATFL and the CFL with marked instability. Clinical exam-ination is difficult to perform acutely due to pain inhibition and local oedema, but a delayed examination (day 5 post-injury), identifying tenderness, haematoma and instability using the drawer and talar tilt test, has a sensitivity of 98 % and specificity of 84 % for having an ATFL injury.26 Ultrasound is a reliable investigation with good sensitivities and specificities but is user dependent. Magnetic resonance imaging (MRI) is sensitive and specific in diagnosing lateral ligament injuries as well as identi-fying associated ankle injuries and, for these reasons, is the recommended investiga-tion in the elite athlete.16,20 Up to 50 % of lateral ligament sprains may have associated osteochondral lesions (OCLs), particularly after sporting injuries.23 Van Dijk et al. 25 identified 20 OCLs in 30 ankles that underwent arthroscopy prior to lateral ligament repair. Other concomitant injuries include those to the deltoid ligament and the dis-tal tibiofibular syndesmosis, and these are known to delay rehabilitation and cause prolonged ankle dysfunction.1,7,17

The majority of acute lateral ligament injuries respond to conservative treatment with functional rehabilitation. A recent Cochrane review 13 revealed that non-surgi-cal treatment of lateral ligament injuries resulted in fewer complications and good functional results. They did, however, report that surgery tended to lead to greater objective ankle stability and faster return to work and sports. Pijnenburg et al. 22 in a meta-analysis also suggested superior results with operative treatment for ruptures of the lateral ligaments. Lee et al. reported excellent long-term results at a mean of 10.6 years following Broström repair reporting 28/30 patients returning to their pre-in-jury levels and 24/30 being competitive athletes. Verghagen et al. 27 demonstrated that residual instability is a predictor of repeat injury. Therefore, surgery has been considered in professional athletes with acute grade III injuries in order to reduce the risk of later complications from recurrent sprains without compromising or delaying return to sports.6 There has, however, been no published data to guide elite athletes as to their predicted time to return to training and to high-level sport. The aim of the study was, therefore, to assess the time to return to training and sports following reconstruction of acute grade III lateral ligament injuries in professional athletes and to assess the effect of associated ankle injuries on that recovery time. Lateral ligament reconstruction was hypothesised to be a safe and effective treatment for acute severe ruptures providing a stable ankle and an expected return to sports at approximately 3 months.

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MATERIALS AND METHODS

Data were prospectively collected on a consecutive single surgeon series of oper-atively treated grade III lateral ligament injuries in professional athletes. The club medical team was contacted to record the time taken from surgery to being able to participate in full training and return to full team sports (medically fit and available for team selection). The FAOS and VAS scores were collected, and at final follow-up, the athlete was asked to provide a simple report on satisfaction with the procedure (very satisfied, partly satisfied or dissatisfied). Any further episodes of severe ankle instability to the same ankle requiring more than 1 week from participating in sport-ing activities as well as the need for taping/bracing were also recorded.

The diagnosis of a grade III injury was made following MRI examination demon-strating complete rupture of the ATFL and CFL plus clinical examination at least 5 days following injury where the ankle was clinically assessed by the senior author to have an unstable anterior drawer and talar tilt when compared to the opposite side. Associated injuries were also recorded. Any patients presenting with grade I and II injuries during this period of data collection were treated non-operatively and excluded from this study. Those sustaining a concomitant fracture to the foot or ankle were also excluded. Patients were not excluded if they had sustained a previous ankle injury in their career. MRI scan, however, demonstrated acute injuries in all patients.

Operative techniqueExamination under anaesthetic was performed to confirm genuine anterior draw and talar tilt tests. Intravenous antibiotic, cephalosporin, was infused prior to inflation of a thigh tourniquet. Anterior ankle arthroscopy was performed in all cases washing out the haematoma enabling assessment of the ligamentous structures and the artic-ular cartilage. Care was taken to ensure the soft tissue envelope was not over-dis-tended, and intra-articular pressures were kept at or below 30 mmHg using a fluid management system. All procedures were performed by the senior author.

The modified Broström method was used for the lateral ligament reconstruction using either bone tunnels made with a 2-mm Kirschner wire through the fibula and no. 2 vicryl sutures (Ethicon, Johnson & Johnson, Sommerville, New Jersey) or bone suture anchors (Twinfix, Smith & Nephew, Andover, Massachusetts or Juggerknott, Biomet, Warsaw, USA). Associated injuries were recorded and treated as appropriate. OCLs were treated with debridement, curettage and microfracture, whilst complete deltoid ligament ruptures (grade III injuries) were also repaired with bone tunnel sutures or bone anchors.

Post-operative careThe patient was mobilised non-weight-bearing in a plaster of Paris back-slab for 2 weeks, and following wound inspection was then mobilised 50 % weight-bearing for 2 weeks increasing to full weight-bearing until 6 weeks post-operatively in a walking boot (Aircast XP Walker, DJO, LLC, Vista, California). The use of a brace or ankle tap-ing was encouraged until 12 weeks post-operatively.

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Physiotherapy was commenced at 2 weeks post-operatively with active assisted range of motion exercises and strengthening/proprioceptive training. Hindfoot inversion was avoided until 6 weeks post-operatively. For those with an isolated lat-eral ligament repair, treadmill running and straight-line running as tolerated was commenced from 6 weeks with the aim of returning to multidirectional training by 8 weeks post-operatively.

Although physiotherapy was started at 2 weeks (range of motion and proprio-ceptive training), rehabilitation was delayed for those with an associated deltoid lig-ament, with partial weight-bearing continued until 6 weeks, whilst those treated for an OCL were discouraged from returning to running until 12 weeks post-operatively. Measurements of return to sport and training were performed in units of days.

Statistical analysisStatistical analysis was performed checking for normality of distribution of the data and then unpaired and paired t tests as appropriate. Significance was accepted with a p value <0.05.

RESULTS

Forty-two elite-level (national or international) athletes sustained severe ankle sprains involving grade III injuries to both the ATFL and CFL on MRI examination and signif-icant instability on anterior draw testing when assessed clinically. Thirty-seven were male, and 5 were female (25 soccer, 9 rugby, 2 hockey, 2 tennis, 2 cricket, 1 netball and 1 kitesurfer) with a median age of 22 years (16–31). Six patients had a history of previous injuries to the ankle with more than six episodes of giving way and reg-ularly used taping/bracing when playing competitive sport. One patient had under-gone a previous lateral ligament reconstruction to the same ankle (Broström–Gould) elsewhere 4 years before.

All patients underwent surgery at a median of 7 days following injury (5–21 days). Median follow-up was 44 months (24–57). At final follow-up, one rugby player reported a further significant inversion injury to the ankle 18 months following sur-gery which prevented him from training for 6 weeks, and he returned to full sports at 9 weeks and was subsequently was asymptomatic. All patients reported their ankles as feeling stable, but eleven soccer players and the one netball player continued to use taping during matches but not in training. The median time to return to training for all athletes was 63 days (49–152) and to play 77 days (56–178). The median VAS score improved from 4 pre-operatively to 0 post-operatively (p < 0.001), and FAOS sub-scores improved in all patients (Table 1) (Fig. 1).

Of 42, 12 athletes sustained associated injuries (five OCL, four deltoid ligament injuries and three combined deltoid ligament injury with OCL). There was no signif-icant difference in the age or time to surgery between the two groups. The median time to full training was statistically significant between athletes with isolated lateral ligament injuries and those with associated injuries, 57 days (49–110) and 86 days

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(63–152), respectively (p < 0.001) This was also the case with return to full play 72 days (56–127) and 105 days (82–178), respectively (p < 0.001).

Interestingly, although the pre- and post-operative VAS scores were not statisti-cally significantly different between those with and those without associated injury, the mean pre- and post-operative FAOS pain sub-score was worse in those with an associated injury (p = 0.032, p = 0.027, respectively). Additionally, the post-operative FAOS symptoms sub-score was also worse in this group (p < 0.001). Forty patients reported being very satisfied and two partly satisfied (both had combined lateral ligament and medial deltoid injuries with a residual discomfort within the medial aspect of the ankle but declined further as they were playing fully and the ankle did not feel unstable).

Table 1 Results of surgery for all athletes and groups broken down into isolated lateral ligament injuries and those with associated injuries.

All injuries Isolated Associated p value isolated and associated injuries

Median time to surgery in days (range)

7 (5–21) 7 (5–21) 6 (5–14) (n.s.)

Median return to training in days (range)

63 (49–152) 57 (49–110) 86 (63–152) p < 0.001

Median return to full sport in days (range)

77 (56–178) 72 (56–127) 105 (82–78) p < 0.001

Median VAS pre-op (range)

4 (1–6) 4 (2–6) 4 (1–5) 0 (n.s.)

Median VAS post-op (range)

0 (0–3) 0 (0–2) (0–3) (n.s.)

Median FAOS pre-op (range)

Pain 50 (22–83) 44 (22–64) 52 (28–83) p = 0.032

Symptoms 43 (36–57) 43 (36–57) 43 (26–50) (n.s.)

ADL 49 (41–82) 49 (41–82) 48 (41–66) (n.s.)

Sport 10 (0–20) 10 (0–20) 15 (5–20) (n.s.)

QOL 25 (6–31) 25 (6–31) 25 (13–31) (n.s.)

Median FAOS post-op (range)

Pain 100 (72–100) 100 (94–100) 97 (72–100) p = 0.027

Symptoms 96 (75–100) 98 (89–100) 93 (75–100) p = 0.002

ADL 100 (91–100) 100 (91–100) 100 (94–100) (n.s.)

Sport 100 (90–100) 100 (90–100) 100 (90–100) (n.s.)

QOL 100 (88–100) 100 (88–100) 100 (88–100) (n.s.)

Return to sport following acute lateral ligament repair | 61

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Complications included two superficial wound infections that responded to oral antibiotics and local dressings. Their post-operative rehabilitation was not inter-rupted. There were no deep infections or other serious complications related to the surgery.

DISCUSSION

The results support the hypothesis that lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and an expected return to sports at approximately 3 months in elite athletes. Lateral ligament injuries are a common cause of prolonged time away from training and play for the pro-fessional athlete. The majority heal without complications following a programme of functional rehabilitation;11 however, 20 and 40 % of ankles may have persistent instability or other pathology leading to prolonged dysfunction.9 A critical review of the literature 13 revealed that surgery for acute lateral ligament rupture led to greater

Fig. 1 Bar graph showing improved post-operative AOFAS scores when compared to pre-operative scores in all three groups: combined, isolated and associated injury groups.

120

100

80

60

AO

FAS

scor

e

40

20

0

Pre-operativ

e pain

Pre operative ADL

Pre operative sp

ort

Pre operative Q

OL

Pre operative sy

mptoms

Post operativ

e pain

Post operativ

e sympto

ms

Post operativ

e ADL

Post operativ

e sport

Post operativ

e QOL

All injuries

Isolated injuries

Associatedinjuries

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stiffness and complications, but limited evidence exists.24 These ankles, however, had better objective stability compared to non-surgically treated ankles. Objective instability may contribute to recurrent sprains in the professional athlete and lead to chronic instability or chondral injury, possibly requiring surgery resulting in further time away from sports.27 For professional athletes with a significantly greater load and demand on their ankle joints, this may have significant commercial and personal consequences.12 High-volume centres with surgeons experienced in lateral ligament repair tend to have better results and lower complication rates .11 Foot and ankle specialists are therefore treating some professional athletes with grade III tears more aggressively with acute surgical repair to avoid recurrent instability and hasten return to play, which has supported by other authors.24 A recent Consensus Meeting has advocated early surgical repair in selected professional athletes with ankle instabil-ity secondary to acute lateral ligament injury, and previous authors have supported this.6,24

The surgical technique used in this group of patients was the anatomical Broström repair without the Gould modification.3 Studies have shown satisfactory clinical and functional results with up to 95 % excellent results in some reports.2,21 This is a reliable technique with a low complication rate, without relying on allograft or autograft. Although the Gould modification has demonstrated improved stability in chronic ankle instability, the senior author chose not to augment the repair in the acute setting as the tissues are not stretched and scarred, but a true anatomical repair may be performed. The clinical results appear to have supported this view in this small series of highly demanding patients.

Examination under anaesthesia was performed followed by an ankle arthroscopy using the standard anterolateral and anteromedial portals in all cases in our series. Despite the excellent results of Broström repair reported in the literature,18 there are still patients that suffer persistent pain despite good objective stability testing and stress radiography.15 This is often due to intra-articular pathology such as a loose body or OCL not identified at the time of the ligament repair. For this reason, we feel that arthroscopy prior to the ligament repair is a useful tool with low morbidity, especially in this group of patients where recovery time is critical. We did not find that this caused significant swelling or obscure the tissue planes for the Broström repair. In three of the four cases with an OCL, there was no radiological evidence of a chondral lesion, and this would have gone undetected without an arthroscopy being performed.

The time to return to sports is affected by any associated injury to the ankle. This may seem a very logical and obvious statement, but these results act as an important guide for treating surgeons to be able to communicate a time frame and a progno-sis to the patient, club medial team and the club management. The rehabilitation programme following the repair of isolated lateral ligament injuries entails 2 weeks of immobilisation with progressive increase in weight-bearing and functional reha-bilitation. The presence of an OCL, deltoid or syndesmotic injury delays and alters the programme: full weight-bearing is only begun after 4–6 weeks in this group, and high impact loading avoided for up to 3 months for OCLs. The presence of multiple injuries may delay rehabilitation further.

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However, return to sports is determined not only by the post-surgical rehabilitation programme for a particular injury, but also by the clinical progress. Persistent pain and swelling may take longer to subside in the multiply injured ankle and limit the individual rehabilitation. Gregush and Ferkel 5 compared the ankle scores of surgi-cally treated isolated chronic lateral ligament instability with instability together with an OCL. All their patients had an arthroscopy prior to a Broström anatomical repair. They concluded that isolated lateral ligament repair had higher ankle and hindfoot scores compared to repair with concomitant treatment of an OCL with debridement and microfracture. Our results after acute injuries were similar.

A return to pre-injury level of participation was seen in all patients in our series. The time to return to play for the professional athlete is critical. Previous comparative trials and RCTs did not look specifically at this population group.13 Further to this, most studies report on whether the patient returned to sport or not and were not specific on the time to return.

Studies have shown that surgical treatment of lateral ligament injuries leads to significant complication rates,13 but in this series of 42 professional athletes there were only two minor wound complications that responded to local wound care and oral antibiotics. These complications did not delay their rehabilitation. Post-operative stiffness is reported to be more common after surgery compared to non-surgical treatment;23 however, all the patients in this series returned to their pre-injury level of professional sport, thus questioning the significance of this finding in this group of patients. Kerkhoffs et al. discussed that lateral ligament injuries grade II and above can lead to a disturbance of proprioception resulting in functional instability, as well as a reduction loss of extensor muscle strength. Post-operative regime is therefore based on a variety of exercises based on proprioception, strength, coordination and func-tion of the extremity.14 Perhaps the recovery of a professional athlete is not a reflec-tion of the general population or recreational athlete. Access to dedicated therapists and rehabilitation experts together with motivational issues drives these patients to get back to their pre-injury level of participation more quickly, and although it was not specifically investigated here, we believe that this is why significant stiffness was not reported in this high-demand group.

This study has some limitations. The study was a single surgeon series; however, a recognised and standard surgical technique was used for repair in all patients. Patients with previous ankle injury were not excluded from this study. A criticism therefore could be that patients with first-time ankle injuries were treated in the same group as patients with acute on chronic ankle instability, as we did not exclude any patients on this basis. The highly documented incidence and prevalence of ankle injuries in all sports particularly elite athletes 4,19 would make it likely that all patients would have had previous ankle injury. This therefore prevented the exclusion of those with previous injury from this study. All patients, however, had a history of acute ankle injury, and all were imaged with MRI scan 24 to confirm acute lateral ligament injuries. Post-operative range of motion was not documented. The return to sport and full participation at the pre-injury level and the subjective scores led us to assume any perceived stiffness was not significant enough to limit them. The fol-low-up is only 2 years. The Cochrane review showed weak evidence that surgically

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treated ankles had increased incidences of ankle arthritis at long-term follow-up compared to non-surgically treated ankles.13 Therefore, some of these patients may have deteriorated and developed recurrent instability or degenerative changes if fol-lowed up for longer – whether this could be a reflection of their sporting activities or recurrent injury is debatable. The major weakness is the lack of a comparative group. A randomised study would probably be impossible to perform in this group of patients, but there are no similar-sized studies in elite athletes with similar injuries looking at the results of non-surgical treatment. All we can conclude is that surgery leads to a high satisfaction rate, low morbidity at a minimum of 2 years and timely return to play.

CONCLUSION

In conclusion, the acute repair of grade III injuries in professional high-demand impact athlete leads to a predictable return to sport and may reduce the incidence of repeat sprains and intra-articular damage. These results act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation. This vital information allows the surgeon and physiotherapist to give informed rehabilitation advice and importantly aids in the management of the expectations of both patient and sports club as to expected return to training and top level sport.

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REFERENCES

1. Boytim MJ, Fischer DA, Neumann L (1991) Syndesmotic ankle sprains. Am J Sport Med 19:294–298

2. Brodsky A, O’Malley M, Bohne W, Deland J, Kennedy J (2005) An analysis of outcome measures following the Broström-Gould procedure for chronic lateral ankle instability. Foot Ankle Int 26:816–819

3. Broström L (1966) Sprained ankles VI: surgical treatment of ‘‘chronic’’ ligament ruptures. Acta Chir Scand 132:551–565

4. Fong D, Hong Y, Chan L, Yung P, Chan K (2007) A systematic review on ankle injury and ankle sprain in sports. Sports Med 37(1):73–94

5. Gregusch RV, Ferkel RD (2010) Treatment of the unstable ankle with and osteochondral defect. Am J Sport Med 38(4):782–794

6. Guillo S, Bauer T, Lee J, Takao M, Kong S, Stone J, Mangone P, Malloy A, Perera A, Pearce C, Michels F, Tourne Y, Ghorbani A, Calder J (2013) Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthop Traumatol Surg Res 99(8):411–419

7. Hinterman B, Valderrabano V, Boss A et al (2004) Medial ankle instability. An exploratory prospective study of fifty-two cases. Am J Sport Med 32:183–190

8. Kannus P, Renstrom P (1991) Current concept review. Treatment for acute tears of the lateral ligaments of the ankle. J Bone Joint Surg Am 73:305–312

9. Karlsson J, Bergstern T, Peterson L (1988) Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg 70:581–588

10. Katcherian D (1994) Soft-tissue injuries of the ankle. In: Lut ter LD, Mizel MS, Pfeiffer GB (eds) Orthopaedic knowledge update: foot and ankle. AAOS, Rosemont, pp 241–253

11. Kerkhoffs GM, Tol J (2012) A twist on the athlete’s ankle twist: some ankles are more equal than others. Br J Sports Med 46(12):835–836

12. Kerkhoffs GM, Van Dijk CN (2013) Acute lateral ankle ligament ruptures in the athlete: the role of surgery. Foot Ankle Clin 18(2):215–218

13. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA (2007) Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev CD000380

14. Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek PA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, Rosenbrand KC, Kuipers T, Hoogstraten JW, Dekker R, Ten Duis HJ, van Dijk CN, van Tulder MW, van der Wees PJ, de Bie RA (2012) Diagnosis, treatment and prevention of ankle sprains: an evidence based clinical guideline. Br J Sports Med 46(12):854–860

15. Kibler WB (1996) Arthroscopic findings in ankle ligament reconstruction. Clin Sports Med 15:799–804.

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16. Lee M, Cha JG, Lee YK et al (2012) The bright rim sign on MRI for anterior talofibular ligament injury with arthroscopic correlation. Am J Roentgenol 198(4):885–890

17. McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN (2013) Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 21(6):1328–1337

18. McCriskin BJ, Kl Cameron, Orr JD, Watermann BR (2015) Management and prevention of acute and chronic instability in athletic patient populations. World J Orthop 6(2):161–171

19. Nelson A, Collins C, Yard E, Fields S, Comstock R (2007) Ankle injuries among United States high school sports athletes, 2005– 2006. J Athl Train 42(3):381–387

20. Oae K, Takao M, Uchio T, Ochi M (2010) Evaluation of anterior talofibular ligament injury with stress radiography, ultrasound and MR imaging. Skeletal Radiol 39(1):41–47

21. Peters J, Trevino S, Renstrom P (1991) Chronic lateral ankle instability. Foot Ankle 12:182–191

22. Pijnenburg ACM, van Dijk CN, Bossuyt PM, Marti RK (2000) Treatment of ruptures of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg 82-A(6):761–773

23. Saxena A, Eakin C (2007) Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sport Med 35(10):1680–1687

24. van den Bekerom M, Kerkhoffs G, McCollom G, Calder J, van Dijk C (2013) Management of acute lateral ligament injury in the athlete. Knee Surg Sports Traumatol 21(6):1390–1395

25. van Dijk C, Bossuyt P, Marti R (1996) Medial ankle pain after lateral ligament rupture. J Bone Joint Surg Br 78(4):562–567

26. van Dijk C, Mol B, Lim L, Marti R, Bossuyt P (1996) Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand 67(6):566–570

27. Verhagen E, Van der Beek A, Bouter L, Bahr R, Van Mechelen W (2004) A one season prospective cohort study of volleyball injuries. Br J Sports Med 38(4):477–48

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part IIANKLE ARTHROSCOPY AND

TALAR OSTEOCHONDRAL LESIONS

5HISTOLOGICAL EVALUATION OF CALCANEAL

TUBEROSITY CARTILAGE – A PROPOSED DONOR SITE FOR OSTEOCHONDRAL

AUTOLOGOUS TRANSPLANT FOR TALAR DOME OSTEOCHONDRAL LESIONS

James D. F. Calder, Moez Ballal, Rupinderbir Deol, Christopher Pearce, Paul Hamilton, Michael Lutz

Foot and Ankle Surgery 2016; 21:193-97

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ABSTRACT

Background: Osteochondral Autologous Transplant (OATs) as a treatment option for Osteochondral lesions (OCLs) of the talar dome frequently uses the distal femur as the donor site which is associated with donor site morbidity in up to 50%. Some studies have described the presence of hyaline cartilage in the posterior superior calcaneal tuberosity.

Aim: The aim of this study was to evaluate the posterior superior calcaneal tuberosity to determine if it can be a suitable donor site for OATs of the talus

Methods: In this cadaveric study, we histologically evaluated 12 osteochondral plugs taken from the posterior superior calcaneal tuberosity and compared them to 12 osteochondral plugs taken from the talar dome.

Results: In the talar dome group, all samples had evidence of hyaline cartilage with varying degrees of GAG staining. The average hyaline cartilage thickness in the sam-ples was 1.33 mm. There was no evidence of fibrocartilage, fibrous tissue or fatty tissue in this group. In contrast, the Calcaneal tuberosity samples had no evidence of hyaline cartilage. Fibrocartilage was noted in 3 samples only.

Conclusions: We believe that the structural differences between the talus and calca-nium grafts render the posterior superior calcaneal tuberosity an unsuitable donor site for OATs in the treatment of OCL of the talus.

Level of evidence III

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INTRODUCTION

The ankle joint is exposed to greater loads than any other joint in the body and any incongruence in the articulation may lead to degenerative change.1 Osteochondral lesions (OCLs) of the talar dome are relatively frequent sequelae of ankle trauma with a reported incidence of 6.5% following ankle sprain.2 Up to 70% of ankle fractures can be associated with articular cartilage injury.3

Debridement and bone marrow stimulation (microfracture) is the treatment of choice for those lesions less than 15mm in diameter that have failed non-operative management.4 The critical size above which microfracture has a poor outcome is difficult to determine with some authors indicating poor outcome in lesions greater than 15mm2, but alternative techniques such as osteochondral autologous trans-plant surgery (OATS) has been advocated for these larger lesions and also following failed microfracture surgery.4-7 The purpose of OATS is to reproduce the structural and biomechanical properties of original articular hyaline cartilage as closely as pos-sible and normally healthy donor osteochondral grafts are usually taken from the ipsilateral knee. However, donor site morbidity in a previously asymptomatic knee is of concern with the OATS procedure with knee pain being reported in up to 36% of such individuals.7-14 Additionally, the histological features of knee hyaline cartilage (with respect to thickness, orientation of the collagen and depth of the tidemark) are known to be very different from that in the talus.15 Therefore, it would be beneficial to identify an alternative donor site which is less liable to give iatrogenic symptoms and where there is comparable articular cartilage to the talus.

The posterior superior calcaneal tuberosity increases the lever arm of the Achilles and therefore resists compressive as well as shear forces. Several studies have iden-tified fibrocartilage covering the tuberosity on the anterior wall of the retrocalcaneal bursa.16,17 However, others have reported that the tuberosity is covered with a hya-line-like cartilage raising an interesting possibility that this could be used as a poten-tial donor site for OATS.18,19

Given the potential clinical benefit of a local donor site for OATS procedures of talar OCLs, we conducted a histological evaluation of the posterior superior calca-neal tuberosity comparing cartilage with that from the talar dome. We hypothesised that this area could be a suitable harvest site for OATS of the talar dome with hyaline cartilage similar to that of the talus.

MATERIALS AND METHODS

This is a lab based cadaveric study conducted on below knee amputated fresh fro-zen cadaveric leg specimens. Local institutional ethical board approval was granted. Specimens were thawed overnight and the samples were harvested within 24 hours. There were seven male and five female specimens with an average age of 60.3 years (41–80 years).

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Osteochondral grafts were taken from consistent sites on both the posterior supe-rior aspect of the calcaneal tuberosity and from the antero-medial talar dome.

The postero-superior aspect of the calcaneal tuberosity, typically defined as the anterior wall of the retrocalcaneal bursa, was located following a medial para-ten-dinous approach to the Achilles tendon just proximal to its insertion (Fig 1). Osteo-chondral harvesting was performed using OATS harvesting equipment with a standard corer harvesting 6.5 mm diameter grafts (Smith & Nephew, Andover, MA).

The talar samples were taken from the antero-medial talar dome via a longitudinal antero-medial arthrotomy.

All specimens were assessed histologically for the presence of either hyaline car-tilage or fibrocartilage. If hyaline cartilage was present, a measurement of its thick-ness/depth to the tidemark region was be made.

Samples were placed in 10% formalin and underwent standardised histolog-ical preparation. Samples were decalcified in 10% formic acid and ethylenedi-amine-tetraacetic acid (EDTA). The specimens were then dehydrated, processed and embedded into paraffin wax using Tissue-Tek VIP tissue processor (Sakura Finetek, Torrance, CA, USA). Sections were then cut so that the cartilage surface was parallel to the blade. Longitudinal sections were taken at 5 µm thickness and stained for Safr-anin O and Hematoxylin and Eosin stains.

Low magnification images of all the stained sections were captured using the Leica DFC 450C camera (Leica Microsystems, Wetzlar, Germany) attached to the DM4000 microscope (Leica Microsystems, Wetzlar, Germany) at x63 magnification (Figs 2 and 3). Images were captured using the JVC KY-F1030 camera (Victor Company of Japan,

RB

RC

EC

AT

OCG

Fig. 1 Diagram of posterior superior calcaneus showing area of entheseal fibrocartilage (EC) and the insertion of the Achilles tendon (AT) and retrocalcaneal fibrocartilage (RC) on the anterior wall of the retrocalcaneal bursa (RB) and the position for harvesting of the osteochondral graft (OCG).

Histological evaluation of calcaneal tuberosity cartilage | 75

5Fig. 2 Sample of talar osteochondral graft (x63 magnification)

Fig. 3 Sample of posterior superior calcaneal tuberosity osteochondral graft (x63 magnification)

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Yokohama, Japan) attached to a Leica MZ6 stereomicroscope (Leica Microsystems, Wetzlar, Germany) at x3 magnification.

Average cartilage thickness measurements were carried out on Safranin O images using Image Pro Plus v.6 software (Media Cybernetics, Rockville, MD, USA). The dis-tance was measured between a line traced along the length of the cartilage surface and another along the interface between the cartilage and subchondral bone (Fig 4). The average distance between the two lines was then calculated. Observational assessments of the slides included assessment of subchondral bone plate, hyaline cartilage, glycosaminoglycans (GAG) staining, fibrocartilage, fibrous tissue and fatty tissue.

RESULTS

Twenty-four graft specimens were harvested and transferred for histological assessment – 12 from the posterior superior calcaneal tuberosity region and 12 har-vested from the Talar dome region. Observations for each specimen and are shown in Table 1.

In the talar dome group, all samples had evidence of hyaline cartilage with varying degrees of GAG staining. A subchondral bone plate was present in all samples and there was no evidence of fibrocartilage, fibrous tissue or fatty tissue in this group.

In contrast, none of the calcaneal tuberosity samples had evidence of hyaline car-tilage. Fibrocartilage was noted in three samples only. Eight out of the 12 samples in this group had a subchondral plate. Six out of the 12 specimens had areas of fibrous tissue and/or fatty tissue.

Fig. 4 Demonstration of measurement of cartilage thickness on 5mm thickness Safranin O specimens (x63 magnification).

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Table 1. Characteristics of the samples. Talus samples are taken from antromedial talar dome. Calcaneal samples are taken from posterior superior calcaneal tuberosity.

Sample area

Subchon-dral bone plate

Hyaline cartilage

Hyaline cartilage thickness (mm)

GAG staining

Fibrocar-tilage

Fibrous tissue

Fatty tissue

TA1 Yes Yes 1.47 YesS No No No

TA2 Yes Yes 1.42 Yesm No No No

TA3 Yes Yes 1.34 YesS No No No

TA4 Yes Yes 1,28 Yesm No No No

TA5 Yes Yes 1.29 YesS No No No

TA6 Yes Yes _b Yes No No No

TA7 Yes Yes 1.25 Yesm No No No

TA8 Yes Yes 0.75 Yesm No No No

TA9 Yes Yes 1.92 Yesm No No No

TA10 Yes Yes _b YesS No No No

TAll Yes Yes 1.38 Yesm No No No

TAl2 Yes Yes 1.2 Yes No No No

CAl Yes No – YesS Yes Yes Yes

CA2 YesS No – No No No No

CA3 Yes No – No No YesS YesS

CA4 Yes No – YesS Yes No No

CA5 No No – No No No No

CA6 Yes No – No No Yes YesS

CA7 Yes No – YesS Yesa YesS Yes

CAS No No – No No No No

CA9 Yes No – No No Yes Yes

CA10 Yes No – No No No Yes

CAll No No – No No No No

CAl2 No No – No No No No

TA, talus dome samples; CA, calcaneal tuberosity samples; S, slight evidence; m, moderate evidence; GAG, Glycosaminoglycans.a Possible TA insertion site.b Not measured due to damage to cartilage layer.

All of the talar samples showed evidence of GAG that ranged from slight to moder-ate amounts. Conversely only 25% (3 out of 12) of the calcaneal tuberosity samples showed any evidence of GAG. Cartilage thickness was measured in 10 out of the 12 specimens in the talar dome group (two samples were excluded from measurement due to damage to the hyaline cartilage layer during histological preparation thus

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making measurement inaccurate). The average hyaline cartilage thickness in the talar dome samples was 1.33mm (range 0.73–1.92mm). As there was no hyaline cartilage in the calcaneal tuberosity group, the thickness of the cartilage was not measured in this group.

DISCUSSION

Good results are published in the literature following OATS procedure of the talus using grafts harvested from the distal femur.4,7,9,11,20 However, donor site morbidity such as knee pain and cyst formation is widely recognised and can lead to functional impairment as measured by the WOMAC and Lysholm scores.8-10,20-22 Additionally, although OATS partially restores contact mechanics of the ankle joint, the histology of knee articular cartilage is very different from the talus leading to incongruence between the graft and the surrounding talar articular cartilage.23 Therefore, identify-ing a local alternative donor site would be advantageous.

Local graft harvest has been described by Kreuz et al. who used the talus as a donor site in patients after failed primary arthroscopic management of talar OCDs.24 The grafts were harvested from the medial and lateral talar articular facets which are low weight-bearing articular areas. By using this technique, they have excluded the donor site morbidity seen with the knee. They recognised that the major limitation of this technique is that the graft size should not exceed 8 mm in diameter due to the small area of the donor site cartilage. Since OATS is usually indicated for those defects greater than 15mm the practical application of this technique is limited. They therefore recommended the knee as a donor site for larger defects.24

Although several studies have documented fibrocartilage covering the posterior superior calcaneal tuberosity, some have also reported the presence of hyaline-like cartilage raising the possibility that this region could be a suitable donor site.18,19,25 This would have the advantage of avoiding iatrogenic damage to an asymptomatic knee and the locality would also not impair postoperative rehabilitation.

Rufai et al. reported that fibrocartilage replaced calcaneal periosteum on the ante-rior wall of the retrocalcaneal bursa whilst there was sesamoid fibrocartilage on the Achilles tendon side of the bursa.16 However, fibrocartilage was only present when the posterior superior calcaneal tuberosity was prominent, whereas when the tuber-osity sloped forwards, and was not in contact with the Achilles tendon, fibrocartilage was absent. They suggest that fibrocartilage acts as an ‘‘articulation’’ protecting the tendon and calcaneal bone when they rub against each other during dorsiflexion of the ankle.

Katchlik et al. likewise described fibrocartilage as covering the posterior calca-neal tuberosity which measured 200–500 mm distally near the insertion of the Achilles but this gradually thinned continuously turning into a 170–200 mm layer of loose collagen connective tissue.26 Milz et al. also recognised differences in the thickness of the fibrocartilage on the calcaneal side of the retrocalcaneal bursa concluding that the thicker calcified fibrocartilage interface found distally at the

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insertion of the Achilles tendon interlocks in a complex manner and is fundamen-tal in the anchorage of tendons and ligaments to bone.17 They suggested that the more proximal changes with thinner fibrocartilage allow the posterior superior tuberosity to act as a pulley against the sesamoid cartilage on the anterior aspect of the Achilles tendon. However, other authors have suggested that in addition to the fibrocartilage of the retrocalcaneal bursa, the posterior superior calcaneal tuberosity undergoes a morphological change to hyaline-like cartilage reducing attrition to the tendon.25

With the practical advantages of using the posterior superior calcaneal tuberosity and the inconsistency in reports on the type of cartilage present we aimed to define the histological characteristics to see if this area could be suitable as a donor site for OATS.

Our results support the findings of Rufai et al., Miltz et al. and Katchlik et al. as we could only demonstrate fibrocartilage in some of the calcaneal tuberosity sam-ple.16,17,26 All our talar dome samples had evidence of hyaline cartilage with an average thickness of 1.33mm (0.73–1.92mm), similar to that reported elsewhere.27 There was no evidence of hyaline cartilage in any of the calcaneal tuberosity samples, despite reports to the contrary.18,19,25

It is also interesting to note that fibrocartilage with slight to moderate GAG content was only present in three of the calcaneal samples and these were all from the specimens where there was a vertical slope on the posterior superior calcaneal tuberosity which would ‘‘articulate’’ with the Achilles tendon, as described by Rufai et al.16 A further three samples had fibrous tissue and this would also concur with the study by Miltz et al. which recognised that there is a gradual change in the covering of the posterior superior aspect of the calcaneus with enthesial fibro-cartilage at the insertional region of the Achilles and a periosteal fibrocartilage layer giving way to fibrous tissue more proximally.17 Our study could be criticised for not taking the graft from the more distal aspect of the tuberosity adjacent to the Achilles tendon insertion as it is possible that this could explain our finding of a relative lack of fibrocartilage (Fig 1)). However, it would be impractical to har-vest osteochondral grafts further distally because of tension in the tendon at the entheseal region and the consequent danger of causing damage to the Achilles tendon itself.

A third of the calcaneal tuberosity samples had no subchondral bone plate. The subchondral plate functions as a support to the articular cartilage and helps in trans-mitting load from the cartilage into the cancellous bone lying beneath the articular surface.28 Zengerink et al. described that to achieve a satisfactory outcome in OATS an autologous graft must reproduce the recipient talar articular defect both structur-ally and functionally as closely as is possible.4 It would appear that these structural factors in addition to the complete lack of hyaline cartilage make the posterior supe-rior calcaneal tuberosity an unsuitable donor site for OATS.

In conclusion, for large OCLs of the talus, the knee, despite possible donor site morbidity, remains the most suitable donor site for OATS procedures and this is sup-ported by published literature. Our study suggests that the posterior superior calca-neal tuberosity is not a suitable site to harvest autologous osteochondral grafts.

| Chapter 580

ACKNOWLEDGMENT

The authors would like to thank D Farrar Smith & Nephew research centre in York for providing access to their bioskills laboratory in which the samples were taken and processed. We also would like to thank M Anderson and J Pitcher at the bioskills lab-oratory for their expertise and technical input in samples processing and histological evaluation.

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5

REFERENCES

1. Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg 2005; 13:152–8.

2. Van Buecken K, Barrack RL, Alexander AH, Ertl JP. Arthroscopic treatment of transchondral talar dome fractures. Am J Sport Med 1989; 17:350–6.

3. Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 2000; 82:345–51.

4. Zengerink M, Struijs PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc 2010; 18:238–46.

5. Al-Shaikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteo- chondral grafting for talar cartilage defects. Foot Ankle Int 2002; 23:381–9.

6. Browne JE, Branch TP. Surgical alternatives for treatment of articular cartilage lesions. J Am Acad Orthop Surg 2000; 8:180–9.

7. Kennedy JG, Murawski CD. The treatment of osteochondral lesions of the talus with autologous osteochondral transplantation and bone marrow aspirate concentrate: surgical technique. Cartilage 2011; 2:327–36.

8. Reddy S, Pedowitz DI, Parekh SG, Sennett BJ, Okereke E. The morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of osteochondral lesions of the talus. Am J Sports Med 2007; 35:80–5.

9. Hangody L, Vasarhelyi G, Hangody LR, Sukosd Z, Tibay G, Bartha L, et al. Autologous osteochondral grafting: technique and long-term results. Injury 2008;39(Suppl.):32–9.

10. LaPrade RF, Botker JC. Donor-site morbidity after osteochondral autograft transfer procedures. Arthroscopy 2004; 20:69–73.

11. Valderrabano V, Leumann A, Rasch H, Egelhof T, Hintermann B, Pagenstert G. Knee-to-ankle mosaicplasty for the treatment of osteochondral lesions of the ankle joint. Am J Sports Med 2009; 37(Suppl.):105–11.

12. Al-Shaikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteo-chondral grafting for talar cartilage defects. Foot Ankle Int 2002; 23:381–9.

13. Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autologous osteochondral grafts. J Bone Joint Surg Br 2002; 84:237–44.

14. Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus: is there a critical defect size for poor outcome? Am J Sports Med 2009; 37:1974–80.

15. Treppo S, Koepp H, Quan EC, Cole AA, Kuettner KE, Grodzinsky AJ. Comparison of biomechanical and biochemical properties of cartilage from human knee and ankle pairs. J Orthop Res 2000; 18:739–48.

16. Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res 1995; 13:585–93.

| Chapter 582

17. Milz S, Rufai A, Buettner A, Putz R, Ralph JR, Benjamin M. Three-dimensional reconstructions of the Achilles tendon insertion in man. J Anat 2000; 200:145–52.

18. Movin T, Ryberg A, McBride DJ, Maffulli N. Acute rupture of the Achilles tendon. Foot Ankle Clin 2005; 10:331–56.

19. Maffulli N. Current concepts review: rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81:1019–36.

20. Paul J, Sagstetter A, Kriner M, Imhoff AB, Spang J, Hinterwimmer S. Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus. J Bone Joint Surg Am 2009; 91:1683–8.

21. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important osteoarthritis of the hip or knee. J Rheumatol 1988; 15:1833–40.

22. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop 1985; 198:43–9.

23. Fansa AM, Murawski CD, Imhauser CW, Nguyen JT, Kennedy JG. Autologous osteochondral transplantation of the talus partially restores contact mechanics of the ankle joint. Am J Sports Med 2011; 39:2457–65.

24. Kreuz PC, Steinwachs M, Erggelet C, Lahm A, Henle P, Niemeyer P. Mosaic- plasty with autogenous talar autograft for osteochondral lesions of the talus after failed primary arthroscopic management: a prospective study with a 4- year follow-up. Am J Sports Med 2006; 34:55–63.

25. Carmont M, Valderrabano V, Maffulli N. Biomechanical considerations of insertional Achilles tendinopathy. In: Ackermann P, Calder J, Karlsson J, Maffulli N, Thermann H, van Dijk CN, editors. Pathology at the insertion of the Achilles tendon. DJO Publishing; 2012. p.37–44 [Chapter 5].

26. Kachlik D, Baca V, Cepelik M, Hajek P, Mandys V, Musil V. Clinical anatomy of the calcaneal tuberosity. Ann Anat 2008; 190:284–91.

27. Sugimoto K, Takakura Y, Tohno Y, Kumai T, Kawate K, Kadono K. Cartilage thickness of the talar dome. Arthroscopy 2005; 21:401–4.

28. Li B, Marshall D, Roe M, Aspden RM. The electron microscope appearance of the subchondral bone plate in the human femoral head in osteoarthritis and osteoporosis. J Anat 1999; 195:101–10.

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6RETURN TO TRAINING AND PLAYING

AFTER POSTERIOR ANKLE ARTHROSCOPY FOR POSTERIOR IMPINGEMENT IN ELITE

PROFESSIONAL SOCCER

James D. F. Calder, Shaun Sexton, Christopher Pearce

American Journal of Sports Medicine 2010 Jan; 38(1):120-124

| Chapter 686

ABSTRACT

Background: Posterior ankle impingement syndrome (PAIS) was first described in bal-let dancers but is increasingly being diagnosed in other sports. Operative treatment may be indicated when nonoperative measures have failed. Traditionally, operative treatment has involved an open approach; more recently, posterior ankle arthros-copy has been employed.

Aim: This study was conducted to describe the factors that influence return to play in professional athletes after posterior ankle arthroscopy for posterior ankle impinge-ment syndrome.

Study Design: Case series; Level of evidence 4.

Methods: A consecutive series of 28 elite professional soccer players who had clini-cally and radiologically diagnosed posterior ankle impingement syndrome that failed to respond to nonoperative treatment underwent posterior ankle arthroscopy for bony or soft tissue posterior ankle impingement syndrome over 5 years.

Results: Of the 28 players, 27 were available for follow-up. Five had a diagnosis of soft tissue impingement and underwent debridement with flexor hallucis longus release, 13 had a symptomatic os trigonum that was excised arthroscopically, and 9 had removal of a bony avulsion fragment from the posterior ankle ligament complex. The mean length of time to return to training postoperatively was 34 days and return to playing was 41 days (range, 29-72 days). The duration of symptoms before surgery and excision of bony impingement were significantly correlated with the time to return to training and playing. There were no major complications and no reopera-tions at an average of 23 months of follow-up (range, 15-49 months).

Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of pos-terior ankle impingement syndrome in the elite soccer player, with return to training expected at an average of 5 weeks.

Level of evidence IV

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6

INTRODUCTION

The symptoms of posterior ankle impingement syndrome (PAIS) are chronic pain, with or without swelling at the back of the ankle. These symptoms are usually associ-ated with activity and especially plantar flexion of the ankle. Ballet dancers are classi-cally prone to developing PAIS because of the repetitive and extreme plantar flexion of the ankle that is required in their sport.2,7

As our awareness of the condition increases, it is frequently being diagnosed in athletes in other sporting activities that involve forced plantar flexion of the foot, such as soccer, basketball, and running.5,6,10,12,16,19,24

Physical examination may reveal slight swelling and tenderness around the poste-rior ankle. The range of motion of the ankle may or may not be affected. Comparison with the unaffected side is helpful in unilateral presentations. Provocative tests are diagnostic and consist of passive plantar flexion of the ankle with the examiner’s thumb placed in the posterolateral and then posteromedial regions of the ankle. Further confirmation can be achieved by repeating the test after infiltration of local anaesthetic, under image guidance, between the posterior talar process (or os trigo-num) and the posterior tibia. It is also useful to test for flexor hallucis longus (FHL) involvement in the impingement by testing forced dorsiflexion and resisted plan-tar flexion of the great toe. Again, image-guided injections around the FHL tendon sheath may confirm the diagnosis and are potentially therapeutic.

Plain radiographs may reveal an obvious os trigonum or excessively long posterior process of the talus (Steida process) on the lateral view, as well as occasionally reveal-ing loose bodies at the back of the ankle joint. However, a fine-slice computed tomog-raphy (CT) scan is recommended as the most accurate method of identifying these.18 Magnetic resonance imaging (MRI) is useful to identify soft tissue oedema, fluid in the FHL sheath (Fig 1), tendinosis of the FHL tendon, and impingement caused by a prom-inent posterior intermalleolar ligament.4,15 Magnetic resonance imaging can also high-light oedema within or around a symptomatic os trigonum or Steida process (Fig 2).9,23

When treating professional athletes, one of the first questions asked of the doctors by both the players and trainers is when they will be able to train and compete again. The average length of time to return to activities (if known) in a general population may not be applicable to the elite athlete. We are often forced to make an educated guess depending on the condition of the player, the symptoms, and the treatment that is planned. Sometimes the decision to delay treatment until the off-season or even which treatment option is chosen depends on the answer given to the ques-tion. We report the first series of the results of posterior ankle arthroscopy from a population restricted to elite soccer players.

METHODS

Local Institutional Review Board approval was granted for this study. We looked ret-rospectively at a prospectively compiled database of a consecutive series of all the

| Chapter 688

Fig. 1 Axial T2-weighted MRI scan showing a large amount of fluid in the flexor hallucis longus tendon sheath.

Fig. 2 Sagittal fat-supressed MRI scan showing oedema around and within a symptomatic os trigonum.

professional soccer players on whom we have performed posterior ankle arthros-copy for both bony and soft tissue PAIS over a 5-year period with a minimum of 1 year of follow-up. All the players had been referred by their team physician or

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6

physiotherapist and had clinical and radiologic (plain radiographs plus MRI and/or CT) evidence of posterior ankle impingement. All had failed non-operative treatment including image-guided injections and were unable to perform at their required level because of the symptoms. We noted the length of symptoms before surgery and number of preoperative injections that they had received. We then assessed the time to return to training and the time to return to match play.

Operative TechniqueThe 2-portal endoscopic approach that we used was first described by van Dijk et al in 2000.22 The operations were undertaken with the patient under general anaesthe-sia. A thigh tourniquet was applied in the anaesthesia room while the patient was supine and then was placed prone on the operating table with the feet just off the end of the table.

Care was taken to ensure that appropriate padding was placed under the shins to prevent pressure areas developing. The limb was exsanguinated and the tourniquet inflated to 300 mm Hg. After standard preparation and draping, the borders of the Achilles tendon and the medial and lateral malleoli were marked with a surgical pen. Posterolateral and posteromedial longitudinal incisions were made for the portals adjacent to the lateral and medial borders of the Achilles tendon at the level of the lateral malleolus.17 The posterolateral portal was made first. Blunt dissection was undertaken using a haemostat aiming toward the second metatarsal until the bone of the posterior talus was felt against the tip. A 4.5-mm, 30° angled arthroscope (Dyonics, Smith & Nephew, Andover, Massachusetts), with normal saline irri-gation delivered by a pressure-controlled pump (Dyonics 25 Fluid Management System, Smith & Nephew), was inserted into the lateral portal via the blunt tro-char, again feeling the bone of the posterior talus against the tip. A haemostat was then introduced into the posteromedial portal and blunt dissection undertaken, aiming toward the arthroscope until the tip of the haemostat could be visualized. An arthroscopic shaver capable of both soft tissue and bony debridement (5.5-mm Bonecutter, Dyonics, Smith & Nephew) was then introduced into the medial por-tal with the cutting blade facing toward the Achilles tendon and arthroscope and away from the neurovascular bundle. When dealing with an os trigonum (Fig 3), the soft tissue attachments around it were first thoroughly released with a com-bination of arthroscopic punches and a shaver before removing it with a pituitary rongeur. If the fragment was very large, it was burred using a bone-cutting shaver and removed in pieces.

The FHL tendon can easily be visualized on the medial side of the joint (Fig 4). Often there is soft tissue impingement around this, which again can be debrided with a combination of arthroscopic punches and a soft tissue shaver. It is vitally important to remain to the lateral and posterior sides of the FHL to avoid the neuro-vascular bundle. When using a shaver, it is advisable to always keep the blade facing away laterally from the FHL and use the suction to draw the soft tissue that is to be removed toward it. It is possible to follow the FHL tendon down into its sheath to ensure that all tenosynovitic and scar tissue is debrided (Fig 5).

| Chapter 690

os trigonum

Sub-talar joint

Hook

Fig. 3 A large os trigonum after removal of the soft tissue attachments. An arthroscopic hook can be seen at the top of the picture and is being used to assess whether any soft tis- sue attachments remain.

TalusFHL

os calcis

Fig. 4 Flexor hallucis longus tendon after removal of an os trigonum.

Postoperative CareUnless there were any contraindications, we gave each player a 10-day course of nonsteroidal anti-inflammatory drugs to minimize the postoperative inflammatory response. We also encouraged them to ice the ankle for the first 5 days. We allowed weight-bearing as tolerated with crutches immediately, and encouraged early range of motion exercises. The physical therapists started to mobilize the FHL at 2 days

Return to Training and Playing | 91

6and the ankle at 5 days after surgery. Sutures were removed in clinic at 2 weeks. We allowed return to training to be determined by the patients and their physical therapists.

We reviewed our clinical and operative notes and those of the Football Association medical team. We also contacted all of the players’ physical therapists to confirm the data and to ensure that there had not been any relapse of symptoms or reoperation on the players that we had not been aware of.

Statistical AnalysisStatistical analysis was performed using MedCalc for Windows, version 9.6.4 (Med-Calc Software, Mariakerke, Belgium). A Spearman rank correlation coefficient was used to correlate nonparametric data and a Kruskal-Wallis test was used for nonpara-metric independent group analysis. Significance was accepted if P ≤ 0.05.

RESULTS

There were 33 players on whom we had performed a posterior ankle arthroscopy during the study period; of these, 28 had a minimum 1-year follow-up and, in fact, all of those had a minimum of 15 months’ follow-up. We were able to collect data on 27 of 28 players from the series. One player had been transferred to an Italian team postoperatively and we could not confirm the time to return to training or playing accurately; therefore, he was excluded from the study. Five players had a diagnosis of soft tissue impingement and underwent debridement with FHL release, 13 had a

FHL

Fig. 5 View down the flexor hallucis longus tendon sheath after release. Note the mild tendinopathic changes.

| Chapter 692

symptomatic os trigonum that was excised arthroscopically, and 9 had a bony pull-off fragment from the posterior ankle ligament complex that was excised and the FHL was released.

The mean follow-up was 23 months (range, 15-49 months). The average age of the players was 25 years (range, 18-32 years). All players were from Premier League or Coca-Cola Championship clubs (the top 2 tiers of English soccer). All of the players had had at least 1 injection of local anaesthetic and steroid into the area before sur-gery with the average number of injections being 2 (range, 1-5). The average length of symptoms before surgery was 8 months (range, 3-18 months). The mean length of time to return to training postoperatively was 34 days (range, 24-54 days) and return to playing was 41 days (range, 29-72 days).

There was a significant correlation between the length of symptoms and the num-ber of preoperative injections (Spearman rank correlation coefficient = 0.806; P < 0.001). There was no correlation between the number of preoperative injections and return to training (correlation coefficient = 0.053; P = 0.794) or the number of preop-erative injections and return to play (correlation coefficient = 0.016; P = 0.938). There was, however, a significant correlation between the length of symptoms preopera-tively and return to training (correlation coefficient = 0.383; P = .048) and return to play (correlation coefficient = 0.385; P = 0.048). Return to training was significantly faster after soft tissue debridement with FHL release (mean 28 days) than after bony surgery (mean 40 days) (P = 0.046 Kruskal-Wallis test). When comparing return to play between surgery for bony and soft tissue impingement, there was a similar trend but this did not quite reach statistical significance (P = 0.078). There was one surgical complication in the form of a persistent portal leakage postoperatively. This was successfully treated by resting the ankle in an Aircast boot (DJO, LLC, Vista, Cali-fornia) for 2 weeks. Only 1 patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound-guided injection of local anaesthetic and steroid, and he remains symptom-free 18 months later. All other players contin-ued training and competing symptom-free at an average of 23 months’ follow-up. There were no reoperations. There were no infections and no incidence of neurovas-cular damage.

DISCUSSION

Traditionally, surgical treatment for PAIS was undertaken with an open procedure via either a posteromedial or posterolateral approach. The results of these in the ortho-paedic literature have been reasonable, with good to excellent results of up to 75% being reported.7 Arthroscopic surgery has improved the reported complication rates of between 15% and 24% as well as the recovery times of between 3 and 5 months for open procedures.1-3,7,11

Recovery time after an injury or operative intervention in a professional athlete may be very different from that of the recreational sportsperson or sedentary indi-vidual. One might assume that, because of the very high levels of performance

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6

expected, the athlete may take longer to return to a preinjury level than the average person. However, better access to expert aftercare by dedicated physical therapists and issues of motivation often mean that an athlete rehabilitates more quickly.

In terms of return to training (5 weeks) and match play (6 weeks) in this series of exclusively professional footballers, the results compare favourably with those in the literature for similar procedures in a general population. In a combined group of both posttraumatic and overuse patients, the originator of the arthroscopic proce-dure that we use found that the average time to return to work after surgery was 3 weeks, with return to sports at 9 weeks.20,21 Jerosch and Fadel 8 found that of their 10 athletic patients (which included 3 professionals), 9 were symptom-free for activities of daily living within 4 weeks. They resumed their sporting activities within 8 weeks. Willits et al 24 reviewed 16 of their 24 posterior ankle arthroscopies. These appear to have been recreational athletes, men and women, with a similar range of causes for posterior impingement as in our series. They reported excellent clinical results with no major complications. The return to sport was, however, relatively slow with an average of 5.8 months and 1 patient did not return to their preinjury level.

Many athletes, especially professionals, will have had 1 or more injections of local anaesthetic and/or steroid into the posterior ankle to treat the impingement symp-toms and these may be successful, especially when imageguided,13,14,16 but we need also to be mindful of the potential complications.14 Often a player’s symptoms can be kept under control during the playing season with image-guided injections and then, if necessary, the definitive procedure can be carried out in the off-season. Although there was no correlation in our series between the number of preoperative injections and the time taken to return to the field of play, there was a correlation between the length of symptoms before surgery and return to training and playing. Doctors, play-ers, and trainers should bear this in mind in their decision making. Similarly, in a series that included some professional athletes, Abramowitz et al 1 found significantly better results after open excision of an os trigonum in patients who had been symptomatic for less than 2 years than in those with symptoms for longer than that Van Dijk 19 found that the results of arthroscopic treatment of bony posterior ankle impingement were better than those of soft tissue impingement. He stated that this may be due to more accurate diagnosis for bony impingement as well as a possible increased incidence of re-accumulation of scar tissue after soft tissue debridement. These findings were not borne out in our series, in that we found that players treated for soft tissue impinge-ment returned to the field of play more quickly than those who had undergone bony debridement. Moreover, our 1 patient who had recurrent symptoms necessitating a postoperative injection had undergone excision of an os trigonum.

CONCLUSION

Posterior ankle arthroscopy is safe and effective in the treatment of PAIS in the elite soccer player, with return to training expected at an average of 5 weeks and return to play at an average of 6 weeks.

| Chapter 694

REFERENCES

1. Abramowitz Y, Wollstein R, Barzilay Y, London E, Matan Y, Shabat S, Nyska M. Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am. 2003;85(6):1051-1057.

2. Brodsky AE, Khalil MA. Talar compression syndrome. Am J Sports Med. 1986;14(6):472-476.

3. Ferkel RD, Small HN, Gittins JE. Complications in foot and ankle arthroscopy. Clin Orthop Relat Res. 2001;391:89-104.

4. Fiorella D, Helms CA, Nunley JA 2nd. The MR imaging features of the posterior intermalleolar ligament in patients with posterior impingement syndrome of the ankle. Skeletal Radiol. 1999;28(10):573-576.

5. Fuller CW, Walker J. Quantifying the functional rehabilitation of injured football players. Br J Sports Med. 2006;40(2):151-157.

6. Hagglund M, Walden M, Bahr R, Ekstrand J. Methods for epidemiological study of injuries to professional football players: developing the UEFA model. Br J Sports Med. 2005;39(6):340-346.

7. Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers: differential diagnosis and operative treatment. J Bone Joint Surg Am. 1996;78(10):1491-1500.

8. Jerosch J, Fadel M. Endoscopic resection of a symptomatic os trigonum. Knee Surg Sports Traumatol Arthrosc. 2006;14(11):11881193.

9. Lee JC, Calder JD, Healy JC. Posterior impingement syndromes of the ankle. Semin Musculoskelet Radiol. 2008;12(2):154-169.

10. Lee KB, Kim KH, Lee JJ. Posterior arthroscopic excision of bilateral posterior bony impingement syndrome of the ankle: a case report. Knee Surg Sports Traumatol Arthrosc. 2008;16(4):396-399.

11. Marotta JJ, Micheli LJ. Os trigonum impingement in dancers. Am J Sports Med. 1992;20(5):533-536.

12. McMaster WC, Walter M. Injuries in soccer. Am J Sports Med 1978;6(6):354-357.

13. Messiou C, Robinson P, O’Connor PJ, Grainger A. Subacute posteromedial impingement of the ankle in athletes: MR imaging evaluation and ultrasound guided therapy. Skeletal Radiol. 2006;35(2): 88-94.

14. Orchard JW. Benefits and risks of using local anaesthetic for pain relief to allow early return to play in professional football. Br J Sports Med. 2002;36(3):209-213.

15. Peace KA, Hillier JC, Hulme A, Healy JC. MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin Radiol. 2004;59(11):1025-1033.

16. Robinson P, Bollen SR. Posterior ankle impingement in professional soccer players: effectiveness of sonographically guided therapy. AJR Am J Roentgenol. 2006;187(1):W53-58.

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17. Sitler DF, Amendola A, Bailey CS, Thain LM, Spouge A. Posterior ankle arthroscopy: an anatomic study. J Bone Joint Surg Am. 2002;84(5):763-769.

18. Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S. Imaging features of avulsion injuries. Radiographics. 1999;19(3):655-672.

19. van Dijk CN. Anterior and posterior ankle impingement. Foot Ankle Clin. 2006;11(3):663-683.

20. van Dijk CN. Hindfoot endoscopy. Foot Ankle Clin. 2006;11(2): 391-414, vii.21. van Dijk CN. Hindfoot endoscopy for posterior ankle pain. Instr Course

Lect. 2006; 55:545-554.22. van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for

diagnosis and treatment of posterior ankle pathology. Arthroscopy. 2000;16(8):871-876.

23. Wakeley CJ, Johnson DP, Watt I. The value of MR imaging in the diagnosis of the os trigonum syndrome. Skeletal Radiol. 1996;25(2):133-136.

24. Willits K, Sonneveld H, Amendola A, Giffin JR, Griffin S, Fowler PJ. Outcome of posterior ankle arthroscopy for hindfoot impingement. Arthroscopy. 2008;24(2):196-202.

part IIITHE PLANTARIS TENDON AND

ACHILLES TENDINOPATHY

7PLANTARIS INJURIES IN ELITE UK TRACK AND

FIELD ATHLETES OVER A 4‑YEAR PERIOD: A RETROSPECTIVE COHORT STUDY

Noel Pollock, Paul Dijkstra, James D. F. Calder, Robin Chakraverty

Knee Surgery Sports Traumatology Arthroscopy 2016 Jul; 24(7):2287-92

| Chapter 7100

ABSTRACT

Background: The plantaris tendon is present in 98–100% of people, and a potential relationship between the plantaris tendon and the development of Achilles tendi‑nopathy has been postulated. There are no studies on the epidemiology of plantaris injuries in a sporting population.

Aim: This retrospective cohort study presents the incidence, nature and outcome of plantaris injuries in elite British track and field athletes.

Method: All 214 elite athletes supported by the British Athletics Medical team from 2009 to 2013 were included in this cohort study. An injury was recorded if a plan‑taris injury was diagnosed and confirmed with imaging or surgical findings. Patient demographics, injury details and return to competitive elite track and field were recorded.

Results: There were 33 new plantaris injuries, with an annual plantaris injury inci‑dence of 3.9–9.3%. There were significantly more right‑sided plantaris injuries in bend running sprinters (15 right‑sided vs. 4 left‑sided). 74% of the athletes who had a plantaris injury also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes during the course of the study with 12 of the 13 athletes returning to the same level on the Tegner activity scale.

Conclusion: This retrospective cohort study demonstrates that plantaris injuries are common in elite track and field athletes and may be underreported in the literature. There may be an association between the biomechanics bend sprinting and plantaris injury. Elite athletes may benefit from appropriate preventative and management strategies implemented by coaching and medical teams.

Level of evidence IV

Plantaris injuries in elite UK track and field athletes | 101

7

INTRODUCTION

The plantaris originates from the posterolateral femoral condyle and traverses medi‑ally in the mid‑calf, between gastrocnemius and soleus, to descend along the medial aspect of the Achilles tendon. It has a variable insertion directly into the Achilles ten‑don or separately into the calcaneus.27 It has a small proximal muscle and a long thin distal tendon. Throughout the literature, it is often discussed as a vestigial structure that is absent in 8–20% of limbs.9,13,18,24 However, more recent cadaveric studies have identified a plantaris tendon in 98–100% of specimens.21, 27 Therefore, the proposi‑tion that the plantaris is a vestigial or irrelevant rudimentary structure may need to be reconsidered.

Complete tears of the plantaris muscle and tendon have been reported in the liter‑ature.4,7,11 Rupture is reported to be most common at the muscle tendon junction in the upper part of the calf 4,10,14 but may also occur in the long thin tendon.4 In recent years, it has been postulated that the plantaris tendon has a role in the development of mid‑portion Achilles tendinopathy.1,25,27 The plantaris tendon is in close proximity to the Achilles tendon, and in some cases, a retinacular like adhesion may be pres‑ent.27 The adherence or invagination of highly innervated peritendinous tissue3,22 to the Achilles may induce tendon region pain. Friction and traction forces may result in inflammatory change around the Achilles tendon and potentially intratendinous pathology through compression or a mechanotransduction stimulus.6

There are a number of published surgical case series of plantaris removal but no studies that comment on surgical and non‑surgical cases of plantaris injury in a sporting population.1,19,26 The aim of this retrospective cohort study was to report on the incidence of plantaris injuries in a cohort of 214 elite track and field athletes who were supported by the British Athletics Medical Team over a 4‑year period from 2009 to 2013. A secondary aim was to explore the nature of these injuries, including the event type, side of injury and outcome data regarding return to elite sport. The potential role of plantaris in sporting function and pathogenesis of plantaris pathol‑ogy in elite track and field athletes is discussed.

MATERIALS AND METHODS

All athletes supported by the British Athletics Medical Team from September 2009 to September 2013 were eligible for inclusion, and athletes with a plantaris injury were asked for consent for their record to be retrospectively analysed. Ethical approval was granted by QMUL, London. These athletes were managed by a full‑time employed medical team of 3 Sports Medicine physicians and a number of physical therapists. Each athlete had competed for the Great Britain Athletics Team at an international competition (European or World Championships or Olympic Games).

Each athlete had detailed electronic medical records (EMR) on the British Athlet‑ics Profiler EMR in which every injury was recorded. For this system, an injury was

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defined as any physical complaint sustained by an athlete that required assessment or treatment by one of three fulltime British Athletics medical doctors. A plantaris injury was included in this study if the sports medicine physician diagnosed plantaris injury in the clinical notes with, in addition, an ultrasound or MRI scan, or in‑surgical findings demonstrating injury to the plantaris. The clinical diagnosis was made, and subsequent imaging undertaken, with the presentation of limitation of function by pain specifically along the medial border of the Achilles tendon.

There were 3 recorded diagnoses related to the plantaris tendon in the study. A complete or partial rupture was diagnosed with an appropriate history of acute onset pain at the medial aspect of the Achilles tendon with 1.5 T or 3 T MRI and ultra‑sound visualisation of the complete or plantaris tear (Figs 1, 2 and 3). A plantaris ten‑dinopathy/plantaris friction syndrome was recorded when an athlete presented with pain at the medial aspect of the Achilles and ultrasound findings of hypoechogenicity

Fig. 1 MR image of complete plantaris rupture

MEDIAL

Ach

Fig. 2 US axial image of complete plantaris rupture

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and vascularity around the plantaris tendon or intrasubstance change within the plantaris consistent with tendinopathy was visualised on ultrasound (Fig 4).

Athlete demographics, sporting event information as well as specific information relating to the injury diagnosis, including date of injury, imaging and the affected side, were all recorded. The time to return to full training was recorded, and further exacerbations of the same injury were also noted. Due to the postulated association of plantaris and Achilles tendon pathology, the incidence of Achilles tendinopathy (as recorded by the team doctor and based on pain, swelling and ultrasound exam‑ination of the Achilles tendon) in all athletes was also recorded. The total number of injuries in the whole athlete cohort (including site of injury) was also recorded.

Injury treatment was determined as conservative or surgical management. Con‑servative management was based on physical therapy rehabilitation prescribed by

Fig. 3 MR image of partial plantaris rupture

med

Fig. 4 Thickened plantaris tendon with peri‑plantaris fluid and vascularity

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the British Athletics medical team. The principles of rehabilitation were stepwise progression of strength‑based exercise in the weights room and pain‑free quality of athletic movements including drills and running. Surgical management was excision and removal of the plantaris tendon using a small medial incision as reported in the literature.2,19 In cases of concomitant Achilles tendon pathology, the ventral aspect of the Achilles tendon was also scraped as described in the literature.2 Indications for surgery were failure of adequate symptom resolution with conservative man‑agement and agreement with the coach and athlete that further intervention was required to improve athletic function.

A Tegner activity level scale and performance details in return to elite sport were also recorded.29

Statistical analysisChi‑squared test was used to test for difference in limb presentation in bend running sprinters. T test was used to assess for difference in age in those athletes with addi‑tional Achilles tendon pathology. p < 0.05 was considered significant.

RESULTS

Over the 4 years of the study, there were a total of 214 athletes eligible for inclusion (95 females (24 years ± 5.5) and 119 males (23 years ± 4.4)). There were 134 power ath‑letes (sprinters (n = 85), jumpers (40), multi‑eventers (9)), 57 endurance athletes and 23 throwing athletes. There were a total of 1,000 injuries during the study period of which 252 were injuries to the lower leg or ankle. There were 33 new plantaris injuries during the study period. These occurred in 30 athletes with 3 athletes having injuries to both plantaris tendons. The annual incidence of a new plantaris injury was 3.9–9.3% (Table 1). The incidence of surgical intervention for all plantaris injuries was 51.5%.

Of the 33 injuries, 19 were in sprinters (representing 22% of all sprinters) and 10 in endurance runners (18% of endurance runners). In the sprinting group, there were 12 right side‑only presentations and only 1 left side‑only presentation (Fig 5). Three sprinters developed symptoms from both plantaris tendons over the course of the study. The increased incidence of right‑sided presentations in bend running sprinters was significant (p < 0.05). In the endurance group, there were 6 left side‑only and 4 right side‑only presentations.

There were 4 complete ruptures of the plantaris tendon. These were all right‑sided, and the athletes returned to full training and competition within 8 weeks (6 ± 2 weeks) without further clinical presentations.

Table 1. Annual plantaris injury incidence

Year 2009–2010 2010–2011 2011–2012 2012–2013

No. of athletes 133 127 117 86

No. of plantaris injuries 11 5 9 8

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There were 4 partial ruptures of the plantaris tendon. Two of these were in sprint‑ers, and both were right‑sided. The other 2 were left‑sided partial tears in endur‑ance athletes. Two of the athletes with partial plantaris ruptures were managed conservatively and returned to full training and competition within 8 weeks without further sequelae. One athlete developed more long‑standing symptoms and under‑went surgical resection of the plantaris. One athlete had early surgical intervention to remove the partially torn plantaris tendon. This athlete returned to full training within 6 weeks.

There were 25 cases of plantaris friction syndrome/ plantaris tendinopathy. Most athletes returned to full training in <8 weeks but 4 athletes had ongoing symptoms for >1 year that required continued modification of training. Of all the cases of plan‑taris injury, 74% of these athletes also had a diagnosis of Achilles tendinopathy on the same side at some point over the study period. The average age of the athletes with plantaris injuries who did not have an Achilles tendinopathy presentation (22.1 ± 3.9 years) was significantly less than the age of the group who did have a presen‑tation of Achilles tendinopathy (26.4 ± 4.0 years) during the study period (p < 0.05). There were 50 athletes who presented with Achilles tendinopathy without plantaris injury.

Surgical resultsOver this study period, 17 plantaris tendons were removed from 13 athletes (4 athletes had simultaneous bilateral removal). Three different experienced foot and ankle surgeons performed the surgery. In 15 of the operated cases, the anterior portion of the Achilles tendon was also scraped as described in the literature.2 All athletes had a standard rehabilitation protocol prescribed and supervised by the British Athletics Medical team doctors and physiotherapists who were employed in a full‑time capacity.

18

16

14

12

10

8

6

4

2

0Sprints Endurance

Bilateral Right only Left only

Fig. 5 Right side‑only, left side‑only and bilateral plantaris injuries by event type

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The indications for surgery were plantaris tendinopathy with associated Achil‑les tendinopathy in 16 cases and a partial plantaris rupture in 1 case. The average post‑surgical follow‑up was 23 months ± 10.5 (range 12–48 months). By the end of the study period, 12 of the 13 athletes had returned to the same level on the Tegner activity scale (Level 8) and 1 athlete was still rehabilitating from further injuries around the Achilles tendon. However, only nine (9/13) athletes returned to at least the same performance level (time or distance) in their athletic event following the surgery. The average time to return to full training following surgery was 2.6(±1.5) months.

Following the operation to remove the plantaris tendon, three (3/13) athletes had further presentations of Achilles pain and required an additional operation. Each of these patients had associated Achilles tendinopathy and initially bilateral surgery. Subsequent intratendinous repair surgery was performed due to a new partial tear in one Achilles tendon. In each case, these occurred within 2 years of their original operation and within the study period.

There was one post‑operative complication with wound dehiscence necessitating surgical debridement.

DISCUSSION

Controversy has existed in the literature regarding the occurrence of plantaris injury with several investigators questioning its existence.17,23 While plantaris injury has been reported in more recent literature, the injury has still been considered rare.4,12 The most important finding in this study is the report of an annual incidence of a new plantaris injury in 3.9–9.3% of elite track and field athletes, more commonly in sprinting ath‑letes, suggesting that plantaris injury may have been previously under recognised.

There may be biomechanical reasons that predispose the plantaris to injury in elite track and field athletes. It is a plantar flexor and therefore will be important in running and sprinting athletes, who require large plantar flexor forces, throughout the full range of plantar flexion. Athletes in other sports and recreational athletes may not require the same range or maximal plantar flexion recruitment. It has a long thin tendon that should confer stiffness and elastic energy return resulting in perfor‑mance improvement in sprinting and fast‑paced running.

It is particularly interesting to note that plantaris injuries occurred significantly more frequently on the right side in bend running sprinters. In addition, all four of the complete plantaris ruptures occurred on the right side. In endurance athletes who do less frequent bend running, and with less force, there were no side‑to‑side differences. Bend sprinting, more so than running, results in different forces on both lower limbs.5 The right leg is required to generate more power, and the left leg has a longer ground contact time and rotational force. Therefore, the greater incidence of right‑sided pathology in bend sprinters may support a proposed role of the plan‑taris as a plantar flexor in fast sprinting and excessive load may be implicated in the pathogenesis of plantaris injury.

A substantial proportion (74%) of athletes with a plantaris injury also presented with Achilles tendinopathy at some point during the study period. There have been

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a number of recent reports suggesting a role of the plantaris in the development of tendinopathy. Adhesions or retinacular tissue that binds the Achilles to the plan‑taris have been identified.27 Further biomechanical studies have identified that the plantaris tendon is stiffer and stronger than the Achilles tendon demonstrating less capacity for elongation in response to load.16 These different mechanical properties could result in a friction‑induced inflammatory reaction between the Achilles and plantaris. This may result in pain from the site, and continued peritendon inflamma‑tion may induce tendinopathic changes directly through neuroinflammatory media‑tion 3 or through a compressive effect on the Achilles tendon (Fig 6).6

It is interesting to note that the group who had both plantaris and Achilles injuries were significantly older than the group with just plantaris injury. The incidence of Achilles tendon injury increases with age 28 but it has been proposed that chronic pathology around the plantaris tendon is implicated in the future development of Achilles tendinopathy.27 However, this study is limited by its methodology in that age comparisons for all other foot and ankle conditions, and training load has not been recorded. This finding should be interpreted with caution, and more work is required to explore the potential temporal relationship between plantaris injury and Achilles tendinopathy.

There may be a role for conservative treatment for plantaris injury, through bio‑mechanical correction, specific tendon loading or manual techniques. Calf‑strength‑ening exercise may be modified to specifically target the plantaris muscle and tendon through loading in external ankle rotation. In considering plantaris friction syndrome, manual therapy to the Achilles and plantaris interface may be important. Other inter‑ventions such as injection therapy with saline or hyaluronic acid have been proposed to alter the relationship between the Achilles tendon and the anterior fat pad.15 Sim‑ilar injection therapy may be helpful in changing the interaction between the Achil‑les and plantaris tendon if adhesions and friction are important in the development of Achilles tendon pathology. The use of these injection therapies, lacking a sound evidence base, should be with caution and perhaps only within a well‑functioning team setting where coach, athlete, physician and therapist work together towards a common performance goal.8

Plantaris embedded in R medial

Medial

Fig. 6 Ultrasound image of medial Achilles in patient with chronic medial pain and a thickened, adherent, embedded plantaris tendon found during surgical intervention

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Surgical intervention to remove the plantaris tendon has been reported as an effective treatment for Achilles tendinopathy.1,19,26 This study has demonstrated that for some athletes, the removal of the plantaris tendon can have excellent results with asymptomatic return to elite track and field. However, there were 3 patients, all of whom had coexistent Achilles tendinopathy, who re‑presented within 2 years of ini‑tial surgery with an intratendinous partial tear within the Achilles tendon. This may reflect progression of intratendon disease but it should be considered whether the removal of the plantaris tendon results in increased load on the Achilles tendon. It must also be considered whether the removal of the plantaris tendon could limit per‑formance in elite sprinting. However, with a significant number of the athletes who underwent surgical removal or sustained complete plantaris rupture, returning to improved performance, including sprinting at the highest level, there is no obvious detriment to athletic performance in this series. It should be recognised that surgical intervention is not without complication, including adhesions or wound breakdown.

This study has reported on a notable incidence of plantaris tendon pathology in an elite athlete cohort. There are a number of limitations to the study. It is a retro‑spective cohort study on injury incidence by the treating clinicians, although the full‑time employed medical teams did document in a systemic way all the medi‑cal encounters in this cohort over the study period. The clinical correlation of pain around the Achilles tendon to structural pathology has also been reported to be clini‑cally challenging.20 There is also likely to be some overlap in the clinical presentations of Achilles and plantaris injuries that make conclusions difficult. There is subjective interpretation to dynamic ultrasound scanning, although in many cases the diagno‑sis was corroborated with MRI scanning or surgical findings. The incidence data are limited by the lack of training information, and patients were not excluded if they were not training due to other injury.

This is the first study on plantaris injuries in a sporting population and reports on the largest group of patients with symptomatic plantaris injuries. The role, function and pathological relevance of the plantaris are still to be fully understood. Further research to determine the biomechanical properties and function of the plantaris in health will be helpful for practitioners in sport. Clinicians should be alert to the pos‑sibility of plantaris injury, although further work is required regarding potential treat‑ment interventions, including exercise prescription, injection therapy and surgery.

CONCLUSION

Plantaris injuries are common in elite track and field athletes and may be underre‑ported in the literature. This retrospective cohort study of elite British track and field athletes demonstrates a possible association between plantaris injury and Achilles tendinopathy.

A possible association also exists between the development of plantaris injuries and bend running in sprinters, and a biomechanical hypothesis is discussed.

Clinicians working in elite track and field should be aware of this injury and the possible contributing factors and management strategies.

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REFERENCES

1. Alfredson H (2011) Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 45:1023–1025

2. Alfredson H (2011) Ultrasound and Doppler‑guided mini‑surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med 45:407–410

3. Andersson G, Danielson P, Alfredson H, Forsgren S (2007) Nerve‑related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 15:1272–1279

4. Bianchi S, Sailly M, Molini L (2011) Isolated tear of the plantaris tendon: ultrasound and MRI appearance. Skeletal Radiol 40:891–895

5. Chang Y‑H, Kram R (2007) Limitations to maximum running speed on flat curves. J Exp Biol 210:971–982

6. Cook J, Purdam C (2011) Is compressive load a factor in the development of tendinopathy? Br J Sports Med 46:163–168

7. Delgado GJ, Chung CB, Lektrakul N, Azocar P, Botte MJ, Coria D, Bosch E, Resnick D (2002) Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 224:112–119

8. Dijkstra HP, Pollock N, Chakraverty R, Alonso JM (2014) Managing the health of the elite athlete: a new integrated performance health management and coaching model. Br J Sports Med 48:523–531

9. Freeman AJ, Jacobson NA, Fogg QA (2008) Anatomical variations of the plantaris muscle and a potential role in patellofemoral pain syndrome. Clin Anat 21:178–181

10. Gopinath TN, Jagdish J, Krishnakiran K, Shaji PC (2012) Rupture of plantaris muscle—a mimic: MRI findings. J Clin Imaging Sci 2:19

11. Hamilton W, Klostermeier T, Lim EV, Moulton JS (1997) Surgically documented rupture of the plantaris muscle: a case report and literature review. Foot Ankle Int 18:522–523

12. Harmon KJ, Reeder MT, Udermann BE, Murray SR (2006) Isolated rupture of the plantaris tendon in a high school track athlete. Clin J Sport Med 16:361–363

13. Harvey FJ, Chu G, Harvey PM (1983) Surgical availability of the plantaris tendon. J Hand Surg 8:243–247

14. Helms CA, Fritz RC, Garvin GJ (1995) Plantaris muscle injury: evaluation with MR imaging. Radiology 195:201–203

15. Humphrey J, Chan O, Crisp T, Padhiar N, Morrissey D, Twycross‑Lewis R, King J, Maffulli N (2010) The short‑term effects of high volume image guided injections in resistant noninsertional Achilles tendinopathy. J Sci Med Sport 13:295–298

16. Lintz F, Higgs A, Millett M, Barton T, Raghuvanshi M, Adams MA, Winson IG (2011) The role of plantaris longus in Achilles tendinopathy: a biomechanical study. Foot Ankle Surg 17:252–255

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17. Miller WA (1977) Rupture of the musculotendinous juncture of the medial head of the gastrocnemius muscle. Am J Sports Med 5:191–193

18. Nayak SR, Krishnamurthy A, Ramanathan L, Ranade AV, Prabhu LV, Jiji PJ, Rai R, Chettiar GK, Potu BK (2010) Anatomy of plantaris muscle: a study in adult Indians. Clin Ter 161:249–252

19. Pearce CJ, Carmichael J, Calder JD (2012) Achilles tendinoscopy and plantaris tendon release and division in the treatment of noninsertional Achilles tendinopathy. Foot Ankle Surg 18:124–127

20. Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J (2014) The pain of tendinopathy: physiological or pathophysiological? Sports Med 44:9–23

21. Saxena A, Bareither D (2000) Magnetic resonance and cadaveric findings of the incidence of plantaris tendon. Foot Ankle Int 21:570–572

22. Schubert TEO, Weidler C, Lerch K, Hofstädter F, Straub RH (2005) Achilles tendinosis is associated with sprouting of substance P positive nerve fibres. Ann Rheum Dis 64:1083–1086

23. Severance HW Jr, Bassett FH 3rd (1982) Rupture of the plantaris—does it exist? J Bone Joint Surg Am 64:1387–1388

24. Simpson SL, Hertzog MS, Barja RH (1991) The plantaris tendon graft: an ultrasound study. J Hand Surg 16:708–711

25. Steenstra F, van Dijk CN (2006) Achilles tendoscopy. Foot Ankle Clin 11:429–438

26. Van Sterkenburg MN, Kerkhoffs GMMJ, van Dijk CN (2011) Good outcome after stripping the plantaris tendon in patients with chronic mid‑portion Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 19:1362–1366

27. Van Sterkenburg MN, Kerkhoffs GMMJ, Kleipool RP, Niek van Dijk C (2011) The plantaris tendon and a potential role in midportion Achilles tendinopathy: an observational anatomical study. J Anat 218:336–341

28. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd‑Smith DR, Zumbo BD (2002) A retrospective case‑control analysis of 2002 running injuries. Br J Sports Med 36:95–101

29. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

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8PLANTARIS EXCISION REDUCES PAIN IN

MIDPORTION ACHILLES TENDINOPATHY EVEN IN THE ABSENCE OF PLANTARIS

TENDINOSIS

James D. F. Calder, Joanna M. Stephen, C. Niek van Dijk

Orthopaedic Journal of Sports Medicine 2016 Dec 13; 4(12):2325967116673978

| Chapter 8114

ABSTRACT

Background: It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear.

Purpose: To determine whether excised plantaris tendons from patients with mid-portion Achilles tendinopathy display tendinopathic changes and whether the pres-ence of such changes affect clinical outcomes.Study Design: Case series

Methods: Sixteen plantaris tendons in patients with midportion Achilles tendinop-athy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively.

Results: Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent sur-gery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris ten-don was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P<0.05).

Conclusion: The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendi-nopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.

Level of evidence IV

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INTRODUCTION

Steenstra and van Dijk22 were the first to suggest involvement of the plantaris tendon in medially located midportion Achilles tendon pain. The plantaris originates from the posterolateral femoral condyle, descends between the gastrocnemius and soleus muscles, and then lies along the medial border of the Achilles tendon. It is frequently described as a vestigial structure absent in 8% to 20% of individuals,10,11,13,19 but more recent studies suggest that it is present in 98% to 100% of specimens,16,24 with a variable insertion into the calcaneus or the Achilles tendon.7,8,24

Lintz et al12 demonstrated increased stiffness in the plantaris compared with the Achilles tendon. Constant compression and/or shearing between the tri-articulate plantaris and the bi-articulate Achilles tendons is thought to provoke a localized inflammatory response leading to adherence to, or invagination into, the highly innervated peritendinous tissue.1,2,6,15,17,26 This painful frictional syndrome may result in inflammatory change around the Achilles tendon and potentially intratendinous pathology.6 It has recently been reported as a significant problem in professional ath-letes, where the annual incidence of injury related to the plantaris tendon was 3.9% to 9.3%, affecting 22% of all sprinters and 18% of endurance runners.15

Image-guided, high-volume injections within the paratenon to strip the neovas-cularization from the Achilles and break down adhesions aiming to separate the plan-taris from the Achilles have been described with variable success.4,9,27 A small number of case series on the surgical sectioning of the plantaris and stripping of the ventral neovascularization from the Achilles have reported with promising results.1,14,25 Spang et al20 suggested that the plantaris tendon is tendinopathic, similar to the Achilles tendon in midportion Achilles tendinopathy, but there is uncertainty as to whether the plantaris tendon is affected in this way in all cases or if it is histologically nor-mal, causing pathological secondary changes in the Achilles and a resultant focal inflammatory response. This study describes the histological features of the plantaris tendon excised from 16 patients who underwent successful surgical treatment for medially located Achilles tendinopathy. The purpose of this investi-gation was to identify whether there were tendinopathic changes in the plantaris tendon or only a surrounding inflammatory reaction adjacent to the Achilles ten-don. A secondary aim was to assess whether the presence or absence of such ten-dinopathy affected the clinical outcome of surgery to excise the plantaris tendon.

METHODS

Sixteen patients underwent surgery for medially located Achilles tendon pain and swelling, having failed conservative measures. All patients had magnetic resonance imaging (MRI) and ultrasound (US) scans confirming the presence of a plantaris ten-don adherent to or invaginated into the ventromedial edge of the Achilles tendon adjacent to the focal area of Achilles tendinopathy. All patients had failed to improve after a minimum of 6 months’ conservative management. At surgery, the plantaris

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tendon was dissected free from the Achilles tendon through a 3-cm medially placed incision. The plantaris was transected distally and then stripped proximally for 10 cm and excised through a proximal stab. Paratenon adhesions and areas of neovas-cularization on the ventral surface of the Achilles tendon were removed with sharp dissection. The plantaris tendon and its surrounding soft tissue were placed in 10% buffered formalin solution. After dehydration and subsequent embedding in par-affin wax, 10-mm sections were stained with Mayer haematoxylin and eosin and underwent light microscopy examination to assess tissue morphology. Patients were assessed pre- and postoperatively using a visual analogue scale (VAS) and Foot and Ankle Outcome Score (FAOS).

STATISTICAL ANALYSIS

Data were analysed using SPSS (version 22; IBM Corp). A Shapiro-Wilk test confirmed that the datasets were normally distributed. Paired t tests were used to compare pre- and postoperative scores, with significance set at P<0.05.

A power calculation based on a 10% minimal clinically relevant difference for FAOS determined that a sample size of 16 would provide 80% power and 95% confidence.

RESULTS

Sixteen patients underwent surgery (13 males; 9 right side). The mean age was 26.2 years (range, 18-47 years), and the mean follow-up was 14 months (range, 6-20 months). Nine patients were elite athletes competing at the national or international level. All patients had improvement in symptoms after surgery and were able to resume sporting activities to their previous level. There was significant improve-ment in mean VAS scores for pain from 6.4 (95% CI, 5.8–7.0) preoperatively to 1.0 (95% CI, 0.2–1.8) postoperatively (P<0.001). There was also a significant improvement in all domains of the FAOS score (Table 1).

Histological examination revealed evidence of inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon in all cases. The plantaris tendon was histologically normal in 13 of 16 patients. Three patients demonstrated abnormality of the plantaris tendon with typical features of mild ten-dinopathy: The slender and spindle-shaped tenocytes seen in normal ten- dons were replaced by morphologically abnormal tenocytes with rounded / widened cells ( Figure 1).

There is increasing interest in the role of the plantaris tendon in the development of medially located Achilles tendinopathy. Surgical stripping of the plantaris tendon with release of paratenon adhesions and the neovascularization and neoinnervation on the ventral surface of the Achilles tendon has good results reported in several studies.1,3,14,25 The exact pathophysiology underlying the development of the con-dition is unclear. Biomechanical causes with compression and the development of

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Table 1 Change in VAS and FAOS scores after surgerya

Presurgery Score Postsurgery Score P Value

VAS 6.4 ± 1.3 1.0 ± 1.5 <.001

FAOS domain

Pain 75.7 ± 7.4 92.0 ± 10.0 <.001

Symptoms 78.1 ± 11.1 85.3 ± 13.6 .017

ADL 83.4 ± 5.2 92.0 ± 6.8 <.001

Sport 52.2 ± 12.5 88.4 ± 15.7 <.001

QOL 38.1 ± 10.9 83.3 ± 21.9 <.001a Data are reported as mean ±SD. ADL, activities of daily living; FAOS, Foot and Ankle Outcome Score; QOL, quality of life; VAS, visual analogue scale

(a)

(b)

Fig. 1 (a) Increased cellularity (blue arrows) and focal fibrinoid and subtle mucoid changes (white arrows) consistent with mild tendinosis (magnification x40). (b) Normal tendon for comparison (magnification x40).

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a painful fictional syndrome with the development of an inflammatory response is supported by studies reporting increased occurrence in endurance runners, with the interesting observation that the right side is affected nearly 4 times as frequently in bend sprinters.5,15 An alternative view is that insertion of the plantaris into the medial edge of the Achilles leads to a differential traction of the tendons and tendinopathy. The current study demonstrates that the plantaris itself is not necessarily histolog-ically abnormal or tendinopathic. The fact that all patients in this series improved clinically after removal of the plantaris supports the concept that it was involved in the development of focal medial Achilles tendinopathy. All 16 patients had a plantaris tendon attached or very close to the Achilles tendon and surrounding inflamma-tory changes seen on MRI and US scans, with mild tendinopathic changes in the adjacent Achilles tendon. However, only 3 patients had histological evidence of tendinopathic changes in the plantaris tendon. Two of these patients had evidence of marked thickening and tendinopathy on MRI and US. The remaining 13 patients had no plantaris tendinopathy histologically, and these tendons also appeared mor-phologically normal on MRI and US. The presence of tendinopathy in the plantaris tendon did not appear to affect the final clinical outcome of surgery. All patients had evidence of inflammatory changes in the surrounding peritendinous tissue, support-ing previous studies reporting compression of the Achilles tendon with inflammation and altered tendon gliding within the ‘‘paratendinopathy’’ as a cause for pain in Achilles tendinopathy.18,21,23

When the MRI and US scans were reviewed, 2 patients with abnormal histological find-ings were those with thickened and abnormal looking plantaris tendons (Figure 2). One patient with histological evidence of tendinopathy had normal thickness of the normal

Figure 2. Magnetic resonance imaging scan noting a thickened plantaris tendon (arrow) consistent with tendinosis and surrounding inflammatory changes adjacent to Achilles tendon.

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plantaris tendon on MRI other than peritendinous inflammatory changes and some tend-inopathy in the adjacent Achilles tendon (Figure 3).

DISCUSSION

It has been postulated that this area of inflammatory change surrounding the mid-portion Achilles tendinopathy results from a neurogenic inflammation induced by the relatively avascular Achilles tendon.

26 The plantaris tendon is incorporated in this inflamed peritendinous tissue, which contains abundant neovascularization and neoinnervation. The different dynamics between Achilles tendon and plantaris ten-don result in a continuous irritation and pain from friction within this inflamed peri-tendinous tissue. The authors attribute the good results of stripping of the plantaris tendon and the anterior side of the Achilles tendon to the denervation of this area.

26

One study has previously found tendinopathic changes in the plantaris tendon of such patients, suggesting that this may be a causative factor in the development of this condition.20 However, it is apparent from the current study that concurrent ten-dinopathy of the plantaris is not necessarily present. We suggest that although ten-dinopathic changes may develop in the plantaris, this may be a secondary and later consequence of chronic inflammatory changes. The primary problem is more likely

Figure 3 Magnetic resonance imaging scan showing a normal appearance of the plantaris tendon (arrow) adjacent to the Achilles tendon.

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a biomechanical one with either a frictional syndrome between the plantaris and the Achilles tendons or a direct tractional problem with attachment of the plantaris to the medial edge of the Achilles tendon.

Limitations of this study include the specific young active population included, although this is representative of the patient group who develop this condition. It was not possible to differentiate between tendons adherent to or invaginated into the Achilles tendon, and the sample size would be too small to determine whether these 2 insertion patterns display differences in the presence of tendinopathic changes.

CONCLUSION

There is increasing evidence to support that the excision of plantaris results in improved clinical outcomes in a subset of patients with midportion Achilles tendi-nopathy. This is the first study to demonstrate histologically normal plantaris tendons in the presence of Achilles-plantaris syndrome resistant to conservative treatment. Since patients improved even when the excised plantaris was not tendinopathic sup-ports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic. We hope that this study may stimulate further research investigating the biomechanical causes and possible treatments of plantaris-related Achilles tendinopathy.

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REFERENCES

1. Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med. 2011;45:1023–1025.

2. Andersson G, Danielson P, Alfredson H, Forsgren S. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2007;15: 1272–1279.

3. Calder JD, Freeman R, Pollock N. Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. Br J Sports Med. 2015;49:1532–1534.

4. Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008;30: 1697–1708.

5. Chang Y-H, Kram R. Limitations to maximum running speed on flat curves. J Exp Biol. 2007;210:971–982.

6. Cook J, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46:163–168.

7. Daseler EH, Anson BJ. The plantaris muscle. J Bone Joint Surg Am. 1943;25:822–827.

8. Dos Santos MA, Bertelli JA, Kechele PR, Duarte H. Anatomical study of the plantaris tendon: reliability as a tendo-osseous graft. Surg Radiol Anat. 2009;31:59–61.

9. Fredberg U, Ostgaard R. Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in chronic Achilles tendinopa- thy: a pilot study. Scand J Med Sci Sports. 2009;19:338–344.

10. Freeman AJ, Jacobson NA, Fogg QA. Anatomical variations of the plantaris muscle and a potential role in patellofemoral pain syndrome. Clin Anat. 2008;21:178–181.

11. Harvey FJ, Chu G, Harvey PM. Surgical availability of the plantaris tendon. J Hand Surg. 1983;8:243–247.

12. Lintz F, Higgs A, Millett M, et al. The role of plantaris longus in Achilles tendinopathy: a biomechanical study. Foot Ankle Surg. 2011;17:252–255.

13. Nayak SR, Krishnamurthy A, Ramanathan L, et al. Anatomy of plan- taris muscle: a study in adult Indians. Clin Ter. 2009;161:249–252.

14. Pearce CJ, Carmichael J, Calder JD. Achilles tendinoscopy and plan- taris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg. 2012;18:124–127.

15. Pollock N, Dijkstra P, Calder J, Chakraverty R. Plantaris injuries in elite UK track and field athletes over a 4-year period: a retrospective cohort study. Knee Surg Sports Traumatol Arthrosc. 2016;24:2287–2292.

16. Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the incidence of plantaris tendon. Foot Ankle Int. 2000;21:570–572.

17. Schubert T, Weidler C, Lerch K, Hofsta¨ dter F, Straub R. Achilles ten- dinosis is associated with sprouting of substance P positive nerve fibres. Ann Rheum Dis. 2005;64:1083–1086.

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18. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187–202.

19. Simpson SL, Hertzog MS, Barja RH. The plantaris tendon graft: an ultrasound study. J Hand Surg. 1991;16:708–711.

20. Spang C, Alfredson H, Ferguson M, Roos B, Bagge J, Forsgren S. The plantaris tendon in association with mid-portion Achilles tendinosis: tendinosis-like morphological features and presence of a non- neuronal cholinergic system. Histol Histopathol. 2013;28:623–632.

21. Stecco C, Cappellari A, Macchi V, et al. The paratendineous tissues: an anatomical study of their role in the pathogenesis of tendinopathy. Surg Radiol Anat. 2014;36:561–572.

22. Steenstra F, van Dijk CN. Achilles tendoscopy. Foot Ankle Clin. 2006; 11:429–438.

23. Tan SC, Chan O. Achilles and patellar tendinopathy: current understanding of pathophysiology and management. Disabil Rehabil. 2008; 30:1608–1615.

24. van Sterkenburg MN, Kerkhoffs GM, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendino- pathy: an observational anatomical study. J Anat. 2011;218:336–341.

25. van Sterkenburg MN, Kerkhoffs GM, van Dijk CN. Good outcome after stripping the plantaris tendon in patients with chronic mid- portion Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1362–1366.

26. van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1367–1375.

27. Wijesekera NT, Calder JD, Lee JC. Imaging in the assessment and management of Achilles tendinopathy and paratendinitis. Semin Musculoskelet Radiol. 2011;15:89–100.

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9PLANTARIS EXCISION IN THE TREATMENT

OF NON-INSERTIONAL ACHILLES TENDINOPATHY IN ELITE ATHLETES

James D. F. Calder, Richard Freeman, Noel Pollock

British Journal of Sports Medicine 2014 Dec; 49(23):1532-1534

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ABSTRACT

Background: Achilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris ten-don in non-insertional Achilles tendinopathy.

Aim: To assess whether excising the plantaris tendon improved the symptoms of Achilles tendinopathy in elite athletes.

Methods: This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preop-erative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed.

Results: At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection.

Conclusions: The plantaris tendon may be responsible for symptoms in some ath-letes with non-insertional Achilles tendinopathy. Excision carries a low risk of com-plications and may provide significant improvement in symptoms enabling an early return to elite-level sports.

Level of evidence III

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INTRODUCTION

Mid-substance Achilles tendinopathy is debilitating condition frequently encoun-tered in elite athletes and it may be a career-ending condition in up to 5% of profes-sional athletes.1 Pain in the Achilles may be due to intrinsic tendon pathology but it may also be secondary to degeneration or inflammation of the surrounding structures (paratendinopathy).2

The most effective rehabilitation for Achilles tendinopathy is appropriate loading of the tendon. This can be achieved by modifying elastic tendon activities and pre-scription of strengthening exercises.3 If conservative measures fail then surgery may be indicated and many different methods have been described. Open Achilles sur-gery may be successful in 75–100%4-8 of patients but debridement with excision of areas of tendinosis weakens the tendon and return to sport may be delayed for up to 18 months.9 Treatments addressing the peritendinous structures may decompress the paratenon, remove adhesions between the tendon and paratenon and fat pad, or denervate the tendon by scraping the ventral aspect while removing areas of neo-vascularisation.4 These procedures avoid violating the tendon itself and therefore a quicker return to sport may be possible. Minimally invasive procedures such as para-tenonectomy and tendinoscopy with plantaris release can achieve good results.10,11

Recent studies have proposed a role of the plantaris tendon in the development of focal medial Achilles tendinopathy and medially located Achilles tendon pain.12

The plantaris arises from the lateral aspect of the supracondylar line of the femur and inserts into the medial aspect of the calcaneus passing deep to the medial gastrocne-mius but superficial to soleus. Anatomical studies show that in some cases there is a direct attachment of the plantaris to the medial Achilles tendon.2 It acts as an inverter and plantar-flexor at the ankle and as a weak flexor at the knee. At the level of the Achilles the plantaris lies within the Achilles paratenon along the medial or ventro-medial aspect of the Achilles tendon.4,13

As plantaris crosses the knee and ankle joints there is a differential movement between it and the Achilles at the medial border of the Achilles tendon. It is also stiffer and stronger than the Achilles tendon and it has been suggested that these factors lead to friction, inflammation and adhesions between the plantaris and the Achil-les tendons.14 Reports of isolated plantaris rupture15-17 and the finding of an intact plantaris with Achilles rupture would support this, as tendons with identical kinetics would be expected to rupture simultaneously.

Recent studies have reported encouraging results with release of adhesions sur-rounding the Achilles and sectioning of the plantaris tendon.10,18,19 However, these are small studies and whether this approach provides long-term symptomatic relief of pain without compromising athletic ability in the highest demanding athletic patients has not yet been demonstrated.

The purpose of this study was to evaluate the clinical results and time of return to sports following mini-incision Achilles tendon release and plantaris excision in a consecutive series of elite athletes with focal medially located Achilles tendon pain.

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METHODS

A prospective consecutive case series of elite athletes (competing at national or inter-national level) underwent surgical excision of the plantaris tendon and paratenon release. Athletes presenting to the Fortius Clinic or the Hampshire Clinic from Jan-uary 2009 to January 2013 with symptoms consistent with non-insertional Achilles tendinopathy were included. All had focal, medially located Achilles tendon pain and swelling along the medial edge of the Achilles tendon approximately 4–7 cm from insertion into the Os calcis. Medial pain was distinguished from lateral pain by palpating each side of the tendon in turn and determining the side of maximal tenderness. All underwent MRI examination that confirmed paratendinitis as defined by a signal change in the paratenon or Kager’s fat pad (with or without a plantaris tendon adherent to, or invaginated into the ventromedial border of the Achilles ten-don). Some also had signal change suggestive of mid-substance Achilles tendinosis. All athletes were initially treated conservatively with an ultrasound-guided paratenon stripping injection of 40 mL local anaesthetic (without steroid) between the Achilles and fat pad and the Achilles and plantaris tendon followed by a formal eccentric stretching exercise programme. Those that failed to improve after a minimum of 6 weeks were then considered for surgery or a further paratenon injection. Athletes with a good response to injection therapy were offered a repeat injection (not usu-ally within 6 months) or surgery. All patients were consented for inclusion in the study which was approved by the institution’s review board.

At surgery, a 2–3 cm incision was made along the medial edge of the Achilles tendon at the point of maximal tenderness/ swelling. The paratenon was opened and adhesions between it and the Achilles tendon were released. Any connections along the ventral aspect of the Achilles tendon were released by sharp dissection. The plantaris tendon was identified, released from the medial aspect of the Achilles tendon and transected. It was then passed on a haemostat as proximally as possible (approximately 10–15 cm) within the paratenon where a stab incision was made and the plantaris tendon was delivered through the skin and sectioned proximally under tension at its musculotendinous junction. A firm compressive bandage was placed over the operative site and athletes were encouraged to elevate the leg for 10 days but allowed to mobilise with crutches weight bearing as able. Ankle range of motion exercises were encouraged from 48 h postoperatively after reduction of dressings to a double elastic bandage. Once wound healing had been ensured, an Achilles strengthening programme was introduced at 2 weeks, to encourage move-ment of the Achilles to reduce the chance of adhesions to the paratenon and ventral fat pad. Individual reconditioning programmes were tailored on a patient-specific basis by their local physiotherapy team. Return to sporting activity was dictated inde-pendently by the athletes’ local medical team.

All athletes were assessed with patient reported outcome measures. Preoperatively and postoperatively a visual analogue score (VAS) and the foot and ankle outcome score (FAOS) was used and post-treatment satisfaction and return to sport score was recorded. The point at which the athlete was able to return to full training was

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taken as the ‘return to sport’ end point. In bilateral cases, all patients had returned to their pre-treatment sporting level before developing symptoms in the other leg.

Statistical analysisThe results were analysed using a spreadsheet (Excel 2007, Microsoft; Seattle, Wash-ington, USA). Data were normally distributed and Student t tests were used to com-pare between groups. A p value of <0.05 was considered significant.

A retrospective power analysis based on a 10% minimum clinically important differ-ence for FAOS, two tails and 5% significance gave 100% power with a sample size of 32.

RESULTS

There were 32 elite athletes (22 men) with a mean age 27.2 years (range 19–42). Fourteen cases involved the right side, sixteen the left side and two were bilateral. There was no loss to follow-up but one athlete did not complete the postoperative FAOS score. Athletic activity is shown below (Table 1); in addition, there was one triathlete, cricketer, golfer, netball and volleyball player.

The mean follow-up was 22.1 months with a minimum follow-up of 12 months (range 12–48). The mean time to return to elite-level sport was 10.3 weeks (95% CI 8.6 to 12, range 5–27). There was a significant improvement in VAS scores for pain from 5.8 (95% CI 5.4 to 6.3) to 0.8 (0.3 to 1.3, p<0.001). There was also a significant improvement in FAOS scores from a mean of 333 (321 to 345) to 449 (431 to 468; (Table 2).

Following surgery 22/32 (69%) patients were very satisfied, 7/32 (22%) partially satisfied and 3/32 (9%) not satisfied. Two athletes had to retire from elite sport, four had stiffness symptoms and one had a superficial wound infection that settled with oral antibiotics.

Although all athletes had MRI evidence of change around the plantaris tendon with tethering to the Achilles tendon and surrounding Achilles paratendinitis, 11/32 (34%) had no signs of Achilles tendinosis on MRI (Table 3).

DISCUSSION

In our cohort of elite athletes we achieved high rates of patient satisfaction and signifi-cant improvements in VAS and FAOS scores. At a mean follow-up of 22.4 months, 90% of athletes were satisfied and 94% had returned to sport (at a mean of 10.3 weeks). The mean VAS score improved from 5.8 to 0.8 and the mean FAOS was significantly improved in all domains.

Alfredson18 recently reported on 56 patients with long-standing Achilles tendi-nopathy comprising 73 tendons. At surgery 58 of the 73 tendons were found to have a thickened plantaris closely related to the tendinopathic Achilles.

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Table 1. Patient characteristics by sport.

Sport Total

Athletics—long-distance running 2

Athletics—sprinting 3

Ballet 2

BasketbaII 3

Hockey 2

Rugby 2

Soccer 11

Tennis 2

Total 32

Table 2. Change in FAOS following surgery.

FAOS domain Mean presurgery score

Mean postsurgery score

p Value

Pain 77.3 92.1 <0.0001

Symptoms 79.7 87.9 <0.0001

ADL 83.3 92.8 0.001

Sport 53.8 90.2 <0.0001

QOL 39.1 86.2 <0.0001

ADL, activities of daily living; FAOS, foot and ankle outcome score; QOL, quality of life.

He excised the plantaris tendons in a combined procedure with scraping and ventral release of the Achilles. Pearce et al10 showed good results by releasing the plantaris tendon endoscopically. In 11 patients who underwent the procedure the mean American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score improved significantly and the Ankle Osteoarthritis Scale (AOS) scores for pain and disability also improved. This followed an earlier report by van Sterkenburg et al19 who describe good results in three patients treated with a mini-open technique. All patients improved in VAS for pain and function and two of the three improved on the Victorian Institute of Sport Assessment questionnaire – Achilles score.

If the plantaris is the underlying pathology, eccentric exercises may not improve symptoms because of the differential in tendon stiffness and the development of adhesions and friction between the plantaris and Achilles tendons. It is thought that the early changes of inflammation may lead to a focal Achilles tendinosis.12 It is also conceivable that a compressive effect of thickened, inflamed tissue next to the Achilles tendon could induce tendinopathic changes with the Achilles tendon. A minimally invasive procedure to remove the adhesions, excise the plantaris tendon and debride

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neovascularisation along the ventral aspect of the Achilles tendon may offer signifi-cant advantages over procedures that violate the Achilles tendon itself by improving symptoms while allowing a rapid return to sporting activities.

We chose to excise a long segment of the plantaris tendon in order to avoid reat-tachment of tendon to the Achilles that could lead to the recurrence of symptoms more proximally. Almost all athletes were able to return to elite-level sporting activity suggesting that despite the fact that the plantaris is used in running and in particular sprinting, excising the plantaris does not compromise function even at the highest levels. Return to elite sporting activity was quicker than the 4–12 months 20 that would be expected if the Achilles tendon had been debrided and areas of tendinosis excised.

One-third of athletes had no Achilles tendinosis on MRI despite showing abnor-malities related to the plantaris. However, they had similar mean baseline VAS score to those athletes with Achilles tendinosis and improved following surgery, yet not as much as those with tendinosis. This suggests that the plantaris has a role in the generation of pain.

Table 3. Differences in improvement between tendinopathic and non-tendinopathic athletes (*indicates significant difference)

Tendinosis (mean)

No tendinosis (mean)

Student t test (p value)

Preoperative VAS 6.0 5.6 0.52

Postoperative VAS 1.2 0 0.02*

Preoperative FAOS

Pain 76 80 0.06

Symptoms 79 81 0.62

ADL 84 83 0.63

Sport 52 58 0.13

QOL 36 45 0.02*

TotaI 326 346 0.08

Postoperative FAOS

Pain 90 96 0.02*

Symptoms 84 94 0.004*

ADL 91 96 0.006*

Sport 87 96 0.01*

QOL 82 94 0.03*

Total 434 477 0.007*

ADL, activities of daily living; FAOS, foot and ankle outcome score; Q0L, quality of life; VAS, visual analogue scores.

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LimitationsThis study had no athletes who underwent isolated excision of the plantaris and stripping of the peritendinous tissues alone could have produced the same results. It is also difficult to quantify the MRI changes seen in the peritendinous structures. Also, the number of athletes who improve with conservative measures alone in unknown, although we attempted conservative treatment initially in all cases. It may be that our cohort placed a higher value on resulting time out of sport than would a non-elite athletic population this reducing the time given to conservative measures.

Our study may also be affected by selection bias, limitations of the scoring assess-ments and a lack of control group. Further studies, ideally a blinded randomised con-trolled trial are needed to confirm the precise involvement of the plantaris tendon in Achilles tendinopathy and whether purely excising the plantaris in those patients without Achilles tendinosis produces a satisfactory result. The temporal relationship between plantaris pathology and the development of subsequent Achilles tendinop-athy and the role of the plantaris in sporting activities also requires further explora-tion.

CONCLUSION

The plantaris tendon may be an important contributory factor in the underlying pathophysiology of medially located Achilles tendon pain and focal non-insertional Achilles tendinopathy. Excision of the plantaris tendon and debridement of the ven-tral aspect of the Achilles tendon appears to be a safe procedure and provides a significant improvement in symptoms with an early return to elite-level sports in a high percentage of athletes.

What are the new findings?• This study supports the concept that the plantaris tendon is a cause for some Achilles

tendinopathy.• Excising the plantaris tendon in elite athletes with non-insertional Achilles

tendinopathy significantly improves FAOs and visual analogue scores.• The procedure is safe and allows as early return to elite sport.

How might it impact on clinical practice in the near future?• The plantaris should be investigated as a possible source of Achilles pain.• This technique should be considered in patients with medial-sided non-insertional

Achilles tendinopathy who fail conservative measures.

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REFERENCES

1. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15: 168–71.

2. van Sterkenburg MN, Kerkhoffs GM, Kleipool RP, et al. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study. J Anat 2011; 218:336–41.

3. Malliaras P, Barton CJ, Reeves ND, et al. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013; 43:267–86.

4. Roche A, Calder JC. Achilles tendinopathy: a review of the current concepts of treatment. Bone Joint J 2013;95-B:1299–307.

5. Nelen G, Martens M, Burssens A. Surgical treatment of chronic Achilles tendinitis. Am J Sports Med 1989; 17:754–9.

6. Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med 1987; 15:308–15.

7. Tallon C, Coleman BD, Khan KM, et al. Outcome of surgery for chronic Achilles tendinopathy: a critical review. Am J Sports Med 2001; 29:315–20.

8. Paavola M, Kannus P, Orava S, et al. Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. Br J Sports Med 2002; 36:178–82.

9. Bohu Y, Lefevre N, Bauer T, et al. Surgical treatment of Achilles tendinopathies in athletes. Multi-center retrospective series of open surgery and endoscopic tech- niques. Orthop Traumatol Surg Res 2009; 95:S72–7.

10. Pearce CJ, Carmichael J, Calder JD. Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg 2012; 18:124–7.

11. Maffulli N, Testa V, Capasso G, et al. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 1997; 25:835–40.

12. Andersson G, Danielson P, Alfredson H, et al. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2007; 15:1272–9.

13. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998; 14:840–3.

14. Lintz F, Higgs A, Millett M, et al. The role of plantaris longus in Achilles tendinopathy: a biomechanical study. Foot Ankle Surg 2011; 17:252–5.

15. Kelley J, Harmon DO, Reeder MT, et al. Isolated rupture of the plantaris tendon in a high school track athlete. Clin J Sport Med 2006; 16:361–3.

16. Helms CA, Fritz RC, Garvin GJ. Plantaris muscle injury: evaluation with MR imaging. Radiology 1995; 195:201–3.

17. Mozena J, Pearson DD. Plantaris tendon ruptures (letter). J Am Podiatr Med Assoc 2004; 94:505–8.

18. Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 2011; 45:1023–5.

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19. van Sterkenburg MN, Kerkhoffs GM, van Dijk CN. Good outcome after stripping the plantaris tendon in patients with chronic mid-portion Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2011; 19:1362–6.

20. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med 2013; 47:536–44

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part IVVENOUS THROMBO-EMBOLISM

RISKS IN FOOT, ANKLE AND ACHILLES TENDON DISORDERS

10META-ANALYSIS AND SUGGESTED GUIDELINES FOR PREVENTION OF

VENOUS THROMBOEMBOLISM (VTE) IN FOOT AND ANKLE SURGERY

James D. F. Calder, Richard Freeman, Erica Domeij-Arverud, C. Niek van Dijk, Paul Ackermann

Knee Surgery Sports Traumatology Arthroscopy 2016 Apr;24(4):1409-1420

| Chapter 10140

ABSTRACT

Purpose: To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.

Methods: Following a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.

Results: 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6% (95% CI 0.4–0.8%) and 1% (95% CI 0.2–1.7%), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5% (95% CI 6.8–18.2%) and 10.5% (95% CI 5.0–15.9%), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7% (95% CI 5.5–8.5%) and radiological incidence of 35.3% (95% CI 26.4–44.3%).

Conclusion: Isolated foot and ankle surgery has a lower incidence of clinically appar-ent VTE when compared to general lower limb procedures, and this rate is not signifi-cantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.

Level of evidence II

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INTRODUCTION

25,000 people die each year in England from venous thromboembolism (VTE), more than the combined total of deaths from breast cancer, AIDS and road traffic acci-dents.28 The total cost (direct and indirect) to the UK for managing VTE is estimated at £640 million.28 VTE has been highlighted as a particular risk following orthopae-dic surgery or injury to the lower limb. However, most studies investigating VTE are conducted in patients undergoing major orthopaedic surgery at or above the knee.4,5,12,13,17,42,49,68 The risk of VTE for patients with isolated foot and ankle conditions, even with plaster cast immobilization, and the possible benefits of mechanical and chemical prophylaxis are poorly studied.

The NICE committee commissioned with assessment of VTE prevention concluded that for patients immobilized in a cast “This is a large patient group for whom the evidence is not clear” and went on to state “There would be a substantial cost to the NHS of providing thromboprophylaxis to all patients with a lower limb plaster cast, particularly if patients use prophylaxis until cast removal which may be a number of weeks”.53 The American College of Chest Physicians (ACCP) most recent review also recommends against chemical prophylaxis in lower leg injuries requiring immobiliza-tion.15 Despite this conclusion, many hospitals are introducing policies which recom-mend the routine use of low molecular weight heparin (LMWH) chemoprophylaxis for those in a cast following ankle fractures and all forms of elective foot and ankle surgery.

In order to make such recommendations, the following criteria must be fulfilled:

1. There is a significant risk of VTE in those with isolated foot and ankle conditions.2. The incidence of VTE is significantly reduced by pre- scribing LMWH prophylaxis.3. The risk of complications from LMWH outweighs the reduction in risk of VTE.4. There is an appropriate cost–benefit using LMWH for VTE prophylaxis.

The purpose of this meta-analysis and review of the literature is to establish the incidence of VTE in orthopaedic foot and ankle patients, specifically investigating the effectiveness and risk of chemoprophylaxis comparing clinical to radiographic outcome measures.

The aim of the paper is to identify those factors that increase the risk of VTE in patients with foot and ankle conditions and establish whether current guidelines should be revised to consider preventive methods in all or specific patients undergo-ing foot and ankle surgery.

MATERIALS AND METHODS

Search strategyA PRISMA compliant search of AMED, EMBASE, HMIC, MEDLINE, BNI and CINAHL databases on the 31 January 2015 was undertaken.51 The search terms were: throm-boembolism and (foot OR ankle) = 308 then combined with a search for: VTE and (foot OR ankle) = 64. Review of meeting abstracts and relevant references identified

| Chapter 10142

an additional 32 studies for potential inclusion. Fifty-two duplicates were removed and 328 articles excluded by title and abstract screening.

The methodological quality of each article was assessed using the Critical Appraisal Skills Programme (CASP).59 The CASP checklist assessed whether the aim of the paper was clear, the methods were valid (including study design, recruitment, bias and ethics) and there were a rigorous analysis of data and a clear statement of findings. In total 28 articles were independently reviewed by two of the authors (RF and EDA) using the CASP tool and Centre for Evidence-Based Medicine (CEBM) level of evi-dence.55 Any discrepancies were resolved by consensus with the senior author (JC). Twenty-two studies met full inclusion criteria for the final analysis (Figure 1).

Exclusions• Case reports• Non-original data, meta-analyses, etc.• Evidence level 4 and below• CASP score of 8 or less• Patients with pathology proximal to the mid-tibia • Studies with <12 patients per subgroup

Assumptions and simplificationsFor the purposes of the meta-analysis, all studies were considered as cohorts, such that an RCT with two arms was considered as two separate cohorts. Patient cohorts have been simplified into two categories: general foot and ankle patients includ-ing elective and trauma patients that may or may not have required a below knee cast and patients with acute Achilles tendon rupture treated with or without sur-gery. Achilles patients were considered in a separate meta-analysis as they have been found to have significantly higher risks of VTE in some studies, and these studies were clearly outliers in our provisional review of the data.

LMWH regimens were considered to be equal although formulations and length of treatment may vary. Two further studies, one using extended intermittent pneu-matic compression devices (IPCDs) and one using aspirin, were also included in the prophylaxis group.

The principal study measures are VTE rates, a sum of the DVT and PE incidence.Statistical advice was sought from the Biostatistics Unit, University College Lon-

don, UK. Analysis was performed using STATA. The results are presented as incidence with 95% confidence intervals. A meta-analysis was performed initially using a fixed effects model with a test for homogeneity. If homogeneity was unlikely (a pre-hoc probability of p=0.2), then a random effects model was used.

RESULTS

Narrative resultsIn total 22 studies met the criteria for inclusion: 10 of these assessed VTE clinically, 7 with ultrasound and 5 with venography.

Meta-analysis and suggested guidelines for prevention of venous thromboembolism| 143

10

Fig. 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram of article selection

372 records identi�ed throughdatabase searching

32 additional records identi�edthrough other sources

404 total records identi�ed

Iden

ti�ca

tion

Scre

enin

gEl

igib

ility

Incl

uded

52 duplicate recordsexcluded

324 excluded based onabstract/title, or data

from authors

6 full-text articlesexcluded, with reasons

352 records screened after duplicatesremoved

28 full-text articles assessed for eligibility

22 studies included in qualitative synthesis

Patient populations

There was heterogeneity in the study populations with some studies offering data on various subgroups. Six studies considered general foot and ankle cases.16,22,24,32,36,40 Twelve studies had trauma cohorts.21,33,36-38,41,56,57,62,66,67,69 Six studies looked at Achilles injury, some of these included patients regardless of treatment whilst others focused specifically on Achilles surgery.9,26,30,36,54,64

Prophylaxis

There was also some heterogeneity in prophylaxis regimens. Most studies used LMWH either in comparison to no prophylaxis 21,32,33,36-38,42 or in isolation.24,57,76 One study compared aspirin with no prophylaxis 22 and another compared an Intermit-tent Pneumatic Compression Device with no prophylaxis.9 The remaining studies used no formal post-operative prophylaxis 16,26,41,54,62,64,66,67 or were unclear.30,69

Methodological quality

The studies showed moderate-to-good methodologies according to the CASP appraisal tool. All studies were focused with an appropriate method and accept-

| Chapter 10144

able recruitment. The exposure was generally measured to minimize bias (21/22) although there was a risk of bias in the out- come measures of some (4/22). Con-founding factors were identified in 14 of 22 studies and accounted for in the analysis of 15 of 23. Follow-up was considered complete enough in all but three of the stud-ies (19/22), seven studies used large hospital databases to follow patients and 12 had over 80% follow-up. The length of follow-up was 35 days or more in 11 studies, in a further seven studies using large hospital databases, it was assumed to be sufficient and in four was considered to be insufficient. All study populations were relevant, and the results were comparable to other studies in most cases (18/22). Overall, the authors were in favour of prophylaxis in seven studies, against in nine, and no clear conclusion was drawn in seven.

Risk factors for VTE

Of the 12 studies that analysed risk factors for VTE, age was found to be a factor in six studies32,36,37,62,66,67; no statistical association with any risk factor was shown in three studies21,56,57; injury severity was associated with risk of VTE in two studies62,66; obe-sity was a factor in three studies16,37,66 and immobilization was a factor in three stud-ies.36,62,67 Other risk factors found in individual studies were as following: non- weight bearing,62 hindfoot surgery,67 tourniquet time,67 varicose vein,37 Charlson score >2,32 NIDDM,32 air travel,24 prior VTE,16 hormone replacement therapy (HRT) and oral con-traceptives.16

Meta–analysis results

To reduce the risk of heterogeneity in the study design affecting the results, the fol-lowing meta-analyses were performed:

• All studies using clinical indicators as the primary assessment of VTE—this group was divided into patients who either received or did not receive prophylaxis.

• All studies using radiological means as the primary assessment of VTE—again this group was divided into patients who either received or did not receive prophylaxis.

• Studies investigating VTE purely following Achilles tendon rupture were assessed separately as the high rates of DVT were obvious outliers when compared to other foot and ankle injuries or treatments.9,26,30,40,54,64

• Studies where the prophylaxis regimen was unclear were excluded.30,69

Clinical assessment of VTE in patients with foot and ankle conditions

A total of 43,381 patients were clinically assessed for the presence of VTE. 126 of 27,139 patients without any form of prophylaxis developed VTE (0.46%). The pooled effect size shows the incidence of VTE without prophylaxis to be 0.6% (95% CI 0.4–0.8%) (Figure 2).

45 of 16,242 patients with prophylaxis developed VTE (0.28%). The pooled effect size shows the incidence of VTE with prophylaxis to be 1% (95% CI 0.2–1.7%) ( Figure 3). There was no significant difference in the rate of VTE between the groups with and without chemoprophylaxis.

Meta-analysis and suggested guidelines for prevention of venous thromboembolism| 145

10

Fig. 2 Forest plot of clinical assessment of VTE without prophylaxis

Study %

ID WeightES (95% CI)

Felcher (2009)

Goel (2009)

Gri�ths (2012)

Jameson (2011)

Lapidus (2013b)

Pelet (2012)

Shibuya (2012)

Overall (I-squared = 98.9%, p=0.000)

0.00 (0.00, 0.00)

0.13 (0.06, 0.19)

0.00 (0.00, 0.01)

0.00 (0.00, 0.00)

0.07 (0.05, 0.09)

0.03 (0.02, 0.04)

0.00 (0.00, 0.01)

0.01 (0.00, 0.01)

23.05

0.14

15.65

27.32

1.69

4.82

27.32

100.00

Note: Weights are from random e�ects analysis

–0.189 0.1890

Fig. 3 Forest plot of clinical assessment of VTE with prophylaxis

Study

ID

%

ES (95% CI) Weight

Goel (2009)

Gri�ths (2012)

Jameson (2011)

Lapidus (2013a)

Pelet (2012)

Overall (I-squared = 89.0%, p=0.000)

0.09 (0.04, 0.14)

0.00 (0.00, 0.01)

0.00 (0.00, 0.00)

0.01 (0.01, 0.02)

0.03 (0.01, 0.05)

0.01 (0.00, 0.02)

2.10

29.41

32.10

26.62

9.77

100.00

Note: Weights are from random e�ects analysis

–0.136 0.1360

Radiological assessment of VTE in patients with foot and ankle conditions

1666 Patients were assessed for radiological evidence of DVT. 120 of 981 patients without any form of prophylaxis developed VTE (12.2%). The pooled effect size shows the incidence of VTE without prophylaxis to be 12.5% (95% CI 6.8–18.2%) (Figure 4).

54 of 685 patients with prophylaxis developed VTE (7.9%). The pooled effect size shows the incidence of VTE with prophylaxis to be 10.5% (95% CI 5.0–15.9%)

| Chapter 10146

Fig. 4 Forest plot of radiological assessment of VTE without prophylaxis

Study %

ID WeightES (95% CI)

Jorgensen (2002)

Kack (1995)

Lassen (2002)

Patil (2007)

Lapidus (2007)

Solis (2002)

Kujath (1993)

Overall (I-squared = 90.8%, p=0.000)

0.17 (0.10, 0.24)

0.04 (0.01, 0.07)

0.28 (0.19, 0.37)

0.19 (0.13, 0.24)

0.05 (0.01, 0.09)

0.04 (0.01, 0.06)

0.17 (0.10, 0.23)

0.01 (0.00, 0.01)

13.23

15.80

11.72

14.38

15.15

16.06

13.67

100.00

Note: Weights are from random e�ects analysis

–0.371 0.3710

Fig. 5 Forest plot of radiological assessment of VTE with prophylaxis

%

WeightES (95% CI)

Study

ID

Jorgensen (2002)

Lassen (2002)

Lapidus (2007)

Kock (1995)

Kujath (1993)

Overall (I-squared = 78.0%, p=0.000)

0.10 (0.04, 0.16)

0.09 (0.05, 0.13)

0.21 (0.13, 0.29)

(Excluded)

0.05 (0.01, 0.09)

0.10 (0.05, 0.16)

23.86

27.86

19.58

0.00

28.70

100.00

Note: Weights are from random e�ects analysis

–0.286 0.2860

( Figure 5). There was no significant difference in the rate of VTE between the groups with and without chemoprophylaxis.

Patients with Achilles tendon rupture

1060 patients were assessed clinically for evidence of DVT, and 74 were confirmed to have VTE (7%). The pooled effect size shows the incidence of VTE to be 7% (95%

Meta-analysis and suggested guidelines for prevention of venous thromboembolism| 147

10

CI 5.5–8.5%) (Figure 6). Hundred and seven patients were assessed for radiological evidence of DVT and 38 were confirmed to have VTE (35.5%). The pooled effect size shows the incidence of VTE to be 35.3% (95% CI 26.4–44.3%) (Figure 7).

Only one RCT reported the effect of LMWH on rate of VTE following immobiliza-tion of 105 patients with Achilles tendon rupture. There was no significant reduction in the rate of DVT with 34% in the LMWH group and 36% in the control group.42

DISCUSSION

The most important finding of this study is that there is a low risk of developing VTE following isolated foot and ankle surgery and no benefit could be demonstrated

Fig. 6 Forest plot of incidence of clinically assessed DVT in Achilles tendon rupture

%

WeightES (95% CI)

Study

ID

Healy (2010)

Saragas (2011)

Lapidus ‘13

Overall (I-squared = 0.0%, p=0.894)

0.06 (0.03, 0.10)

0.07 (0.02, 0.12)

0.07 (0.05, 0.09)

0.07 (0.05, 0.08)

20.14

7.99

71.87

100.00

–0.121 0.1210

Fig. 7 Forest plot of incidence of radiologically assessed DVT in Achilles tendon rupture

%

WeightES (95% CI)

Study

ID

Domij (2013)

Nissan-Holander (2009)

Overall (I-squared = 13.3%, p=0.283)

0.50 (0.22, 0.78)

0.34 (0.24, 0.43)

0.35 (0.26, 0.44)

10.00

90.00

100.00

–0.782 0.7820

| Chapter 10148

by using chemoprophylaxis. The incidence of VTE without prophylaxis was 0.6% when diagnosed clinically and 12.2% with radiological diagnosis which is similar to the meta-analyses by Ettema et al. and Testroote et al. who both also reported on VTE following lower limb immobilization.14,70,71 It is also similar to the background risk of spontaneous VTE of 0.2–0.5%.18,25 This is lower than in general orthopaedic surgery where the rate of DVT is reported as 40–60%,23 but similar to the incidence of DVT following knee arthroscopy which has been reported as 0.6% when diag-nosed clinically and up to 17.9% when using radiography.31,60 The consequences of asymptomatic below knee DVT and the importance of its prevention and treatment remains controversial and a systematic review of the treatment of below knee DVT’s concluded there was insufficient evidence to recommend treatment over mere sur-veillance.8,19,29,34,43,45,58,61,74

Various methods of prophylaxis may be employed but no method completely pro-tects against VTE.35 LMWH is the current standard by which other chemical agents are compared. However, the ideal duration of treatment has yet to be confirmed in orthopaedic surgery with some proto- cols advocating treatment only whilst in hos-pital and others whilst immobilized or for an arbitrary period ranging from 2 weeks to 35 days.

Out of hospital, compliance rates may drop below 85% and oral agents may increase patient compliance.15,47,73 The ACCP review concluded that a 160 mg dose of aspirin for 35 days following lower limb injuries would prevent 7 per 1000 VTE’s but at the expense of three major bleeding episodes and two non-fatal myocardial infarc-tions.15 Only one paper investigated the use of aspirin in foot and ankle surgery, and no benefit in protecting patients from VTE could be demonstrated.22 To our knowl-edge, warfarin has not been investigated with regards to VTE prophylaxis in foot and ankle surgery. New oral anticoagulants such as dabigatran and rivaroxaban are only currently licensed for use following elective hip and knee arthroplasty, and to date no studies have investigated their use in patients undergoing foot and ankle surgery.48

Therefore, if chemoprophylaxis is to be recommended it would appear that only LMWH has a body of evidence to support its use. However, this meta-analysis has failed to demonstrate any significant reduction in the risk of VTE with the use of LMWH in foot and ankle conditions irrespective of the method of assessment – clini-cal assessment 0.6 versus 1% with prophylaxis (p=n.s.) and radiological assessment 12.5 versus 10.5% with prophylaxis (p=n.s.).

In addition to the lack of effectiveness of chemoprophylaxis following isolated foot and ankle surgery, it is recognized there are potential risks of administering LWMH. These risks include bleeding (0.3–1% following lower limb surgery),17,42,46,52 bruising and haematomas (12%),33,42 wound healing problems and increased rate of wound infection, of particular concern in the foot and ankle.33,36,42 Heparin-induced throm-bocytopenia (HIT) is a potentially life-threatening adverse effect, more common in post-operative patients than medical patients with a rate of 2.6–6.5% using unfrac-tionated heparin and 0.2–0.35% with LMWH.6,20,44

The risk of developing VTE in the subgroup of patients with Achilles tendon rup-ture appears to be particularly high whether treated surgically or non-operatively. Nilsson-Helander et al. and Lapidus et al. both reported an incidence of 36% when screened with USS.39,54 We separated Achilles tendon rupture patients from the main

Meta-analysis and suggested guidelines for prevention of venous thromboembolism| 149

10

analysis as the results were clear outliers when compared with other foot and ankle conditions with few good-quality studies and only a small number of patients. It may be that because of direct involvement and de-functioning of the gastro-soleus com-plex, Achilles tendon ruptures need to be considered separately from general foot and ankle cases with regards to VTE prophylaxis. Although LMWH has been shown to have little or no effect in prevention of DVT following Achilles rupture,39 a recent RCT of 150 patients using mechanical IPCDs for 2 weeks following Achilles tendon repair has demonstrated an absolute risk reduction for DVT of 37–21% in the treated group (OR 2.60; 95% CI 1.15–5.91; p = 0.022).10 Active mechanical methods address the problems of stasis, and further research into this area is justified.

This meta-analysis could be criticized for including studies with a wide variety of foot and ankle cases including both elective and trauma. This trade-off increases the numbers included in the analysis at the expense of some clinical heterogeneity. However, we believe it represents the realities of clinical practice. The studies were also statistically heterogeneous which reflects differences in study protocols, and we recognize that this heterogeneity limits the interpretation of any study on VTE rates in this population.

With the exception of age, the studies included in this review show conflicting results regarding risk factors such as restricted weight bearing, obesity and smok-ing where some studies report an association with VTE.3,11,50 However, there was too much study heterogeneity to specifically investigate the effect of individual risk fac-tors. A his- tory of previous VTE and thrombophilia has been shown to significantly increase the risk of further VTE with a 23% 5-year rate of recurrence of proximal DVT, 6% for calf DVT and pulmonary embolus 3–4 times as likely to recur in a meta-anal-ysis by Baglin et al.1,2

Previous studies of chemical prophylaxis and RCTs of LMWH for lower limb immo-bilization have reported insignificant effects in the prevention of DVT.14,22,38,65 A retro-spective study of 664 total ankle replacements reported a clinical VTE rate of 0.6% without prophylaxis, unless there was a previous history of VTE and a recent double- blind RCT of the effects of LMWH following surgery and immobilization for lower leg fractures was stopped after interim analysis of 258 patients demonstrated an incidence of clinical VTE of 1.9% and no significant benefit of using chemical prophylaxis.27,65

This paper would support the view that the risk–benefit of chemoprophylaxis for those with isolated foot and ankle conditions should be assessed separately from those under- going general lower limb orthopaedic surgery. Although there was inconsistency in their effect on VTE risk in foot and ankle surgery, undoubtedly cer-tain patient-related factors increase the risk of VTE including smoking, obesity, age >60 years, malignancy, HRT, oral contraception, previous VTE and thrombophilia and these should continue to be taken into account when assessment is made as to the need for chemoprophylaxis. It is also recognized that multiple risk factors are cumulative and two or more risk factors may lower the threshold for considering the benefit of chemoprophylaxis over the risks and costs of its use.7,63 Mechanical methods such as TEDS and IPCDs may be a targeted alternative to chemoprophy-laxis for DVT prevention in lower limb-immobilised patients after foot and ankle sur-gery. These patients should also routinely be encouraged to mobilize early and avoid dehydration (Table 1).

| Chapter 10150

Tab

le 1

. C

hara

cter

istic

s of

incl

uded

stu

dies

Aut

ho

r (y

ear)

[r

efer

ence

]St

udy

des

ign

Num

ber

of

pat

ien

tsPa

tien

tsD

etec

tio

n m

eth

od

CA

SP s

core

(m

ean

)

Dom

eij (

2013

) [4

0]RC

T 24

DV

T 2

and

6 w

eeks

follo

win

g su

rger

y fo

r A

chill

es r

uptu

re –

IP

CD

ver

sus

no p

rop

hyla

xis

DV

T –

US

9

Felc

her

(200

9) [1

9]Re

tros

pec

tive

coho

rt 

7264

Dat

abas

e se

arch

for

VTE

w

ithin

6 m

onth

s of

sur

ger

yD

VT

– U

SSPE

– V

Q/C

TPA

sca

n10

Goe

l (20

09)

[27]

RCT

238

LMW

H v

ersu

s p

lace

bo

follo

win

g su

rger

y fo

r be

low

kn

ee fr

actu

res

DV

T - v

enog

rap

hy10

Grif

fiths

(20

12)

[20]

Cas

e co

ntro

l26

5475

mg

asp

irin

vers

us n

o ch

emic

al p

rop

hyla

xis

Sym

pto

mat

ic V

TE9.

5

Han

slow

(20

06)

[21]

Retr

osp

ectiv

e co

hort

608

Foot

and

ank

le s

urg

ery

(hig

h ris

k p

atie

nts

rece

ived

LM

WH

)Sy

mp

tom

atic

VTE

8.5

Hea

ly (

2010

) [3

7]Re

tros

pec

tive

coho

rt20

8A

chill

es r

uptu

re (

cast

an

d su

rger

y) n

o ch

emop

rop

hyla

xis

Sym

pto

mat

ic V

TE c

onfir

med

by

USS

/CTP

A10

Ingv

ar (

2005

) [3

5]Re

tros

pec

tive

coho

rt19

6A

chill

es r

uptu

re tr

eate

d co

nser

vativ

ely

Sym

pto

mat

ic V

TE8

Jam

eson

(20

14)

[22]

Retr

osp

ectiv

e co

hort

8824

1D

atab

ase

sear

ch fo

r V

TE

befo

re a

nd a

fter

intr

oduc

tion

of N

ICE

guid

elin

es

Hos

pita

l ep

isod

e st

atis

tics 

10.5

Jorg

ense

n (2

002)

[28]

RCT

300

Belo

w k

nee

cast

im

mob

ilisa

tion

– LM

WH

ve

rsus

no

pro

phy

laxi

s

DV

T - v

enog

rap

hy9

Kock

(19

95)

[23]

RCT

339

Belo

w k

nee

cast

im

mob

ilisa

tion

– LM

WH

ve

rsus

no

pro

phy

laxi

s

DV

T - U

SS c

onfir

med

with

ve

nogr

aphy

10.5

Meta-analysis and suggested guidelines for prevention of venous thromboembolism| 151

10

Kuja

th (

1993

) [2

9]RC

T25

3Be

low

kne

e ca

st

imm

obili

satio

n –

LMW

H

vers

us n

o p

rop

hyla

xis

DV

T –

USS

PE –

VQ

12

Lap

idus

(20

13)

[24]

Pros

pec

tive

coho

rt58

94N

o ro

utin

e p

rop

hyla

xis

for

foot

and

ank

le s

urg

ery

exce

pt

LMW

H fo

r an

kle

frac

ture

s

DV

T –

USS

PE –

VQ

/CTP

A s

can

11

Lap

idus

(20

07)

[30]

RCT

272

Ank

le fr

actu

res

- LM

WH

un

til c

ast r

emov

al v

ersu

s no

p

rop

hyla

xis

DV

T - v

enog

rap

hy10

.5

Lass

en (

2002

) [3

1]RC

T44

0A

nkle

frac

ture

s - L

MW

H

until

cas

t rem

oval

ver

sus

no

pro

phy

laxi

s

DV

T –

USS

PE –

VQ

/CTP

A s

can

10.5

Nils

son-

Hel

ande

r (2

009)

[3

9]RC

T95

Surg

ery

vers

us n

o su

rger

y fo

r A

chill

es r

uptu

re –

no

rout

ine

pro

phy

laxi

s

DV

T –

USS

PE –

VQ

/CTP

A s

can

9

Patil

(20

07)

[32]

Pros

pec

tive

coho

rt10

0Be

low

kne

e ca

st

imm

obili

satio

n fo

r an

kle

frac

ture

s –

no r

outin

e p

rop

hyla

xis

DV

T –

USS

10.5

Pele

t (20

12)

[ 33]

Retr

osp

ectiv

e co

hort

1540

Surg

ery

for

ankl

e fr

actu

re –

no

rou

tine

pro

phy

laxi

s (1

41

low

dos

e as

piri

n; 2

53 L

MW

H)

Sym

pto

mat

ic V

TE c

onfir

med

by

USS

/VQ

/CTP

A s

can

11

Riou

(20

07)

[34]

Pros

pec

tive

coho

rt27

57Be

low

kne

e ca

st

imm

obili

satio

n -

chem

opro

phy

laxi

s ve

rsus

no

pro

phy

laxi

s

DV

T –

USS

10.5

Shib

uya

(201

2) [

35]

Retr

osp

ectiv

e co

hort

7566

4D

atab

ase

sear

ch fo

r fo

ot a

nd

ankl

e tr

aum

aSy

mp

tom

atic

VTE

10.5

| Chapter 10152

Aut

ho

r (y

ear)

[r

efer

ence

]St

udy

des

ign

Num

ber

of

pat

ien

tsPa

tien

tsD

etec

tio

n m

eth

od

CA

SP s

core

(m

ean

)

Sara

gas

(20

11)

[41]

Retr

osp

ectiv

e co

hort

88Su

rgic

al r

epai

r A

chill

es

rup

ture

– n

o p

rop

hyla

xis

Sym

pto

mat

ic V

TE c

onfir

med

by

USS

8.5

Solis

(20

02)

[26]

Pros

pec

tive

coho

rt20

1N

o ro

utin

e p

rop

hyla

xis

for

foot

and

ank

le s

urg

ery

DV

T –

USS

9

Sooh

oo (

2011

) [3

6]Re

tros

pec

tive

coho

rt57

183

Dat

abas

e se

arch

for

ankl

e fr

actu

res

unde

rgoi

ng s

urg

ery

Read

mis

sion

for

VTE

9

RCT,

ran

dom

ized

con

trol

led

tria

l; IP

CD, i

nter

mitt

ent p

neum

atic

com

pre

ssio

n de

vice

; VQ

/CTP

A sc

an, v

entil

atio

n-p

erfu

sion

/com

put

eriz

ed to

mog

rap

hic

pul

mon

ary

angi

ogra

phy

sca

n

Tab

le 1

. C

ont.

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The findings of this meta-analysis are summarized using a Grade of Recommenda-tion (Tables 2 and 3), and guidelines for considering VTE prophylaxis in isolated foot and ankle conditions is proposed in Table 4.75

CONCLUSION

The incidence of clinically apparent VTE following foot and ankle surgery is less than 1% without using chemical prophylaxis, and no benefit could be demonstrated by using LMWH. Routine chemoprophylaxis cannot be recommended following iso-lated foot and ankle surgery. The one group where there may be a significant risk of VTE is following Achilles tendon rupture when specific preventative measures such as IPCDs may be indicated, and further research should investigate mechanical meth-ods.

Table 2. Grades of recommendation for orthopedic surgical studies

Grade of recommendation

Description

A Good evidence (Level I studies with consistent findings) for or against recommending intervention

B Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention

C Poor quality evidence (Level IV or V studies with consistent findings) for or against recommending intervention

I There is insufficient or conflicting evidence not allowing a recommendation for or against intervention

Table 3. Grade of recommendation assigned summarizing main findings of the meta-analysis

Routine chemoprophylaxis is not indicated for patients undergoing isolated foot and ankle surgery (Grade A recommendation)

Routine chemoprophylaxis is not indicated for patients with restricted weight bearing or immobilized for isolated foot and ankle conditions (Grade B recommendation)

Routine use of mechanical anti-VTE methods is indicated following Achilles tendon rupture whether treated surgically or non-operatively as there is a higher risk of VTE (Grade B recommendation)

Chemoprophylaxis with LMWH should be considered if two or more risk factors (smoking, obesity, age >60 years, malignancy, HRT, oral contraception, previous VTE and thrombophilia) are present in patients with isolated foot and ankle conditions (Grade C recommendation)

| Chapter 10154

Table 4. Suggested guidelines for prevention of VTE in routine isolated foot and ankle surgery (with/without immobilization and reduced weight-bearing)

Start mechanical VTE prophylaxis at admission using one of the following:

Anti-embolic stockings (thigh or knee length)—assuming no contraindications

Foot impulse devices

Intermittent pneumatic compression devices (thigh or knee length)

If patient has a history or previous VTE/thrombophilia or two or more risk factors below consider chemical prophylaxis (LMWH commencing 6-12 hours after surgery until discharge from hospital or if immobilized and/or reduced weight-bearing continue until the patient no longer has significantly reduced mobility)

Active cancer or cancer treatment

Age over 60 years

Smoking

Critical care admission

Dehydration

Obesity [body mass index (BMI) over 30 kg/m2] Use of hormone replacement therapy

Use of oestrogen-containing contraceptive therapyVaricose veins with phlebitis

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32. Jameson SS, Rankin KS, Desira NL, James P, Muller SD, Reed MR, Rangan A (2014) Pulmonary embolism following ankle fractures treated without an operation—an analysis using National Health Service data. Injury 45(8):1256–1261

33. Jørgensen P, Warming T, Hansen K, Paltved C, Vibeke Berg H, Jensen R, Kirchhoff-Jensen R, Kjaer L, Kerbouche N, Leth- Espensen P, Narvestad E, Rasmussen S, Sloth C, Tørholm C, Wille-Jørgensen P (2002) Low molecular weight heparin (Inno-hep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res 105(6):477–480

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36. Kock HJ, Schmit-Neuerburg KP, Hanke J, Rudofsky G, Hirche H (1995) Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet 346(8973):459–461

37. Kujath P, Spannagel U, Habscheid W (1993) Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis 23(suppl 1):20–26

38. Lapidus LJ, Ponzer S, Elvin A, Levander C, Lärfars G, Rosfors S, de Bri E (2007) Prolonged thromboprophylaxis with Dalteparin during immobilization after ankle fracture surgery: a randomized placebo-controlled, double-blind study. Acta Orthop 78(4):528–535

39. Lapidus LJ, Rosfors S, Ponzer S et al (2007) Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 21:52–57

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40. Lapidus LJ, Ponzer S, Pettersson H, de Bri E (2013) Symptomatic venous thromboembolism and mortality in orthopaedic surgery—an observational study of 45 968 consecutive procedures. BMC Musculoskelet Disord 14(1):177

41. Lassen MR, Borris LC, Nakov RL (2002) Use of the low- molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med 347(10):726–730

42. Lassen MR, Ageno W, Borris LC et al (2008) Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med 358(26):2776–2786

43. Lee TH, Alonzo BJ, Differding J, Underwood SJ, Hamilton G, Kremenevskiy I, McNamara S, Schreiber MA (2013) The effects of location and low-molecular-weight heparin administration on deep vein thrombosis outcomes in trauma patients. J Trauma Acute Care Surg 74(2):476–481

44. Martel N, Lee J, Wells PS (2005) Risk for heparin-thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 106(8):2710

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47. Mengiardi S, Tsakiris DA, Lampert ML, Hersberger KE (2011) Drug use problems with self-injected low-molecular-weight heparins in primary care. Eur J Clin Pharmacol 67(2):109–120

48. Messerschmidt C, Friedman RJ (2015) Clinical experience with novel oral anticoagulants for thromboprophylaxis after elective hip and knee arthroplasty. Arterioscler Thromb Vasc Biol 35(4):771–778

49. Milbrink J, Bergqvist D (2008) The incidence of symptomatic venous thromboembolic events in orthopaedic surgery when using routine thromboprophylaxis. Vasa 37(4):353–357

50. Mizel MS, Temple HT, Michelson JD et al (1998) Thromboembolism after foot and ankle surgery: a multicenter study. Clin Orthop Relat Res 348:180–185

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54. Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI (2009) High incidence of deep venous thrombosis after Achilles ten- don rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc 17(10):1234–1238

55. Oxford Centre for Evidence-Based Medicine (2011) Levels of evidence. http://www.cebm.net/wp-content/uploads/2014/06/ CEBM-Levels-of-Evidence-2.1.pdf

56. Patil S, Gandhi J, Curzon I, Hui AC (2007) Incidence of deep- vein thrombosis in patients with fractures of the ankle treated in a plaster cast. J Bone Joint Surg Br 89(10):1340–1343

57. Pelet S, Roger ME, Belzile EL, Bouchard M (2012) The incidence of thromboembolic events in surgically treated ankle frac- ture. J Bone Joint Surg Am 94(6):502–506

58. Persson LM, Lapidus LJ, Lärfars G, Rosfors S (2011) Deep venous thrombosis after surgery for Achilles tendon rupture: a provoked transient event with minor long-term sequelae. J Thromb Haemost 9(8):1493–1499

59. Public Health Resource Unit (2006) The critical skills appraisal programme: making sense of evidence. Public Health Resource Unit, England. Retrieved from http://www.casp-uk.net/

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62. Riou B, Rothmann C, Lecoules N, Bouvat E, Bosson JL, Ravaud P, Samama CM, Hamadouche M (2007) Incidence and risk factors for venous thromboembolism in patients with nonsurgical isolated lower limb injuries. Am J Emerg Med 25(5):502–508

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64. Saragas NP, Ferrao PN (2011) The incidence of venous thrombo- embolism in patients undergoing surgery for acute Achilles ten- don ruptures. Foot Ankle Surg 17(4):263–265

65. Selby R, Geerts W, Kreder H, Crowther M, Kaus L, Sealey F (2015) A double-blind, randomized controlled trial of the prevention of clinically important venous thromboembolism after isolated lower leg fractures. J Orthop Trauma 29(5):224–230

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69. SooHoo NF, Eagan M, Krenek L, Zingmond DS (2011) Incidence and factors predicting pulmonary embolism and deep venous thrombosis following surgical treatment of ankle fractures. Foot Ankle Surg 17(4):259–262

70. Testroote M, Stigter W, Janzing H, de Visser D (2008) Low molecular weight heparin for prevention of venous thrombo- embolism in patients with lower leg immobilization. Cochrane Database Syst Rev (Issue 3):CD006681

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GENERAL DISCUSSION AND SUMMARY

11GENERAL DISCUSSION, CONCLUSIONS

AND FUTURE RESEARCHENGLISH SUMMARY

NEDERLANDSE SAMENVATTING

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GENERAL DISCUSSION

Sports injuries to the ankle and the Achilles tendon may vary from the simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover. Some of these injuries can be easily missed or misdiagnosed with poten-tially devastating effects on future performance and thus may be career threatening to the professional athlete.

Treatment of elite athletes may differ from that of the recreational athlete or “ normal” patient because of their pressures and expectations of returning to the same level of sporting activities at the earliest opportunity. Therefore, operations may be considered before giving conservative treatment a chance. Clinicians are con-stantly searching for those key clinical points and investigations that may ensure an early diagnosis to ensure optimal conservative management or predict when surgery is required plus provide a timeframe of expected return to training. Novel techniques may speed the recovery of patients and enable early active rehabilitation and prevent deconditioning in the elite athlete. Current literature has focused on the treatment of sports injuries in general populations but rarely the athlete. This thesis has investi-gated investigations, novel treatments and the expected return to sports in the elite level athletic population.

Part I – Ankle InjuriesAnkle sprains are the commonest lower limb sporting injuries. Ankle injuries account for 10-15% of all sporting injuries with around 23,000 estimated to occur every day in the United States and certain sports including basketball, soccer and netball there is an incidence rate of between 0.02 and 34.83 injuries per 1000 player hours.1–3

The incidence of ankle syndesmosis injuries ranges between 1 to 18% of all ankle sprains.4,5 Syndesmosis injuries have an unpredictable outcome and may be diffi-cult to diagnose.6–13 Chapter 2 reported on the results of treating grade II injuries in professional athletes and demonstrated that although an isolated syndesmosis injury may lead to a predictable time away from play those with a positive squeeze test, concomitant deltoid ligament or posterior tibiofibular ligament injury are more likely to be dynamically unstable and benefit from early arthroscopic assessment and stabilization. Although arthroscopic assessment and early stabilization has been previously described this is the first report of such treatment in a cohort of elite level athletes and provides treating medical teams with an estimate of the likely time to return to play (essential information for players and coaches).13,14 It also reported on those factors that are likely to lead to a delay in return to play. The importance of the findings reported in this chapter is that specific clinical signs or combination of clinical and MRI findings appear to increase the likelihood of an unstable injury. This may be used by club medical teams to ensure early arthroscopic assessment is considered. It also gives these clinicians some evidence to guide answers as to timing of return to play which will be demanded from the player and the team manage-ment.

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Early identification and treatment of syndesmosis injuries may prevent long term adverse sequelae such as ankle pain from chronic instability and yet several syndesmosis injuries are unrecognised.13–16 Chapter 3 investigated specific MRI find-ings that could be used to predict the presence of a syndesmosis injury by measure-ment of the height of fluid in the interosseous ligament. Although this measurement was inaccurate with considerable inter-observer variability and had significant over-lap with standard lateral ligament injuries this study did identify a new “Broken Ring of Fire” sign which appears highly predictive of significant of syndesmosis injury. Currently the diagnosis of syndesmosis injuries may be delayed because of lack of clinical suspicion but also an underestimation of the importance of radiographic findings suggesting a more serious injury.14,16–18 This new sign may help to “flag-up” the possibility of a syndesmosis injury to the treating medical team enabling reassess-ment of the clinical findings ensuring early appropriate management for the injury. Furthermore, it demonstrated the importance of ensuring that sports-trauma related MRI sequences of the ankle need to routinely start 4cm proximal to the ankle joint in order to identify relevant pathology. The identification of circumferential stripping of the tibial periosteum is the first to provide radiological support for previous ana-tomical and biomechanical studies that have suggested a rotational mechanism in syndesmosis injuries.19–23

Chapter 4 reported the results of the largest series of professional athletes undergoing early repair of acute combined ATFL and CFL injuries. The conclusions that such athletes may be able to return to their previous level of sports within a predictable timeframe is an important finding. It confirms that concern regarding whether surgery leads to a delay in return to sport is unfounded and also that there is a low incidence of recurrent instability post operatively.24 These conclusions conflict with the Cochrane reviews which conclude that for the general population initial non-operative treatment is best for such patients but supports the more recent discussions that have taken place in forums such as ESSKA-AFAS.24,26 It is difficult to justify early reconstruction in all patients presenting with acute rupture of the ATFL and CFL but this paper does support the meta-analysis of Pijnenburg et al which concluded there are superior results with operative treatment and for elite athletes this approach would seem justified as residual ankle instability is a sig-nificant factor in recurrent ankle injury whilst early operative repair leads to a predictably acceptable timeframe of return to play.26,27

Part II – Osteochondral lesions of the talus and ankle arthroscopyArthroscopy has become an increasingly important technique in the treatment of sport related foot and ankle conditions. It was seen in Chapter 2 that the presence of a talar osteochondral lesion (OCL) was a significant factor leading to delay in return to sports following syndesmosis injury. Although the majority of OCLs may be treated with debridement and microfracture those >14mm have a less predictable outcome and techniques such as osteochondral autologous transplantation (OATs) may be indicated.28–39 Currently this usually requires harvesting donor osteochondral plugs from knee which is less than ideal given the potential morbidity associated

| Chapter 11168

with this, especially in an elite athlete. The patient may have an excellent clinical result from the ankle surgery but potentially may be unable to return to the same level of sports because of knee pain.40,41 Although alternative donor sites such as the proximal tibio-fibula syndesmosis and the iliac crest have been explored none have proven to be advantageous.42–45 Chapter 5 therefore explored the possibility of using the posterior superior calcaneal tuberosity as a donor site as there have been conflicting conclusions in the literature as to whether it is covered with hyaline-like cartilage.46–49 Careful histochemical analysis of fresh-frozen cadaveric specimens was performed and it is the first investigation to demonstrate conclusively that is a fibro-cartilage covering and therefore would not be a suitable area for OATs where hyaline cartilage is required.

Dramatic improvements in arthroscopy for posterior ankle pathology have taken place with the understanding of safe portal placement and an understand-ing of the posterior ankle anatomy.50,51 As a result, this has become a standard method for treating posterior ankle impingement (PAI) in the athlete with the assumption that endoscopy may lead to improved visualization of the pathology, less local tissue damage/scarring and improved time to recovery when compared to open techniques. This may be the case when treating PAI in ballet dancers but Chapter 6 is the first investigation to report on the results of arthroscopic treat-ment of such conditions in professional athletes.52 The main findings are that it does indeed provide an excellent chance of returning the athlete to full function without symptoms in a predictable timeframe which clubs and players may use to plan timing of such surgery. It also suggested that repeated injections for bony impingement was associated with a less satisfactory overall outcome and longer recovery and this new finding is an important factor to be considered by teams managing this condition mid-season.

Part III – The plantaris tendon and Achilles tendinopathyThe plantaris tendon is becoming increasingly recognized to have a potentially important role in the development of non-insertional Achilles tendinopathy since this was first suggested by Steenstra and van Dijk.53,54 Whether this translates into a genuinely significant burden for elite athletic teams has not been previously docu-mented. Chapter 7 followed 214 track and field athletes from the UK Athletics team over a four year period and reported an annual incidence of plantaris related Achilles tendon problems in up to 9.3% of the athletes with 22% of all sprinters and 18% of all long distance runners being affected. Interestingly, in the bend sprinters there were 12 right side only presentations and 1 left side only presentation supporting the possibility that there is a significant biomechanical component causing a fric-tional or compressive pathological process and that this warrants further investiga-tion. This is the first study on plantaris injuries in a sporting population and reported on the largest group of patients with plantaris injuries.

The concept that the pathophysiology underlying the development of plantaris related Achilles tendinopathy is a compressive or frictional phenomenon was further supported in Chapter 8. Histological analysis was performed on the plantaris tendon

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from 16 patients undergoing plantaris excision for medially based Achilles tendon pain. All patients had symptomatic improvement in both pain and clinical scores and all specimens demonstrated histological evidence of inflammation in the connective tissue surrounding the plantaris. However, only 3 of the 16 specimens had any tend-inopathic change. This new finding suggests that the pain generator is a mechanism other than degeneration within the plantaris tendon and may be abnormal “glid-ing” within the paratendinous tissue creating a focal inflammatory response.55–57 This would support the biomechanical studies which have reported a different stiffness in the plantaris when compared to the Achilles tendon and anatomical studies which have demonstrated a variable insertion of the plantaris tendon.58–60

Chapter 9 further explored the clinical results following excision of the plantaris tendon in 32 elite level athletes with painful Achilles tendinopathy recalcitrant to conservative treatment. This was the first and to date largest series of elite level ath-letes undergoing this procedure. Thirty of thirty-two athletes returned to their sport at the same competitive level at about 10 weeks following surgery – those with sig-nificant and diffuse degenerative changes in the Achilles tendon fared worse than those with a focal tendinopathy adjacent to the plantaris tendon. It is supported by a more recent paper by Bedi et al who have reported excellent results in 14 of 15 ath-letes undergoing a similar procedure.61 It was not possible to differentiate how much improvement was due to excision of the plantaris tendon and removal of its frictional and/or compressive action on the Achilles tendon initiating a tendinopathic process and how much was secondary to the ventral debridement of neovascularization and paratenon stripping since both were performed. It could be that the symptomatic improvement was from denervation of the Achilles tendon.55–56 What is interesting is that since the publication of Chapter 7 it has been recognized that three athletes who required revision surgery because of recurrent pain all underwent sectioning of the plantaris and the remaining ten athletes who had a good result had sectioning and removal of a length of plantaris tendon. At subsequent revision surgery, the proxi-mal stump of the plantaris tendon had become re-attached with scar tissue onto the Achilles tendon. It is possible that optimal surgical results of treatment for plantaris related medial Achilles tendinopathy require excision of a length of plantaris tendon to prevent its reattachment in addition to ventral stripping of neovascularization and the paratenon.

Part IV – Venous thrombo-embolism risks in foot, ankle and Achilles tendon disordersVenous thrombo-embolism (VTE) may be fatal and in the professional athlete the morbidity associated with a non-fatal VTE may significantly affect their sporting activ-ities. The need for anticoagulation may prevent participation in contact sports as well as the possible effects of a post-thrombotic lower limb. Although the risks and preventive measures in hip and knee surgery has been studied in some depth, there is very little in the world literature about risks specific to those undergoing isolated foot ankle surgery.62–68 A balance needs to be struck between identifying the true risk of VTE for a specific patient against the risk of complications following the use of

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chemical prophylaxis and whether there is any true benefit from their use.69,70 In the more general healthcare setting there is also an enormous cost implication to both chemoprophylaxis and treatment of the consequences of VTE. In some centres the fear of law suits following development of VTE has led to the introduction of guide-lines and routine use of chemoprophylaxis following foot and ankle surgery based on extrapolation of data for hip and knee surgery. The meta-analysis in Chapter 10 reported on the incidence of VTE following treatment for foot and ankle conditions and the relative effects of giving chemical prophylaxis. The results suggest that such conditions are not liable to the high VTE risk for those undergoing hip and knee arthroplasty and furthermore that the potential benefit of using chemical prophylaxis agents such as low molecular weight heparin is questionable. With the risk of VTE following foot and ankle surgery being similar to those undergoing knee arthros-copy the conclusion is that routine use of chemoprophylaxis is not required but a patient-specific approach should be undertaken with individual risk factors being assessed. The proposed guidelines suggest that chemical prophylaxis should be con-sidered only for those patients with a history of previous VTE/thrombophilia or two or more of the following risk factors: active cancer or cancer treatment; age >60yrs; smoking; critical care admission; dehydration; body mass index >30kg/m2; use of hormone replacement therapy or oestrogen-containing contraceptive therapy; vari-cose veins with phlebitis. This approach is different from the routine use of chemical prophylaxis frequently recommended following hip and knee arthroplasty and gen-eral lower limb trauma. The paper also highlights the high risk for those patients with an acute Achilles tendon rupture and recommends a combination of mechanical and chemical prophylaxis because of the high rate of VTE when no prophylaxis is offered.

CONCLUSIONS AND FUTURE RESEARCH

Management of the elite athlete requires an appreciation of many factors that affect their ultimate outcome. Not only are accurate early assessment, diagnosis and treatment required but pre-conceived expectations of the time to return to sports require careful management. Any delay in their return may mean loss of confidence in the treating medical team as well as missing a crucial match such as a Champions League game in football or a qualifying run for the Olympic games. Therefore, spe-cific investigations may be used and early operative treatment recommended for an elite athlete when a more conservative “wait and see” approach may be taken for the remainder of us mere mortals! The strive for excellence in sports goes beyond the individuals training and the sports participation as it also affects those members of the team who push boundaries to improve medical care and rehabilitation. The “spin-off” is that advances in the treatment of the professional athlete may trans-late to improvements in treatments of similar conditions in the general population. With the increasing participation in recreational sports it is vitally important that this knowledge is used to optimize sports injury management and prevent the long term consequences such as post-traumatic osteoarthritis.

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This thesis has explored some of the more difficult and controversial hindfoot injuries which frequently affect athletes. From the chapters in Part I it is apparent that early surgical repair of the lateral ligaments following acute severe lateral liga-ment injuries may lead to a predictable return to sports. What it has not answered is whether such management is better than a structured rehabilitation programme – does it return the individual to play quicker with better stability and a reduced chance of recurrent injury than with conservative treatment? The same questions apply to grade II syndesmosis injuries in which surgical management appears safe and effective. It could be argued that since the only definitive way of assessing sta-bility is by arthroscopy some injuries clinically assessed as stable (grade IIa) in fact may have been dynamically unstable (grade IIb) and yet they recovered well with non-operative management. Ideally a randomized controlled study could answer these questions but randomization of professional athletes is difficult if near-impossi-ble. A prospective case-controlled two centre cohort study with one group treating patients non-operatively and the other with early surgical intervention may be able to help answer the former lateral ligament injury questions. Routine arthroscopic evaluation of stability in grade II syndesmosis injuries may help to ensure accurate grading in future studies. However, a separate cohort of grade IIb patients treated without stabilization will still be required to answer the questions fully. It is unrealis-tic to expect an athlete or ethical committee to accept non-operative stabilization of such an injury following confirmation that it is dynamically unstable. Perhaps further research could investigate non-interventional methods to accurately assess for insta-bility? Chapter 3 in Part I attempted to do this by MRI and identified a sign which may raise the possibility of a syndesmosis injury and increase the likelihood of the diagnosis being made early and/or reduce the risk of it being missed. This study also identifies an area where future anatomical evaluation of syndesmosis injury is war-ranted to see if the periosteum is indeed lifted during significant injuries rather than there being only a tear in the interosseous membrane.

Further investigation into optimizing the management of larger OCLs is required and finding alternatives to harvesting OATS from the knee thereby risking post-oper-ative knee pain. The philosophy that the cause of pain is primarily a “bone problem” since articular cartilage has no innervation has been previously discussed by van Dijk’s group in Amsterdam.40 The use of iliac crest bone graft plugs has been reported and the purpose of microfracture after debridement of OCLs is to encourage the for-mation of a stable fibrocartilage layer, not hyaline cartilage.45 Therefore, although Part II of this thesis failed to demonstrate hyaline cartilage on the posterior-superior calcaneal tuberosity it is possible using this donor site to stabilize the subchondral bone with a fibrocartilage layer may provide significant improvement in symptoms.

Part III has confirmed that although the plantaris tendon may be histologically normal it may be a significant factor in the development of Achilles tendon pain in athletes and its removal appears to lead to satisfactory results. However much remains unknown as to the underlying pathophysiology with some studies suggest-ing differential movement of the tendons as a cause of friction or compression lead-ing to Achilles tendinopathy. Future biomechanical, neurophysiological and imaging studies may demonstrate such differential movement during the gait cycle. Further-

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more, research into the role of lower limb alignment may help to explain why certain athletes, such as bend sprinters are more prone to plantaris generated pain and help develop strategies to prevent its development or treatments to reverse the process so that surgery may be avoided.

Prospective studies investigating the risk of VTE and potential benefits of using chemical prophylaxis are fraught with difficulties because of the large numbers required to determine a difference, the need for scans to ensure accurate diagnosis and the potential difficulty with follow-up at additional time-points. The meta-anal-ysis in Part IV highlighted those with an acute rupture of the Achilles as a particu-larly high risk group but failed to demonstrate conclusively that chemoprophylaxis is beneficial. To date, there have been only a few studies published involving small numbers of patients but in view of the high rate of VTE reported it would seem sensible that this is an area where future research could be targeted. These patients are in a defined group, generally of similar age, require close follow-up and with a relatively frequent incidence of both rupture and VTE achieving the numbers is real-istic. Investigating the rates of VTE following different weight bearing status, use of chemoprophylaxis and mechanical methods is an important area since the outcome from this complication is not only a limitation in returning to a similar level of sport but can be potentially fatal.

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ENGLISH SUMMARY

Chapter 1. General Introduction

Sport-related trauma may result in injury to the ankle or Achilles tendon in up to 40% of individuals and these represent some of the commonest injuries to affect athletes. They pose a particular problem for the elite athlete in whom it is crucial to make an early and accurate diagnosis to ensure optimal treatment. The purpose of this thesis was to investigate the mechanisms, diagnosis and also to present novel management strategies for some of the more frequently encountered injuries to the ankle and the Achilles tendon. The overall aim of the thesis was to raise awareness of, and give some clarity to, injuries in which management is controversial. It also aimed to provide an estimation of their expected time of return to sport – information that is lacking in the current literature.

Part I ANKLE INJURIES

Chapter 2. Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilisation and time to return to sports.

Chapter 2 investigated grade II syndesmosis injuries in athletes and aimed to identify factors important in differentiating stable from dynamically unstable ankle sprains and those associated with a longer time to return to sports.

Methods: Sixty-four athletes with an isolated syndesmosis injury (without fracture) were prospectively assessed, with a mean follow-up period of 37 months (range, 24 to 66 months). Those with an associated deltoid ligament injury or osteochondral lesion were included. Those whose injuries were considered stable (grade IIa) were treated conservatively with a boot and rehabilitation. Those whose injuries were clinically unstable underwent arthroscopy, and if instability was confirmed (grade IIb), the syndesmosis was stabilized. Clinical and magnetic resonance imaging (MRI) assessments of injury to individual ligaments were recorded, along with time to return to play. A power analysis estimated that each group would need 28 patients.

Results: All athletes returned to the same level of professional sport. The 28 patients with grade IIa injuries returned at a mean of 45 days (range, 23 to 63 days) compared with 64 days (range, 27 to 104 days) for those with grade IIb injuries (P<0.0001). There was a highly significant relationship between clinical and magnetic resonance imaging assessments of ligament injury (anterior tibiofibular ligament [ATFL], anteri-or-inferior tibiofibular ligament [AITFL], and deltoid ligament, P<0.0001). Instability was 9.5 times as likely with a positive squeeze test and 11 times as likely with a del-toid injury. Combined injury to the anterior-inferior tibiofibular ligament and deltoid ligament was associated with a delay in return to sports. Concomitant injury to the ATFL indicated a different mechanism of injury – the syndesmosis was less likely to be unstable and was associated with an earlier return to sports.

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Conclusions: A positive squeeze test and injury to the AITFL and deltoid ligament are important factors in differentiating stable from dynamically unstable grade II inju-ries and may be used to identify which athletes may benefit from early arthroscopic assessment and stabilization. They may also be important in predicting the time frame for athletes’ expected return to play.

Chapter 3. The broken “Ring of Fire” – A new radiological sign as predictor of syndesmosis injury?

We noticed that subcircumferential periosteal oedema above the ankle joint was fre-quently present on MRI with syndesmosis injuries but was not previously reported. Fluid height within the interosseous membrane has also not been shown to be asso-ciated with syndesmosis injury severity. Chapter 3 investigated whether a new sign on MRI and measurement of the length of fluid within the interosseous membrane above the ankle may be used to enable early identification of a syndesmosis injury and allow differentiation from lateral ligament injury.

Methods: Three groups of patients were identified from a database and the MRI scans retrieved – those with an isolated syndesmosis injury (SI group), isolated lat-eral ligament injury (LLI group) and or no injury (NI group) who had an ankle MRI for another reason. The scans were anonymized and independently assessed by eight clinicians (surgeons and radiologists) who were blinded to the diagnosis. The maximum length of fluid above the ankle within the intraosseous membrane was measured for each patient. The presence or absence of distal anterior, lateral and posterior tibial periosteal oedema was recorded (‘Broken Ring of Fire’).

Results: Measurement of the length of fluid above the ankle had excellent intra-ob-server reliability (ICC=0.97 [0.93-0.99]) but poor inter-observer reliability. Fluid extended higher in both the LLI group (p=0.0043) and SI group (p=0.0058) than the NI group but there was no significant difference between the LLI and SI groups (p=0.3735) indicating that this measurement cannot differentiate between the inju-ries. The presence of the ‘Ring of Fire’ around the distal tibia was significantly more frequent in the SI group when compared to both LLI and NI groups (p<0.00001). The sensitivity of this sign is 49% but when present this sign has a 98% specificity for syndesmosis injury.

Conclusion: The presence of tibial subcircumferential periosteal oedema 4-6cm above the ankle joint (the broken “Ring of Fire”) is highly suggestive of a significant syndesmosis injury. This new radiological sign can assist with early identification of such injuries. The measurement of height of fluid above the ankle within the interos-seous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

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Chapter 4. Return to sport following lateral ligament repair of the ankle in professional athlete.

Recent literature supports early reconstruction of severe acute lateral ligament inju-ries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Predicting the time to return to training and play is important to both athlete and club but it has not previously been reported. Chapter 4 evaluated the effectiveness and complications of lateral ligament reconstruction in professional athletes. It aimed to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

Methods: A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

Results: The median return to training and sports for isolated injuries was 63 days (49–110) and 77 days (56–127), respectively. However, for concomitant injury results were 86 days (63–152) and 105 days (82–178). This delay was significant (p< 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p=0.027, p<0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

Conclusion: Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

Part II ANKLE ARTHROSCOPY AND TALAR OSTEOCHONDRAL LESIONS

Chapter 5. Histological Evaluation of Calcaneal Tuberosity Cartilage - A Pro-posed Donor Site for osteochondral Autologous Transplant for Talar Dome Osteochondral Lesions.

Osteochondral Autologous Transplant (OATs) as a treatment option for Osteochon-dral lesions (OCLs) of the talar dome frequently uses the distal femur as the donor site which is associated with donor site morbidity in up to 50%. Some studies have described the presence of hyaline cartilage in the posterior superior calcaneal tuber-osity. Chapter 5 aimed to evaluate the posterior superior calcaneal tuberosity to determine if it can be a suitable donor site for OATs of the talus.

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Methods: In this cadaveric study, we histologically evaluated 12 osteochondral plugs taken from the posterior superior calcaneal tuberosity and compared them to 12 osteochondral plugs taken from the talar dome.

Results: In the talar dome group, all samples had evidence of hyaline cartilage with varying degrees of GAG staining. The average hyaline cartilage thickness in the sam-ples was 1.33 mm. There was no evidence of fibrocartilage, fibrous tissue or fatty tissue in this group. In contrast, the Calcaneal tuberosity samples had no evidence of hyaline cartilage. Fibrocartilage was noted in 3 samples only.

Conclusions: We believe that the structural differences between the talar and calca-neal grafts render the posterior superior calcaneal tuberosity an unsuitable donor site for OATs in the treatment of OCL of the talus.

Chapter 6. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer.

Posterior ankle impingement syndrome (PAIS) was first described in ballet dancers but is increasingly being diagnosed in other sports. Operative treatment may be indi-cated when non-operative measures have failed. Traditionally, operative treatment has involved an open approach; more recently, posterior ankle arthroscopy has been employed. Chapter 6 aimed to describe the factors that influence return to play in professional athletes after posterior ankle arthroscopy for posterior ankle impinge-ment syndrome.

Methods: A consecutive series of 28 elite professional soccer players who had clini-cally and radiologically diagnosed posterior ankle impingement syndrome that failed to respond to non-operative treatment underwent posterior ankle arthroscopy for bony or soft tissue posterior ankle impingement syndrome over 5 years.

Results: Of the 28 players, 27 were available for follow-up. Five had a diagnosis of soft tissue impingement and underwent debridement with flexor hallucis longus release, 13 had a symptomatic os trigonum that was excised arthroscopically, and 9 had removal of a bony avulsion fragment from the posterior ankle ligament complex. The mean length of time to return to training postoperatively was 34 days and return to playing was 41 days (range, 29-72 days). The duration of symptoms before surgery and excision of bony impingement were significantly correlated with the time to return to training and playing. There were no major complications and no reopera-tions at an average of 23 months of follow-up (range, 15-49 months).

Conclusions: Posterior ankle arthroscopy is safe and effective in the treatment of pos-terior ankle impingement syndrome in the elite soccer player, with return to training expected at an average of 5 weeks.

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Part III THE PLANTARIS TENDON AND ACHILLES TENDINOPATHY

Chapter 7. The incidence and nature of Plantaris pathology in elite UK Track & Field athletes over a 4 year period.

The plantaris tendon is present in 98–100 % of people, and a potential relationship between the plantaris tendon and the development of Achilles tendinopathy has been postulated. There are no studies on the epidemiology of plantaris injuries in a sporting population. Chapter 7 presented the incidence, nature and outcome of plantaris injuries in elite British track and field athletes.

Methods: All 214 elite athletes supported by the British Athletics Medical team from 2009 to 2013 were included in this retrospective cohort study. An injury was recorded if a plantaris injury was diagnosed and confirmed with imaging or surgical findings. Patient demographics, injury details and return to competitive elite track and field were recorded.

Results: There were 33 new plantaris injuries, with an annual plantaris injury inci-dence of 3.9–9.3 %. There were significantly more right-sided plantaris injuries in bend running sprinters (15 right-sided vs. 4 left-sided). 74 % of the athletes who had a plantaris injury also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes during the course of the study with 12 of the 13 athletes returning to the same level on the Tegner activity scale.

Conclusions: This retrospective cohort study demonstrates that plantaris injuries are common in elite track and field athletes and may be underreported in the literature. There may be an association between the biomechanics bend sprinting and plantaris injury. Elite athletes may benefit from appropriate preventative and management strategies implemented by coaching and medical teams.

Chapter 8. Plantaris excision reduces pain in mid-portion Achilles tendinopa-thy even in the absence of plantaris tendinosis.

It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with mid-portion Achilles tendinopathy. However, the nature of its involvement remains unclear. The aim of chapter 8 was to determine whether excised plantaris tendons from patients with mid-portion Achilles tendinop-athy display tendinopathic changes and whether the presence of such changes affect clinical outcomes.

Methods: Sixteen plantaris tendons patients with mid-portion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the pres-ence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analogue scores (VAS) and foot and ankle outcome scores (FAOS) were recorded pre- and post-operatively.

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Results: Sixteen patients (mean age 26.2; 18-47 years) underwent surgery with a mean follow-up of 14 months (range 6-20 months). The plantaris tendon was histo-logically normal in 13/16 cases (81%). Inflammatory changes in the loose peritendi-nous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (p<0.05) and all domains of the FAOS post-operatively (p<0.05).

Conclusions: The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendi-nopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.

Chapter 9. Plantaris excision in the treatment of non-insertional Achilles tendi-nopathy in elite athletes.

Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy and chapter 8 confirmed that this may be a particular problem in elite athletes. Chapter 9 aimed to assess whether excising the plantaris tendon improves the symptoms of Achilles tendinopathy in such athletes.

Methods: This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preop-erative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed.

Results: At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection.

Conclusions: The plantaris tendon may be responsible for symptoms in some ath-letes with non-insertional Achilles tendinopathy. Excision carries a low risk of com-plications and may provide significant improvement in symptoms enabling an early return to elite-level sports.

Part IV VENOUS THROMBO-EMBOLISM RISKS IN FOOT, ANKLE AND ACHILLES TENDON DISORDERS

Chapter 10. Meta-analysis and suggested guidelines for prevention of venous thrombo-embolism in foot and ankle surgery

Venous thrombo-embolism (VTE) may be a career and life-threatening complication and yet it’s prevention and treatment remains controversial. The purpose of chap-ter 10 was to establish the incidence of VTE in patients following isolated foot and

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ankle surgery, specifically investigating the effectiveness and risk of chemoprophy-laxis comparing clinical to radiographic outcome measures. The aim was to identify those factors that increase the risk of VTE in patients with foot and ankle conditions and establish whether current guidelines should be revised to consider preventive methods in all or specific patients undergoing foot and ankle surgery.

Methods: Following a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.

Results: 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6 % (95 % CI 0.4–0.8 %) and 1 % (95 % CI 0.2–1.7 %), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5 % (95 % CI 6.8–18.2 %) and 10.5 % (95 % CI 5.0–15.9 %), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria.

The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7 % (95 % CI 5.5–8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4–44.3 %).

Conclusions: Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE fol-lowing Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.

Chapter 11. General discussion and conclusions

The evolution of medicine has led to the demand for a more “evidence-based” approach to the management of our patients. When compared to the general pop-ulation, professional athletes along with their medical and coaching staff may have very different expectations for injury recovery and sometimes these may be unrealis-tic. There is a paucity of research specific to treatment of the elite athlete upon which one can rely when advising them on their optimal management and expected out-come. This thesis has highlighted the clinical and radiological features of some of the more controversial ankle injuries that affect athletes enabling their early recognition and treatment. It has identified those athletes that may benefit from early operative intervention. It has shown that surgical management of acute lateral ligament inju-ries, syndesmosis injuries, plantaris-related Achilles tendinopathy and posterior ankle pathology may lead to a good outcome in elite-level athletes. It has also provided a timeframe for expected recovery and return to play. Finally, it has identified risk fac-tors for VTE and discussed the effectiveness of preventive measures following injury

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to the foot and ankle or Achilles tendon so that patients may receive appropriate and specific advice.

The research in this thesis may have raised more questions than it has answered but it is hoped that this will provide a basis for further debate and stimulate the next generation of orthopaedic surgeons with enquiring minds.

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DE NEDERLANDSE SAMENVATTING

Hoofdstuk 1. Algemene introductie

Sporttraumatologie kan resulteren in letsels aan de enkel en de Achillespees in ongeveer 40 % van de individuen. Letsels op dit niveau komen het meest voor in de atletische populatie. Ze vormen een specifiek probleem voor de professionele top-sporters voor wie het van cruciaal belang is dat de diagnose snel en accuraat wordt gesteld om zeker te zijn van een optimale behandeling. Het doel van dit proefschrift was om te onderzoeken welke mechanismen, diagnoses en tevens om nieuwe behandelstrategieën te bespreken over veel voorkomende letsels aan de voet, enkel en de Achillespees. Het algemene doel van het proefschrift is om bewustwording en verduidelijking te bewerkstelligen over letsels waar de behandeling controversieel is. Ook zal een schatting van de verwachte duur tot de (top)sporter terug is op zijn of haar niveau worden gegeven, iets wat op dit moment nog onbekend is in de literat-uur.

Deel I ENKELLETSELS

Hoofdstuk 2. Stabiele versus instabiele graad II hoge enkelbandletsels: een prospectieve studie naar de voorspelbaarheid van een chirur-gische stabilisatie en de duur tot de sportactiviteiten kunnen worden hervat.

Hoofdstuk 2 onderzoekt graad II syndesmoseletsels in atleten met als doel de fac-toren te identificeren die belangrijk zijn voor de differentiatie tussen stabiele- en dynamisch instabiele enkelbandletsels. Ook werd onderzocht welke enkelbandlet-sels geassocieerd zijn met een langere duur totdat sportactiviteiten kunnen worden hervat.

Methoden: Vierenzestig atleten met een geïsoleerd syndesmoseletsel (zonder frac-tuur) werden prospectief gevolgd, de gemiddelde follow up was 37 maanden (spre-iding 24 tot 66 maanden). Atleten met tevens een ligamentum deltoideum letsel of een osteochondraal defect werden geïncludeerd. De stabiele letsels (Graad IIa) werden conservatief behandeld in een geprefabriceerde onderbeenorthese en een herstelprogramma. De instabiele letsels werden arthroscopisch geopereerd. Indien tijdens deze kijkoperatie een instabiliteit werd bevestigd (Graad IIb), volgde een chirurgische stabilisatie van de syndesmose. Zowel klinische gegevens alsmede een MRI ter inventarisatie van de individuele ligamenten werd verricht en ook de duur totdat de sportactiviteiten konden worden hervat. Een poweranalyse toonde aan dat in iedere groep 28 patiënten moesten worden geïncludeerd.

Resultaten: Alle atleten kwamen terug op hun voormalige professionele sportniveau. De 28 patiënten met een graad IIa letsel keerden terug op hun niveau na gemiddeld 45 dagen (spreiding 23 tot 63 dagen) vergeleken met 64 dagen (spreiding 27 tot

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104 dagen) voor de atleten met een graad IIb letsel (P<0,0001). Er was een sterk significant verband tussen het klinisch- en radiologisch onderzoek naar het ligamen-taire letsel (anterieur tibiofibulair ligament [ATFL], antero-inferieurtibiofibulair liga-ment [AITFL] en ligamentum deltoideum, P<0,0001). Er was 9,5 keer meer kans op instabiliteit bij een positieve squeeze test en 11 keer meer kans indien er ook een ligamentum deltoideum letsel was. Gecombineerde letsels aan het antero-inferieure tibiofibulaire ligament en het ligamentum deltoideum waren geassocieerd met een vertraagde sporthervatting. Gelijktijdig letsel aan de ATFL en de syndesmose typeert een ander letselmechanisme- instabiliteit van de syndesmose was minder waarschi-jnlijk en was geassocieerd met een snellere sporthervatting.

Conclusie: Een positieve squeeze test en letsels aan de AITFL en het ligamentum deltoideum zijn belangrijke factoren om te differentiëren tussen stabiele- en dyna-misch instabiele graad II letsels. Deze factoren zouden kunnen worden gebruikt om te bezien welke atleten baat kunnen hebben bij een vroeg arthroscopisch onderzoek en chirurgische stabilisatie. Ook kunnen deze factoren worden gebruikt in het voor-spellen wanneer een atleet verwacht wordt terug te zijn op zijn of haar voormalige sportniveau.

Hoofdstuk 3. De gebroken ‘’Ring of Fire/ Ring van Vuur’’ – Een nieuwe radiolo-gische aanwijzing voor syndesmoseletsel?

Het viel ons op dat bij een MRI scan van de enkel, in het geval van een syndes-moseletsel, vaak gedeeltelijk circumferentieel periostaal oedeem waarneembaar was boven het niveau van het enkelgewricht, iets wat niet eerder werd beschreven in de literatuur. Het vloeistofniveau in het interossaal membraan werd ook niet eerder geassocieerd met de ernst van een syndesmoseletsel. In hoofdstuk 3 werd onder-zocht of deze nieuwe radiologische aanwijzing en het oedeemniveau in het inter-ossaal membraan boven het niveau van het enkelgewricht, zouden kunnen worden gebruikt om een syndesmoseletsel vroegtijdig te identificeren, en of dit onderschei-dend is ten opzichte van een lateraal enkelbandletsel.

Methoden: Drie groepen patiënten werden geïdentificeerd uit een database waar-bij een MRI scan was aangevraagd voor een andere reden dan enkelligament – of syndesmose pathologie. De navolgende groepen werden gevormd – geïsoleerd syndesmoseletsel (SI groep), geïsoleerd lateraal enkelbandletsel (LLI groep) en geen afwijkingen (NI groep). De MRI scans werden geanonimiseerd en onafhankelijk bestudeerd door acht medici (chirurgen en radiologen), allen geblindeerd voor de gestelde diagnose. Het maximale vloeistofniveau in het interossaal membraan werd gemeten voor iedere patiënt. De aan- of afwezigheid van distaal anterieur, lateraal en posterieur tibiaal oedeem werd gescoord (Gebroken ‘Ring of Fire’ / ‘Ring van Vuur’).

Resultaten: De vloeistofniveau metingen toonden een zeer goede intraobserver betrouwbaarheid (ICC=0,97 [0,93-0,99] maar slechte interobserver betrouwbaar-heid. Er werd een hoger vloeistofniveau gemeten in de LLI groep (p=0,0043) en de SI groep (p=0,0058) vergeleken met de NI groep. Er was echter geen significant

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verschil tussen de LLI en SI groepen (p=0,3735) wat betekent dat deze metingen niet kunnen worden gebruikt om tussen deze pathologieën te differentiëren. De aan-wezigheid van de ‘Ring of Fire’/ ‘Ring van Vuur’ rond de distale tibia werd significant vaker waargenomen in de SI groep, vergeleken met zowel de LLI als de NI groepen (p<0,00001). De sensitiviteit van deze radiologische aanwijzing is 49% en indien aan-wezig een specificiteit voor een syndesmoseletsel van 98%.

Conclusie: De aanwezigheid van, gedeeltelijk circumferentieel, periostaal oedeem, 4-6 cm boven het niveau van het enkelgewricht (gebroken ‘Ring of Fire’/ ‘Ring van Vuur’) is zeer suggestief voor een significant syndesmoseletsel. Deze nieuwe radiologische aanwijzing kan bijdragen aan een vroege identificatie van zulke let-sels. Vloeistofniveau metingen in het interossaal membraan boven het niveau van het enkelgewricht is variabel en kan niet differentiëren tussen ernstige laterale enkel-bandletsels en syndesmoseletsels.

Hoofdstuk 4. Sporthervatting na operatieve behandeling van lateraal enkel-bandletsel in de professionele atleet.

De recente literatuur toont een voorkeur voor reconstructie van de ernstige laterale enkelbandletsels in de professionele atleten, met als voordeel het sneller starten van het herstelprogramma en een verminderde kans op recidief instabiliteit. Een voor-spelling over de duur tot de training kan worden hervat en de speler weer wed-strijdfit is, is zowel voor de atleet als zijn club belangrijk maar is tot op heden in de literatuur onbekend. Hoofdstuk 4 evalueert de effectiviteit en de complicaties na de chirurgische laterale enkelbandreconstructie in de professionele atleet. Het doel is om een inschatting te maken over de duur totdat de atleet weer kan gaan trainen en wedstrijdfit is na geïsoleerde- en bij atleten met additionele letsels.

Methoden: Achtereenvolgens werd een groep van 42 atleten, met een acuut graad III lateraal enkelbandletsel, operatief behandeld door middel van een gemodificeerde Broström procedure. Van de 42 atleten hadden er 30 een geïsoleerd letsel van de ATFL en CFL. De overige 12 hadden gecombineerde letsels (osteochondraal defecten, ligamentum deltoideum letsels). Alle patiënten werden postoperatief tenminste 2 jaar gevolgd.

Resultaten: De mediane duur tot herstart van de trainingen en wedstrijdfitheid was respectievelijk 63 dagen (49-110) en 77 dagen (56-127). Voor begeleidende letsels waren de resultaten 86 (63-152)- en 105 (82-178) dagen respectievelijk. Het ver-traagde herstel was significant verschillend (p<0.001). Ondanks dat er geen verschil was in de pre- en postoperatieve VAS scores tussen de groepen, hadden de patiënten met gecombineerde letsels een significant lagere FAOS voor pijn en voor de postop-eratieve symptoom sub-scores (p=0,027, P<0,001). Twee oppervlakkige wondinfec-ties werden succesvol behandeld met orale antibiotica. Niemand ontwikkelde recidief instabiliteit. Alle patiënten keerden terug op hun eerdere professionele sportniveau.

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Conclusie: De laterale enkelbandreconstructie is een veilige en effectieve behandeling voor ernstige laterale enkelbandinstabiliteit; een stabiele enkel wordt verkregen met een geschatte terugkeer naar de sportactiviteiten bij ongeveer 10 weken. Ondanks de terugkeer op het oude sportniveau moeten de sporter en de club bewust zijn van een vertraagd herstel met mogelijke restklachten in het geval van begeleidende letsels. Deze resultaten kunnen worden gebruikt als een richtlijn ter voorspelling van de duur tot de herstart van de training en het volledig herstel na operatieve behan-deling van een acuut lateraal enkelbandletsel in de atleet. De gecombineerde letsels resulteren in een vertraagd herstel.

Deel II ENKELARTHROSCOPIE EN OSTEOCHONDRALE LETSELS VAN DE TALUS

Hoofdstuk 5. Histologische evaluatie van kraakbeen van het tuberositas van de calcaneus – Voorstel voor het gebruik als donorplek in het geval van autologe transplantaties bij osteochondrale letsels van de talus.

Voor osteochondrale autologe transplantaties (OATs) als behandelstrategie bij osteo-chondrale letsels (OCLs) van het talus wordt vaak gebruik gemaakt van het distale femur als donorplek. Dit geeft tot in 50% van de gevallen morbiditeit ter plaatse van de donorplek. Enkele studies rapporteren over het bestaan van hyaliene kraakbeen in het postero-superieure tuberositas van de calcaneus. Hoofdstuk 5 evalueert de mogelijkheid om het postero-superieure tuberositas van de calcaneus te gebruiken als donorplek voor OATs van de talus.

Methoden: In deze kadaverstudie zijn 12 osteochondrale pluggen, geoogst uit het postero-superieure tuberositas van de calcaneus, histologisch vergeleken met 12 osteochondrale pluggen genomen uit de talus.

Resultaten: In de osteochondrale pluggen, geoogst uit de talus, werd in elk monster bewijs gevonden voor hyaliene kraakbeen met wisselende GAG kleuringen. De gem-iddelde hyaliene kraakbeendikte in de monsters was 1,33mm. In deze groep was geen bewijs voor het bestaan van fibrocartilagineus kraakbeen, littekenweefsel of vetweefsel. In tegenstelling tot de eerder genoemde groep, werden in de monsters van het tuberosi-tas van de calcaneus geen bewijzen gevonden voor het bestaan van hyaliene kraakbeen. Fibrocartilagineus kraakbeen werd gezien in 3 van de verkregen monsters.

Conclusie: Gezien de structurele verschillen tussen de monsters van de talus en het tuberositas van de calcaneus kan worden geconcludeerd dat het postero-superieure tuberositas ongeschikt is als donorplek voor OATs in de behandeling van een OCL van de talus.

Hoofdstuk 6. Sporthervatting na posterieure enkelarthroscopie bij posterieure impingement in de professionele topvoetballer.

Het posterieure enkelimpingement syndroom werd initieel beschreven in ballet-dansers, maar wordt tegenwoordig ook steeds vaker beschreven bij sporters in

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andere disciplines. De operatieve behandeling kan worden overwogen indien de conservatieve behandeling onvoldoende resultaat oplevert. In het verleden werd een open chirurgische benadering toegepast, echter wordt tegenwoordig vaker een posterieure enkelarthroscopie gedaan. Hoofdstuk 6 heeft als doel de factoren te bes-chrijven die invloed hebben op de sporthervatting in de professionele atleten na een posterieure enkelarthroscopie voor een posterieur enkelimpingement syndroom.

Methoden; 28 professionele topvoetballers met klinische en radiologische bewijzen voor het posterieure enkelimpingement syndroom, welke onvoldoende reageert op een conservatieve behandeling, ondergingen een posterieure enkelarthroscopie voor een enkelimpingement syndroom op basis van weke delen of benige compo-nent. Patienten werden geincludeerd over een periode van 5 jaar.

Resultaten: Van de 28 spelers waren 27 beschikbaar voor de follow up. Vijf spel-ers waren gediagnostiseerd met een weke delen impingement en ondergingen een debridement waarbij de flexor hallucis longus werd losgemaakt. Dertien spelers hadden een symptomatisch os trigonum, deze werd arthroscopisch geëxcideerd. In negen spelers werd een benig avulsie fragment uit één van de posterieure enkellig-amenten verwijderd. De gemiddelde duur tot de training postoperatief kon worden hervat was 34 dagen, wedstrijdfit waren ze gemiddeld na 41 dagen (spreiding van 29-72 dagen). De duur van de klachten tot de operatieve behandeling van het benige impingement waren significant gecorreleerd aan de duur tot de trainingen konden worden hervat en de speler wedstrijdfit was. Er waren geen grote complicaties en er waren geen re-operaties na een gemiddelde follow up van 23 maanden (spreiding 15-49 maanden).

Conclusie: De posterieure enkelarthroscopie is veilig en effectief in de behandeling van het posterieure enkelimpingement syndroom bij professionele topvoetballers, de training kan postoperatief na gemiddeld 5 weken worden hervat.

Deel III DE PLANTARISPEES EN ACHILLESPEES TENDINOPATHIE

Hoofdstuk 7. De incidentie en aard van plantarispathologie in de topatletiek atleten in het Verenigd Koninkrijk over een periode van 4 jaar.

De plantarispees is aanwezig in 98-100% van de mensen waarbij er een potentieel verband verondersteld wordt tussen deze pees en het ontwikkelen van een Achilles-pees tendinopathie. Er bestaan geen studies over de epidemiologie van plantari-speesletsels in sporters. Hoofdstuk 7 behandeld de incidentie, aard en de uitkomsten van plantarispeesletsels in de Britse topatletiek atleten.

Methoden: Alle 214 topatleten ondersteund vanuit het Brits Medisch Atletiek team tussen 2009 en 2013 werden geïncludeerd in deze retrospectieve studie. Een let-sel van de plantarispees werd geregistreerd indien de diagnose werd bevestigd met beeldvorming en chirurgische bevindingen. Demografische gegevens van de patiënt, gedetailleerde informatie inzake het letsel, en de duur tot de atleet terug was op een competitief atletiekniveau werden geregistreerd.

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Resultaten: Er waren 33 nieuwe plantarisletsels, met een jaarlijkse incidentie van 3.9 %-9.3%. Er waren significant meer rechtszijdige plantarisletsels in de ‘bend running sprinters’ (15 rechtszijdig versus 4 linkszijdig). 74% van de atleten met een plantaris-letsel hadden op een zeker moment ook een Achillespees tendinopathie gedurende de studieperiode. Van 13 atleten werden zeventien plantarispezen chirurgisch ver-wijderd gedurende de studieperiode, waarvan 12 terugkwamen op dezelfde Tegner activiteitenschaal waardering.

Conclusies: Deze retrospectieve cohort studie toont aan dat plantarisletsel veelvuldig voorkomt onder topatletiek atleten, een prevalentie die in de huidige literatuur mogelijk wordt onderschat. Er is een mogelijk biomechanisch verband tussen plan-tarisletsel en ‘bend sprinting’. Topatleten zouden mogelijk profijt kunnen hebben van preventieve en beleidsmatige strategieën die zouden kunnen worden geïmple-menteerd bij het trainen van medische teams.

Hoofdstuk 8. Excisie van de plantaris verminderd de pijn in het geval van een tendinopathie in het middelste deel van de Achillespees, ook bij afwezigheid van tendinose van de plantaris.

Het wordt meer en meer duidelijk dat, in een deel van de patiënten, de plantaris kan bijdragen aan de symptomen van een tendinopathie in het middelste deel van de Achillespees. Echter blijft de aard van deze betrokkenheid onduidelijk. Het doel van hoofdstuk 8 is om te bepalen of een verwijderde plantaris, bij patiënten met een tendinopathie in het middelste deel van de Achillespees, tendinopathische veran-deringen lieten zien en of deze peesveranderingen invloed hebben op de klinische uitkomsten.

Methoden: Bij zestien patiënten met een tendinopathie in het middelste deel van de Achillespeespees, niet reagerend op een conservatieve behandeling, werd de chirurgisch verwijderde plantaris histologisch onderzocht op de aanwezigheid van tendinopathische veranderingen. Van iedere patiënt was beeldvorming beschikbaar bewijzend dat de plantaris direct gelegen was naast- of instulpte in de lokale Achilles-pees tendinose. Zowel pre- als postoperatief werden Visuele analoge-scores (VAS) en voet en enkel uitkomstmaten (FAOS) afgenomen.

Resultaten: Zestien patiënten (gemiddelde leeftijd 26,2 jaar; spreiding 18-47 jaar) ondergingen een chirurgische behandeling met een gemiddelde follow up van 14 maanden (spreiding 6-20 maanden). De plantarispees was histologisch normaal in 13 van de 16 gevallen (81%). Inflammatoire veranderingen in het losse peri-tendineuze bindweefsel om de plantarispees werd in alle gevallen waargenomen. Er was een significante verbetering te zien in de gemiddelde VAS scores (P<0,05) en in alle domeinen van de postoperatieve FAOS (P<0,05).

Conclusie: De afwezigheid van tendinopathische veranderingen in de verwijderde plantarispezen in elk van de 13 patiënten, die allen klinisch verbeterden, suggereert betrokkenheid van de plantarispees bij het ontwikkelen van een tendinopathie in het

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middendeel van de Achillespees. Ook al kan dit niet geheel worden verklaard, sugg-ereert het wel het concept dat de plantarispees druk en frictie geeft op de Achilles-pees en niet puur een tendinopathisch effect sorteert.

Hoofdstuk 9. Plantaris excisie in de behandeling van Achillespees tendinopa-thieën, uitgezonderd de insertie, bij de top atletische populatie.

De recente literatuur suggereert dat de plantarispees mogelijke betrokken is bij het ontstaan van Achillespees tendinopathieën uitgezonderd de insertie, en hoofdstuk 8 bevestigt dat dit mogelijk een specifiek probleem is bij de topatleten. Hoofdstuk 9 heeft als doel te onderzoeken of excisie van de plantarispees resulteert in minder symptomen bij de topatleet in het geval van een Achillespees tendinopathie.

Methoden: Deze prospectieve opeenvolgende studie onderzoekt 32 topatleten bij wie de plantarispees door een kleine incisie chirurgisch werd verwijderd als behan-deling voor lokale pijn welke geassocieerd was met Achillespees tendinopathie niet gelegen in de insertie. Zowel pre- als postoperatief, werden Visuele analoge-scores (VAS) en voet en enkel uitkomstmaten (FAOS) afgenomen. Tevens werd onderzocht wat de duur was tot de atleet weer volledig kon sporten en werden tevredenheidss-cores afgenomen.

Resultaten: Bij een gemiddelde follow up van 22,4 maanden (12-48) waren 29 van de 32 topatleten (90%) tevreden met het behaalde resultaat. Dertig van de 32 topat-leten (94%) waren na 10,3 weken terug op hun voormalige sportniveau (5-27). De gemiddelde VAS score verbeterde van 5,8 naar 0,8 (P<0,01) en de gemiddelde FAOS verbeterde in elk aspect (P<0,01). Enkele complicaties werden gezien, vier topatleten hadden last van kortdurende stijfheid en 1 topatleet ontwikkelde een oppervlakkige wondinfectie.

Conclusies: De plantarispees kan verantwoordelijk zijn voor klachten in topatleten met een Achillespees tendinopathie uitgezonderd de insertie. Chirurgische verwij-dering van deze pees is relatief veilig met weinig complicaties, echter kan lijden tot een significante verbetering in de symptomen met een snellere terugkeer naar het professionele topsportniveau.

Deel IV VENEUZE TROMBO-EMBOLIEËN KUNNEN RISICO’S IN VOET, ENKEL EN ACHILLESPEES

Hoofdstuk 10. Meta-analyse naar het tromboserisico bij patiënten die een operatie ondergaan voor een voet – of enkel afwijking, specifiek werd gekeken naar de incidentie en preventie bij patiënten met een acute Achillespeesruptuur.

Veneuze trombo-embolieën kunnen (VTE) lijden tot carrière beëindiging en zelfs tot een levensbedreigende complicatie, desalniettemin zijn de preventie en behandeling nog steeds controversieel. De doelstelling van hoofdstuk 10 was om de trombose incidentie bij patiënten die voet – of enkelchirurgie ondergaan in kaart te brengen.

General discussion, conclusions and future research|

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Specifiek werd de effectiviteit en de risico’s van chemoprofylaxe onderzocht, waar-bij klinische- en de radiologische uitkomstmaten werden vergeleken. Het doel was om de factoren die het risico op een VTE verhogen, bij patiënten met een voet of enkel aandoening, in kaart te brengen om te bezien of de huidige richtlijnen moeten worden herzien. Ook werd gekeken of preventieve maatregelen moeten worden get-roffen bij alle patiënten of dat dit alleen noodzakelijk is bij specifieke patiëntencate-gorieën.

Methoden: Na een PRISMA compliantie zoekopdracht werden 372 artikelen geïden-tificeerd waarbij een meta-analyse werd gedaan van 22 artikelen gebruikmakend van het Critical Appraisal Skills Program en het Centre for Evidence Based Medicine level of evidence.

Resultaten: 43.381 patiënten werden klinisch onderzocht op een VTE en de inci-dentie met- en zonder chemoprofylaxe was respectievelijk 0,6% (95% betrouwbaar-heidsinterval (BI) 0,4-0,8%) en 1% (95% BI 0,2-1,7%). 1666 werden radiologisch onderzocht en de incidentie van een VTE met en zonder chemoprofylaxe was respec-tievelijk 12,5% (95% BI 6,8-18,2%) en 10,5% (95% BI 5,0-15,9%). Er was zowel klin-isch als radiologisch geen significant verschil tussen het ontwikkelen van een VTE met- of zonder het gebruik van een chemoprofylaxe. Het risico op het ontwikkelen van een VTE in patiënten met een acute Achillespeesruptuur was groter met een klinische incidentie van 7% (95% BI 5,5-8,5%) en een radiologische incidentie van 35,3% (95% BI 26,4-44,3%).

Conclusie: Geïsoleerde chirurgie aan de voet en enkel heeft een lagere incidentie op een klinische VTE in vergelijking met algemene chirurgische procedures aan de onderste extremiteit en dit percentage neemt niet significant af door het gebruik van laagmoleculair-gewichtsheparine. De incidentie van een VTE bij een acute Achilles-peesruptuur is hoog, zowel bij conservatieve- als chirurgisch behandeling. Met uit-zondering van de Achillespeesruptuur, is routinematig gebruik van een chemische VTE profylaxe niet geïndiceerd voor patiënten die een operatie aan de voet of enkel ondergaan. Patiënt specifieke risicofactoren moeten worden gebruikt om het indivi-duele VTE risico in te schatten.

Hoofdstuk 11. Algemene discussie en conclusies

De ontwikkeling binnen de geneeskunde heeft geleid tot de vraag naar een meer ‘’evi-dence-based’’ benadering in de behandeling van onze patiënten. Vergeleken met de algemene populatie hebben professionele topatleten, samen met de medische staf en trainers, een ander verwachtingspatroon met betrekking tot herstel na een letsel, welke soms onrealistisch is. Er is gebrek aan specifiek onderzoek naar de behandeling van een professionele topatleet waarop als clinicus gebouwd kan worden, indien een advies moet worden gegeven over de optimale behandeling en verwachte uit-komst. Dit proefschrift richt zich met name op de klinische en radiologische ken-merken van enkele controversiële enkelafwijkingen bij professionele topatleten om deze snel te kunnen onderkennen en behandelen. Het heeft een specifieke groep

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van atleten geïdentificeerd die voordeel kunnen hebben bij een vroege chirurgische interventie. Ook heeft het laten zien dat een chirurgische interventie bij acute laterale enkelbandletsels, syndesmoseletsels, plantaris gerelateerde Achillespees tendinopa-thieën en posterieure enkelpathologieën kunnen resulteren in een goede uitkomst bij de professionele topatleten. Het proefschrift heeft ook een tijdspanne gegeven voor het herstel en de termijn totdat het sporten kan worden hervat op wedstrijd-niveau. Tenslotte heeft het risicofactoren voor het ontwikkelen van een VTE onthult en zijn de effectiviteit van de preventieve maatregelen na een letsel aan de voet of enkel of Achillespees bediscussieerd zodanig dat patiënten een adequaat en gericht advies kunnen krijgen.

Het onderzoek in dit proefschrift heeft mogelijk meer vragen gegenereerd dan het heeft beantwoord, echter heeft het hopelijk een basis gelegd voor verdere discussie en stimuleert het de volgende generatie orthopedische chirurgen met hun onder-zoekende geest.

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ACKNOWLEDGEMENTSCURRICULUM VITAE

PHD PORTFOLIO

198 | Acknowledgements

ACKNOWLEDGEMENTS

Every person met will influence and shape one’s life but some have a lasting affect either by challenging immature (and frequently incorrect) opinions or through nur-turing enthusiasm and developing ideas. Certain people have affected my academic career and personal life more than I can give them credit for in a few sentences of a thesis but I will endeavour to at least give them some recognition here.

Professor Mike Floyer, Dean at the London Hospital Medical College was an impressive character, great athlete and a truly inspirational teacher. He guided me and encouraged me to work hard and play harder. Whilst working as a junior doctor in cardiac surgery, Professor Sir Magdi Yacoub sowed the seed of academia taking me with him to many meetings around the UK and introducing the importance of understanding basic science. Professor Julia Polak, a frighteningly intelligent lady who had received a heart-lung transplant from Sir Magdi, supervised my M.D. thesis and whipped me into shape in the lab!

Terry Saxby enabled Joanna, Toby, Alice and me to have the most amazing year in Australia. He taught me not only the practicalities of surgery but also which clinical results are important to write about rather than just publishing for a CV. My co-au-thors have tolerated my pursuit of finishing a paper however long it takes – Chris Pearce even fled the UK in the hope of avoiding further projects but ironically we have published more together than with anyone else and continue to do so.

Professor Niek van Dijk is truly an “International Orthopaedic Legend” with whom I have developed a very good friendship. Niek suggested that I become his oldest PhD student! He has guided me through the last 15 years of my career since attending his AMC Foot and Ankle course and introduced me to Professor Leendert Blankewart who persuaded me that writing up this thesis is indeed possible. I am sincerely grateful to them both for their supervision, suggestions and corrections to ensure that only the highest quality research would be submitted to the University of Amsterdam. Professor Jon Karlsson took me under his wing at the KSSTA journal and taught me the importance of attention to detail both in research but also in the writing-up and editing processes. I was unable to get even one incorrectly placed full-stop or comma past his Editorship!

Niek also introduced me to so many of his co-workers whom I am lucky enough to now call friends. Gino (now Full Professor Gino Kerkhoffs!) has the brain the size of a planet, exudes enthusiasm and yet has the personality quite unlike a boffin! We have presented together at some great meetings and I look forward to travelling with our families to far flung destinations, continuing to learn from each other and enjoying his company until the early hours. Dr Peter de Leeuw kindly offered to find a translator for me as Google Translate really was not up to the task! Peter took it upon himself to personally translate the summary into Dutch, generously spending precious time between his Fellowship and Consultant post looking after my aca-demic interests.

Professor Andrew Amis needs no introduction in the world of biomechanics and I admit to being somewhat intimidated by his knowledge and brilliance of mind when

199Acknowledgements |

I first met him in Nice 20 years ago. He very kindly accepted me into his laboratory at Imperial College to work on several biomechanical problems that have puzzled me. He is quite simply amazing at turning my basic theories into practical experiments and yet can then decipher and explain a list of results with such clarity such that even an orthopaedic “bear with very little brain” can understand it! I was also lucky enough to be introduced to Dr Jo Stephen whom Andrew supervised for her PhD. Possibly the hardest working post-doc I have ever come across, Jo is not only great fun to work with but her incredibly impressive knowledge and practical support has been invaluable to me and my fellows. I very much look forward to continuing our collaboration in the future.

The Fortius Clinic has supported this research and continues to encourage aca-demic interests in the belief that it is a cornerstone in the pursuit of clinical excellence. Jim McAvoy as CEO has been at the forefront of not only building a business and brand but also recognises the importance and the intangible benefits research may have for our future colleagues. He has never faltered in his support of our research ambitions. Andy Williams is an internationally acclaimed knee surgeon at Fortius and more importantly a good friend. He also emphasises the need to question our per-ceived understanding of clinical problems and explore research to stimulate the next generation of orthopaedic surgeons. His energy has spurred me on, ensuring that I attempt to achieve only the best! Mark Kenny has helped my clinical studies by anaesthetising patients for me at the most unreasonable hours, ensured that club medical teams are kept busy if I am looking concerned during a complex procedure in theatres and is also the best “Ref!Link” to sit next to during a rugby match!

Fundamentally, however, it comes down to friendship and family support. With-out my parents providing me with the stable background and educational opportu-nities for both Tiggy, my sister, and me I am sure that this thesis would not have even started. My wife, Joanna, has been the giant upon whose shoulders I can stand; the anchor upon which I can rely to stop me from drifting; the voice of reason when I am frustrated that things are not progressing as I would like; the honest friend who can tell me not to show off! My children Toby and Alice enable me to be proud every day that I wake as their love and their own achievements are everything to me.

200 | Curriculum Vitae

CURRICULUM VITAE

James Calder grew up in Cambridge and after the Leys School he studied medicine at The London Hospital Medical College. After taking more examinations than were strictly necessary and passing his M.B. B.S. examinations in 1991 he worked as a junior doctor in London and Chichester passing his FRCS(England) examination in 1995. He then commenced Higher Surgical Training in Trauma and Orthopaedic Sur-gery with the London Deanery and passed his FRCS(Tr & Orth) examination in 2001. James was awarded the Laming Evans Research Fellowship from the Royal College of Surgeons in England and took time out of the clinical rotation to complete his Doc-torate of Medicine thesis at Imperial College, London investigating the pathophysi-ology of osteonecrosis of the hip. This experience stimulated his desire to continue and develop a research mind but also cemented his view that pure scientists were possibly more adept at performing intricate histochemical analyses than enthusiastic academic orthopaedic surgeons. He was awarded his M.D. in 2001.

James completed a one year fellowship in foot and ankle surgery with Dr Terry Saxby in Brisbane, Australia. He returned to the UK in 2002 and was appointed Consultant Trauma and Orthopaedic surgeon at The North Hampshire Hospital, Basingstoke and Honorary Senior Lecturer at Imperial College, London. James was awarded the American Orthopaedic Foot and Ankle Society Travelling Fellowship in 2004 and became Fellow of the Faculty of Sports and Exercise Medicine (UK) in 2007. He was appointed Consultant Trauma and Orthopaedic surgeon at The Chelsea and Westminster Hospital, London in 2010 and Visiting Professor at Imperial College in 2014. He co-founded the Fortius Clinic, London in 2010

James’ main subspecialty interest is in the management of sports related foot and ankle conditions which has led to many clinical and basic science research projects collaborating with various colleagues from Europe, USA and the Far East. He has over 100 publications in peer reviewed journals and authored 30 book chapters. He became Fellow of the Royal Geographical Society with his interest in medical support

201Curriculum Vitae |

in remote areas (including post-tsunami Sri Lanka and post-earthquake Pakistan) and authored a chapter in the Oxford Handbook of Expedition and Wilderness Medicine.

James is Vice-president of ESSKA-AFAS, immediate past Chairman of the Achilles tendon Study Group, a committee member of the International Cartilage Research Society and Medical Advisor to Dance UK. He is on the Editorial Board and Associate Editor of the Bone and Joint Journal and past Associate Editor of the Knee Surgery, Sports and Traumatology Journal.

Outside medicine he served in the military seeing active service in the Balkans, Northern Ireland and Middle East. James is supported by his family - Joanna whom he married in 1995 and their two children Toby and Alice. He continues to love rec-reational sports participating in tennis, triathlons and sailing.

202 | PhD Portfolio

PhD PORTFOLIO

Name PhD student: James D F Calder PhD period: 2013-2016 Name PhD supervisor: Prof C N van Dijk

1. PhD trainingYear Workload

(ECTS)

General courses Reviewing and writing papers (BJJ editorial)Foot and ankle anatomy teaching – RCS EnglandSports injuries in rugby (Twickenham)Ankle instability symposium (Bordeaux)

2013201320132013

0.250.250.50.5

Specific courses Sports Medicine in FootballArthroscopy tips and tricks course (Sydney)Sports Medicine and high altitude physiologyFoot and ankle Injuries in Football

2013201420152016

1.0 1.01.00.5

Seminars, workshops and master classesAnkle instability cadaveric workshop (Strasbourg)Ankle arthroscopy course (York)Ankle instability and syndesmosis injuries (Rome)Singapore cadaveric F&A symposiumWarwick Sports F&A courseESSKA-AFAS Cartilage meeting (Prague)Ankle arthroscopy course (York)Sports Instability Workshop (Chicago)International Dance Medicine Congress (Basal)Warwick Sports F&A courseESSKA-AFAS ankle workshop (Barcelona)

20132013201320132013201420142015201520152016

0.50.50.51.01.01.00.51.00.51.01.0

203PhD Portfolio |

PresentationsInstructional Course lectures and paper presenta-tions AAOS ChicagoIsokinetics Meeting South African F&A Society congressVuMedi LectureFoot and ankle trauma fixationBOFAS presentationsFrench F&A SocietyESSKA congress (Amsterdam)Combined Services orthopaedic meetingSports Arthroscopy Surgery (Sydney)Baltimore F&A meetingIsokinetics meetingICRS meeting (Zurich)Fortius IRB Rugby World Cup meetingNorwegian Orthopaedic Association congressBOFAS congressESSKA congress (Barcelona)Scottish FA meetingInternational Skeletal Society meeting (Paris)ICRS meeting (Sorrento)BOFAS congressDutch Orthopaedic Trainee annual meeting

2013

2013201320132013201320142014201420142014201420142015201520152016201620162016201621016

2.0

0.51.00.250250.50.51.00.51.01.00.250.51.00.50.51.00.51.00.50.50.25

204 | PhD Portfolio

2. TeachingYear Workload

(Hours/ECTS)

LecturingEnglish Institute of SportFA St George’s ParkPhysiotherapy cadaveric F&A course

2013-20162015-20162013-2016

4.02.04.0

Tutoring, MentoringFellowship programme Fortius Clinic and Chelsea & Westminster HospitalMedical Student Interviews and teaching Imperial College School of Medicine, London

2013-2016

2013-2014

4.0

2.0

Supervising PhD and MSc supervision 2014-2016 4.0

3. Parameters of EsteemYear

Grants

£48,000 Research fellowship Grant (DJOGlobal)£150,000 - Research post (Arthrex, UK) $12,500 – Research Grant (Smith and Nephew)$12,500 – Research Grant (Smith and Nephew)£5,000 – BOFAS Research Grant$15,000 – AOFAS Research Grant

201320142014201520162017

205PhD Portfolio |

4. Publications

Year

Peer reviewed

Calder J, Grice J, Mitchell A, Lomax A, Lee J, van Dijk N. The broken ‘Ring of Fire’ – A new radiological sign as predictor of syndesmosis injury? Orth J Sports Med

Calder J, Stephens J, van Dijk C Plantaris excision reduces pain in Mid-portion Achilles tendinopathy even in the absence of plantaris tendinosis. Orth J Sp Med. 2016 December 4(12) doi: 10.1177/2325967116673978

Calder J, Freeman R, Aukvarson E, van Dijk C, Ackermann P Meta-analysis of risk and treatment of thrombo-embolic disease following foot and ankle injuries. Knee Surg Sports Traumatol Arthrosc. 2016 24(4), 1409-1420. DOI: 10.1007/s00167-015-3976-y

White W, Calder J, McCollum G Return to sport following lateral ligament repair of the ankle in professional athlete. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1124-9

Calder J, Bamford R, Petrie A, McCollum G. Grade II syndesmosis injuries in elite athletes - predicting the need for surgical stabilization and time to return to sports. Arthroscopy. 2016 Apr;32(4):634-42.

Calder J, Freeman R, Pollock N. Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. Br J Sp Med 2015 Dec;49(23):1532-1534. doi: 10.1136/bjsports-2014-093827.

Calder J, Ballal M, Lutz M, Deol R, Hamilton P, Pearce. Histological Evaluation of Calcaneal Tuberosity Cartilage - A Proposed Donor Site for osteochondral Autologous Transplant for Talar Dome Osteochondral Lesions. Foot Ankle Surg 2015 Sep;21(3):193-7. doi: 10.1016/j.fas.2014.11.008 N Pollock, J Calder, P Dijkstra, R

2017 [In print]

2016

2016

2016

2016

2015

2015

206 | PhD Portfolio

Chakraverty. The incidence and nature of Plantaris pathology in elite UK Track & Field athletes over a 4 year period. Knee Surg Sports Traumatol Arthrosc. 2016 Jul;24(7):2287-92

Calder J, Pearce C, Sexton S. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. Am J Sports Med. 38(1):120-4; Jan 2010.

Other (book chapters)

Lomax A, Calder J. Retrograde drilling for the treatment of osteochondral lesions in the ankle. Chapter 85 In: Advances in Arthroscopic Techniques. Editor CN van Dijk. ESSKA; Springer Publishing 2016.

Roche A, Calder J. Arthroscopy of the ankle - new approaches. In Sports Injuries – Prevention, Diagnosis, Treatment and Rehabilitation. Chapter 134, p1684-1698. Editors: J Karlsson, M Doral. Springer publishing, 2016. ISBN: 978-3-642-36568-3

Freeman R, Calder J. Non-insertional Achilles tendinosis. Chapter 19:177-184. In: Arthroscopy Association of North America – The Foot and Ankle. Editors: Stone J, Kennedy J, Glazebrook M; Slack Inc 2016: ISBN 978-1-61711-998-9

Ballal M, Calder J. Lateral ligament reconstruction for ankle instability. Chapter 14: 279-308. In: Arthroskopie an Sprunggelenk und Fuß, Editor: Galla M, Walther M. Schattauer publishing 2016.

Eleftheriou K, Calder J, Kloen J, d’Hooghe P. Ankle Fractures, including avulsion fractures. Chapter 7 in: “The Ankle in Football”. First Edition. Editors: d’Hooghe P, Kerkhoffs G. FIFA/ Springer Publishing, 2014.

Longo G, Calder J. Achilles tendon rupture treatment: still the weak spot? Chapter 13 in: ESSKA INstructional Course Lecture Book, Amsterdam 2014. Editors: Zaffagnini S, Becker R, Kerkhoffs G, Mendes J, van Dijk C. Springer publishing 2014.

2016

2010

2016

2016

2016

2016

2014

2014

207PhD Portfolio |

Lee B, Pearce C, Calder J. Epidemiology of Achilles tendon disorders. Chapter 3 in: Achilles tendon disorders - a comprehensive overview of diagnosis and treatment. Editors: Karlsson J, Calder J, van Dijk C, Maffulli N, Thermann H. DJO publications, 2014.

Elliot R, White W, Calder J. Minimally invasive and percutaneous surgery for Achilles tendon disorders. Chapter 19 in: Achilles tendon disorders - a comprehensive overview of diagnosis and treatment. Editors: Karlsson J, Calder J, van Dijk C, Maffulli N, Thermann H. DJO publications, 2014.

Calder J, Arverud E, Nilsson-Helander K, Ackermann P, van Dijk C. Thromboprophylaxis and wound complications in Achilles tendon surgery. Chapter 26 in: Achilles tendon disorders - a comprehensive overview of diagnosis and treatment. Editors: Karlsson J, Calder J, van Dijk C, Maffulli N, Thermann H. DJO publications, 2014.

Smith G, Calder J, Maffulli N. Cartilage pathology with concomitant ankle instability. In Operative Techniques in Orthopaedics. Editor: F Fu. Elsevier publishing, 2014; 24(3) Sept: 152-156.

van Eekeren I, Eleftheriou K, van Bergen C, Calder J. Rehabilitation After Arthroscopic bone marrow stimulation. Chapter 14 in: Talar osteochondral defects with special emphasis on diagnosis, planning and rehabilitation. Editors: C.N. van Djik, J.G. Kennedy. Springer publishing, 2013.

2014

2014

2014

2014

2013