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R E C U R R E N T S P R A IN O F TH E A N K L E JO IN T W I T H D I A S T A S I S

J F P

M U L L I N S

and J. G . S A L L IS , D U R B A N , SO U T H A F R IC A

F ro m the d d in gto n H o spita l D urb an an d S t M arys H ospita l M ar ian hill

W e b elieve tha t d iasta sis o f the ank le jo in t is a co m m o n cau se o f recu rren t sp ra in s.

It is n o t w ell recog n ised , a lthoug h it has been desc ribed b y various au tho rs, no tab ly b y

O utland 19 43). T h e tru e inc idence of pa rtia l d ia sta sis in recu rren t sp ra ins is no t k now n ,

bu t w e b elieve it to b e 70 o r 80 pe r cen t.

In th is pape r w e desc rib e th e treatm en t o f recu rren t sp rain s by stab ilisa tion o f the in fe r io r

tib io -f ibu lar jo in t w ith a lag sc rew .

C L IN IC A L M A T E R IA L

S even ty -f ive pa tien ts w ere treated in th is se r ies . T he ir ag es rang ed fro m six teen to

six ty -f ive y ea rs w ith an approx im a tely equa l sex in cid en ce . T h e co nd itio n h as a lso been

recog n ised in ch ild ren from the ag e o f e ig h t yea rs , bu t o pe ra ton h as no t been used . G ross

d ia sta sis w h ich is qu ite o bv io us is exc lud ed from th is stud y .

C L IN IC A L F E A T U R E S

H isto ry -T here is a h is to ry of in ju ry to the ank le -usua lly a sp ra in -and from then on th e

pa tien t h as a w eak an k le , w h ich is sp ra ined rep ea ted ly . A p ro m inen t featu re is a sense o f

in stab ility o f the an k le . T he re is a ch ron ic ach ing pa in , w ith tiredn es s. P ain is o ften fe lt ove r

the late ral ligam en t.

xam in a tio n In a cu te ca ses

the re a re pa in , sw e lling an d d isco lo ra tion . T ende rness to

p a lpa tion m ay be gene ralis ed ove r the usua l lig am en tous a rea s, bu t th ere is a lso sp ec ia lly

m arked ten de rn es s ove r the an te r io r in fe r io r tib io -fibu lar lig am en t, and p ossib ly ove r th e

po ste rio r in fer io r tib io -fib u la r lig am en ts . T he pa tien t is unab le to b ea r w e igh t. T h e ta lus can

be rocked from side to sid e w ith a cha rac ter is tic fee ling of a click in th e ank le m ortise . T h is

is e licited b y h o ld in g th e ta lus just be low the m a lleo li w ith th e foo t a t rig h t ang le s and slid ing

it from side to sid e . T h e leg m u st b e he ld w e ll abo ve th e m a lleo li, so tha t the re is n o

com p ressio n and n arrow ing of the ank le m ortise . It is im portan t to ex clu de inve rsion and

ev ersio n a t the sub tala r jo in t. T h is ro ck ing cau ses pa in , w h ich in acu te case s in terfere s

w ith the ex am ina tion , and an an aesth etic m ay b e requ ired . In som e cases a slig h t rock is

no rm a l and th is can be check ed b y te sting th e un in ju red an k le . In ch ro n ic ca ses th e re m ay be

no obv ious sw e lling , b u t w id en ing of the m alleo li m ay be ap pa ren t. T he re is usua lly ten de rn ess

ove r th e an te r io r in fe rio r tib io -f ibu la r ligam en t, an d the typ ica l s id e -to -side ro ck o f the

ta lus can so m e tim es b e e lim ina ted or m arked ly d im in ished by co m pression of the m a lleo li.

T h is co nfirm s th e d iagno sis . T h ere is usu ally p ain on ro ck ing , and in o ld case s the re m ay

be c rep itu s . M ovem en ts o f the jo in t o the rw ise a re fu ll and pa in -free.

R ad iog raph ic fea tu re s-R ad iog raphs o f the an k le tak en in fu ll inv ersion and in fu ll ev ersion

sh ow th e fo llow ing fea tu re s. 1 ) T ilting o f the ta lus in re latio n to the in fe rio r a rticu la r su rface

o f the tib ia. T ilting is m ore u sua lly show n on inv ersion , u n le ss the inne r pa rt o f the m ed ial

ligam en t is to rn , in w hich case tilting can be show n a lso on eve rsion . 2 ) T he re is som etim es

a pe rcep tib le w iden ing of the sy ndesm osis be tw een the tib ia and th e fibu la just ab ove its

a rticu la r su rface. 3 ) In ch ron ic case s roug hen ing o f th e tib ia an d fib u la m ay be pre sen t w he re

the lig am en ts have been avu lsed .

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JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

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R E C U R R E N T S PR A IN O F T H E A N K L E JO IN T W IT H D IA S T A S IS

27 1

V O L

4 0 B , N O . 2,

M AY

1958

T R E A T M E N T

C o stigan 19 53) used a sta in le ss steel sc rew ac ro ss the tib io -fibu la r syn desm o sis w ith app aren tly

sa tisfac to ry re su lts in tw en ty -fiv e cases an d d id no t f ind it n ecessa ry to rem o ve the sc rew .

L ee and H oran 19 43) p assed th readed K irsch ne r w ire s th rou gh th e tib ia and fibu la and

drew the bo nes tog e the r w ith thu m b n u ts . L eon a rd 1 949 ) trea ted fif ty -one pa tien ts by

F I G

1

C ase l-R ad iog raph s sho w in g , on bo th s ides, tilting o f the ta lus o n

invers ion .

F I G

2

C ase 1-A fte r stab ilisa tio n of the in fe rio r tib io -

fibu la r jo in t with a lag sc rew .

im m obilis atio n in a w a lk in g p las ter fo r six w eeks. O u tland 194 3) also u sed p laste r, bu t he

be lieved tha t tib io -fib u la r fusio n m ig h t be necessa ry in ch ron ic cases .

W e have been d isappo in ted w ith conse rva tive m e tho ds in bo th acu te and chron ic case s,

and fo r the la st s ix yea rs w e hav e a lw ay s adv ised ope ra tiv e stab ilisa tion w ith a lag sc rew .

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F I G

3

27 2

J . F . P . M U L L IN S A N D J. G . SA L L IS

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

O P E R A T I O N

T he low er end of th e fib u la is expo sed , and a ho le is d rilled th ro ugh the fibu la in to th e

tib ia w ith a sligh t c ran ia l an d an te rio r inc lin a tion . T he ho le m us t be as lo w as po ss ib le so

th at the sc rew w ill ex ert p ressu re at th e ju nc tion of the articu la r su rfaces o f the f ibu la and

tib ia. A Jo hannsen lag sc rew usua lly l in ch es lon g) is in se rted in to th e d rill-ho le and driven

firm ly h om e . A fte r th is the rock ing te st w ill sh ow w h eth e r the reco nstruc tion h as b een

effect ive.

Pos t opera t ive

ca re -Im m ob ilis atio n in p la ste r is no t req u ired . A fte r th ree o r fou r d ay s in

bed w ith the fo o t e leva ted an k le m ov em en ts a re encouraged and the p atien t is a llow ed up .

S w e llin g o f the an k le som e tim es p ersis ts fo r a few w eeks , bu t th is g radua lly d isapp ea rs . S o m e

pa tien ts m ay be com fo rted by a crepe ban dage , bu t the re is no c lin ical necessity fo r th is .

.

C ase 2 -T ilting o f le f t talu s o n inv e rsio n . T he righ t an k le is sh ow n

f or c o m pa ri so n.

C O M M E N T S

O nly a lag sc rew gives the n ecessa ry com pression a t th e tib io -fibu la r sy ndesm osis : it

grips the cance llou s b one w e ll, coun ter p re ssu re be ing ex erted o n the fibu la by the w ash er

w h ich sh ou ld alw ays be used . A S he rm an sc rew does no t g ive a co m pression fo rce becau se

o f its fin e th read . T he re has been no need to rem ov e th e sc rew .

Th e

resul t s

in our seve n ty -five ca ses

h av e been u n ifo rm ly su ccessfu l. W e hav e no t don e

th is op era tion in ch ild ren , because of th e dang er o f d istu rb ing the ep iphy sis.

S in ce our experience w ith th ese sp ra in s w e have trea ted ank le frac tu res w ith ex tra care,

and frequ en tly u se screw fix atio n a t th e tim e of in ju ry to avo id pa rtial d ia sta sis w ith its

in s tab ility , recu rren t sp ra ins an d late r os teo arth r itis . I f it is no t poss ib le to ope rate at the tim e

of the frac tu re b ecause the fractu re line trav erse s the site w he re on e inse r ts th e sc rew , o pe ra tion

is p erfo rm ed w hen th e frac tu re has un ited .

IL L U S T R A T IV E C A SE S

Case 1 A man aged twenty six years complained of instability of both ankles since spraining them

ab ou t tw o y ea rs be fo re . E x am ina tion show ed th at m o vem en ts w ere fu ll an d p a in -free . T he re w as

ten de rn ess ove r b o th an te rio r in fe r io r tib io -f ibu la r lig am en ts . T he ta lus cou ld be rocked in bo th

an k le s-especia lly th e lef t, in w h ich c rep itu s w as m arked . R ad iog raphs show ed tilting o f th e ta lus,

on inv ersion on ly , in b o th ank les F ig . I) . T he re w as w iden ing of the tib io -f ibu lar sy ndesm osis ,

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R E C U R R E N T SP R A IN O F T H E A N K L E JO IN T W IT H D IA S T A S IS 27 3

espec ia lly o f th e righ t. T h e rig h t fibu la sho w ed a rou ghened a rea w here the pe rio steu m h ad

be e n

to rn by th e p u ll o f th e lig am en ts . T h e tib io -fib u la r jo in t

w as s tab ilis ed

by a lag sc rew on b o th sides

F ig . 2 ) . T h e pa tien t has re tu rned to com pe titive badm in ton and leads a n o r m a l life , w ith n o sym ptom s

from e ithe r ank le.

C ase 2-A w om an ag ed fo rty -seven years

compla ined

th at he r le ft ank le had

be e n

w eak fo r m any

years .

S h e g ave a h istory of h av in g sp ra in ed th e an k le som e

years p rev iou sly . O n exam in a tio n ,

m ov em en ts o f th e an k le w ere fu ll and pa in -free , bu t the re w as tend e rness o ve r the an ter io r in fe rio r

tib io -fib u la r ligam en ts , an d the talu s co u ld b e rocked . R ad io g rap hs sho w ed tiltin g o f th e ta lus on

b o th inv ersion an d eve rsio n , and p ercep tib le w id en ing of the tib io -fib u la r syn desm o sis F ig . 3 ) . T he

tib io -f ibu la r jo in t w as stab ilised by a lag screw . S ince th en sh e

ha s

h ad a stab le ank le , a fu ll rang e o f

m ovem en ts , an d has b een b ack to h er n o rm a l activ e life w ith ou t sym p tom s.

S U M M A R Y

I. P a rtia l d ia sta sis o f the tib io -f ibu lar syn desm o sis is be lieved to be com m on , b u t it is o f ten

ove rlook ed as a cause o f recu rren t sp ra ins o f the ank le.

2 . T he trea tm en t o f recu rren t sp rain s o f the ank le b y stab ilis in g the in fe rio r tib io -fib u la r

jo in t w ith a lag sc rew is desc ribed . T he m e thod has b een used in seven ty -f ive pa tien ts aged

be tw een s ix teen and six ty -f ive yea rs . T he lo ngest fo llow -u p h as b een six yea rs .

R E F E R E N C E S

A L L D R E D G E R . H . 1940) : D iasta sis o f the D ista l T ib io f ibu lar Jo in t and A sso cia ted L es ions. Jou rna l o f the

A m erican M ed ica l A sso cia tion , 1 15 , 2 ,136 .

C O S T I G A N , P.

G . 195 3): T rea tm en t o f T rue W iden in g of A nk le M ortis e. C an ad ian M ed ica l A ssoc ia tion

Jo urna l, 69 , 310 .

L E E , H . G ., and

H O R A N

T . B . 1 943 ): In te rna l F ixa tion in In ju ries o f the A nkle . S urg ery , G yn eco lo gy an d

O bste t r ic s , 7 6 , 5 93 .

L E O N A R D M . H . 194 9): In ju r ie s o f the L a tera l L igam en ts o f th e A nk le . Jou rn al o f B o ne and Jo in t S urge ry ,

31 A 373.

OUTLAND T. 1943) : S prain s and S epa ra tion s o f the In fer io r T ib io f ibu la r Jo in t W ithou t I m p o r t a n t Fractu re.

A m erican Journa l o f S u rg ery ,

N .S . 59 , 320 .

V O L

40 B

NO

2,

M AY

1958