The Fortius Clinic Lecture Series - May 2015 Issue

Hyperlaxity and Joint Instability

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In this issue:

Hyperlaxity in the Wrist and Hand

David Hargreaves

Shoulder Hypermobility

Susan Alexander

Chronic Ankle Instability

Nick Savva

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Our presentation team covered hand, elbow, shoulder, foot and ankle specialisms so we had a good range of perspective on hyperlaxity and instability as seen across a number of joints.

The evening was opened by David Hargreaves – Consultant Orthopaedic Hand and Elbow Surgeon, speaking on Hyperlaxity in the Hand & Wrist. Mr Hargreaves covered common types of hyperlaxity in the wrist and hand including midcarpal instability, swan neck deformity and thumb IP/MP/CMC. He explained how patients with these conditions will always have had hyperlax joints, so laxity itself is not a problem, unless it develops into painful instability. Hargreaves did a demo and had everyone doing the examination he was talking about with themselves as subjects.

He was followed by Susan Alexander, Consultant in Shoulder and Elbow Surgery, who addressed the issues of Shoulder Hypermobility.

Ms Alexander reinforced the importance of Physiotherapists in treating shoulder instability. She used the Stanmore instability triangle in outlining three condition groups, supported by case studies. She then covered diagnosis and treatment, including surgical options, as well as mention of new research in shoulder instability.

Nick Savva, Orthopaedic Foot and Ankle Surgeon completed our team, with a presentation on Chronic Ankle Instability, using some good video footage to help to demonstrate his points. He explained that this covers a huge spectrum of symptoms, from an ankle that regularly gives way painlessly, to a very painful ankle which locks, clicks and collapses. The unifying factor is that almost all patients with chronic ankle instability have experienced a significant ankle injury at some point.

Look forward to seeing you next month!

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists and Sports & Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.]

Sophie Whitby, Marketing Assistant

e: sophie.whitby@fortiusclinic.com T: +44 (0) 203 815 3043

MAY TOPIC:

Hyperlaxity and Joint Instability

May’s lecture was on the topic of Hyperlaxity and Joint Instability, which attracted another good turn out. This topic was obviously of interest as it also generated great enthusiasm and involvement in the Q&A session. Thanks everyone for your participation and the very positive feedback we had after the lecture.

Don’t forget to follow us on Twitter @FortiusClinicUK.

You will also find us on Facebook and LinkedIn.

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The first Fortius International Sports Injury Conference is taking place on October 13th-14th, at the Queen Elizabeth II Conference Centre in central London. The multi-disciplinary conference is aimed at orthopaedic surgeons, sports physicians, physiotherapists and other sports and exercise medicine professionals. The theme for FISIC ’15 is Recovery and Return to Play. Timed to coincide with the Rugby World Cup and supported by World Rugby and The RFU, the content is focused on rugby but has wider relevance, applying lessons learnt in a range of sports to current rugby issues.

For more information please visit the FISIC website: www.fisic.co.uk or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

Fortius Clinic Imaging Department is open on a Saturday for MRI, Ultrasound and X-ray.

Call 0203 195 2446 or email imaging@fortiusclinic.com

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FEATURE | Hyperlaxity in the Hand and Wrist

Common types of hyperlaxity in the wrist and hand are midcarpal instability, swan neck deformity and thumb IP/MP/CMC. Patients with these conditions will always have had hyperlax joints, but laxity itself is not a problem, unless it develops into painful instability. The clinician should initially try to establish the cause of the onset of problematic hyperlaxity. This may be a minor trauma, a fall for example, which causes a small fracture and puts the patient’s arm or hand into plaster. During this immobilisation, something happens to the firing of muscles which co-ordinate the hand, and when the plaster comes off, there is suddenly instability, a loss of proprioceptive control. Almost all hand and wrist hyperlaxity issues are palmar, where the wrist angles forwards. However, a small percentage of cases can be dorsal, a combination of palmar and dorsal, or another extrinsic angulation altogether. The pain is usually vague and the patient finds it hard to describe both symptoms and precise location. Ask them whether they can lift a kettle and they will say yes. Ask them if they can pour out the kettle and the answer is no, pouring requires the other hand for stability.

Pinpointing the cause is particularly important because all types of imaging – X ray, MRI, arthroscopy and dynamic fluoroscopy - will show a normal joint, so the diagnosis has to be clinical.There are various physical tests a clinician can use, the most useful of which is the mid carpal drawer. Here the examiner exerts axial traction while holding the patient’s forearm with one hand and the metacarpal heads with the other – when there is midcarpal instability, the patient usually reacts by saying “Yes, that’s it!” then the consultant will know what they are dealing with.

Treatment options include:Splints – an ulnar boost splint will stop the ulna carpus falling forward, but it won’t re-educate the cortical firing of the appropriate muscle and so splints can sometimes aggravate the problem;

Physiotherapy – as patients need to regain proprioception, physiotherapy is beneficial as it will

strengthen the wrist so they can move it into radial ulnar deviation without it collapsing. Learning to control the

wrist in supination really helps, as this is a stable state, so the patient can start this way and then develop the

technique to bring the movement mid pro, then neutral

Lecture by Mr David Hargreaves Consultant Orthopaedic Hand and Elbow Surgeon

Common types of hyperlaxity in the wrist and hand are midcarpal in-stability, swan neck deformity and thumb IP/MP/CMC. Patients with these conditions will always have had hyperlax joints, but laxity itself is not a problem, unless it develops into painful instability.

“Trials show that ten years after thermal capsular shrinkage, 90% of patients still have a good range

of movement”

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FEATURE | Hyperlaxity in the Hand and Wrist

and finally into pronation. Then they are ready for serious strengthening using a gyroscope or spin ball.

Surgery – both midcarpal fusions and ligament reconstruction can sometimes help, but many patients will develop loss of movement, stiffness and pain as a

result. However, a procedure more commonly used for shoulder injuries, thermal capsular shrinkage, has proved to be successful with wrist and hand surgery. Trials show

that ten years after thermal capsular shrinkage, 90% of patients still have a good range of movement, which may be due to the ease with which a wrist can be immobilised

after an operation.Swan neck deformity, caused by stretching of the PIP

volar plate, can develop quite spontaneously, and for this condition, an FDS tendonesis is usually successful.

Interphalangeal thumb issues mean the thumb won’t operate accurately - a real problem for a golf player for

example. Splints won’t work but the sesamoid bone can be tethered which is usually effective.

The same procedure works well for hyperextension in the MP thumb joint, which often heralds osteoarthritis. An

abducted thumb can’t hold a glass for example, as it over extends.

Finally the base of the thumb is an area which takes an enormous amount of pressure and tension and so thumb CMC hyperextension is a condition often experienced by surgeons! The anterior oblique ligaments have started to

stretch, causing laxity and instability, and this too often develops into osteoarthritis. Splints and taping may help

here but otherwise ligament reconstruction using the tendon is recommended.

Mr David Hargreaves Consultant Orthopaedic Hand, Wrist and Elbow SurgeonConsultant Orthopaedic Surgeon treating a wide range of degenerative and traumatic conditions of the hand and wrist, with special interest in arthroscopic surgery.

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FEATURE | Shoulder Hypermobility

Ian Bayley, who was Medical Director of the RNOH, co-founder of the British Elbow and Shoulder Society, and a designer of shoulder implants, came up with the concept of the Stanmore instability triangle.

This triangle has three groups:

The first group is the traumatic structural group – a rugby player who collides with someone and tears their labrum, for example. The second group is the atraumatic structural group, who usually suffered the injury when doing something low-key, such as shaking a duvet. The third group is the habitual non-structural (muscle patterning) group whose problems involving muscle co-ordination or activation.

I’m going to look particularly at the axis between the second and third group, because while a patient may start with a traumatic injury with recurrent dislocation,

this often becomes atraumatic, prompting dislocation with something as minor as turning over in bed. Or, the patient may start off in the second group but exhibit evidence of muscle pattern features and a lack of co-ordination which have to be addressed. Shoulder joint hypermobility can also be associated with the Ehlers-Danlos syndrome (EDS), a collection of inherited conditions to do with disorders of connective tissue, of which joint hypermobility is the most common subtype.

So what is the most important thing to start with when a patient presents with shoulder hypermobility? Taking the history in as much depth as possible is really important, as is the clinical examination, and the involvement of physiotherapists. Working with Anju Jaggi, the RNOH Consultant Physiotherapist, has fundamentally changed my thinking and my protocol.

I examine the posture first – is it upright, kyphotic, flat back or sway back? Are the shoulders in joint? Is there evidence of winging on the scapula? What is balance like, on one leg, on one leg with eyes shut, or attempting a one-legged squat? I look for laxity using the Beighton score – can the patient put their hands flat on the floor or push their thumbs back? How about their knees – do they go backwards? Can they hyperextend their elbows or bend the little finger? All these factors give you a picture of the whole person’s structure.

Then I observe movement. What is the scapulothoracic rhythm when coming down slowly from forward elevation? Is there winging, or is the shoulder dislocating backwards? As they lift their arm up, is the ball of the humeral head dropping backwards slightly?

Next it’s muscle strength, which needs to be

Lecture by Ms Susan Alexander Consultant in Shoulder Surgery

When I started training, as a rare woman in orthopaedics, there was an established hierarchy with the surgeon at the top and the physiotherapist awaiting instruction further down. As I will show, this hierarchy has changed utterly.

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investigated in several positions: standing; lying supine; lying prone and with different degrees of abduction. A series of improvement tests explore whether the kinetic chain is engaged, which may indicate that core stability needs attention. Periscapular strengthening work and cuff improvement exercises may all help.

As regards treatment, there are several options. Botox injections help to treat tight muscles and give time for rehabilitation. Functional electrical stimulation helps very weak muscle fire up. We’re researching electromyography (EMG) with regard to muscle activation, comparing results with surface electrodes and fine-wire electrodes.

With surgery, we have moved on from metal or plastic anchors to slimmer interrupted sutures and I have been developing the double-barrel stabilization with two anchors front and two back, which I hope will re-programme the sensitivity of the receptors. This is undergoing a randomized clinical trial with

one group of patients having only a diagnostic arthroscopy plus physiotherapy, and the other group having the double-barrel stabilization procedure. Frustratingly, both groups are currently doing well!

In conclusion, patients who present with shoulder instability may need more than one health professional and more than one type of therapy or treatment. History is everything. The physiotherapist and the consultant should work together to unpick the issues and I need to be convinced that every angle has been explored before I recommend surgery. What surgery does is stabilize the shoulder but more importantly, it temporarily improves proprioception, altering feedback, so that physiotherapists can rehabilitate the area – which is the key. Today, the surgeon is facilitating the physiotherapist, not the other way around.

Ms Susan Alexander Consultant Shoulder Surgeon.Clinical interests in complex reconstructive arthroscopic surgery, shoulder arthroplasty, complex instability and hypermobility of the shoulder and shoulder sports injuries.

What exactly is chronic ankle instability? There’s a huge spectrum of presentations ranging from an ankle that regularly gives way painlessly to a painful ankle that locks, clicks and collapses. The unifying factor is that almost all patients with chronic ankle instability have experienced a significant ankle injury at some point. The classic is an ankle sprain, an inversion supination type injury, causing pain, swelling and difficulty walking. These are extremely common and the majority of patients don’t ever seek medical advice. However, it is also the most common traumatic injury seen by GPs and in the accident department, which indicates how many are happening every day.

Ankle sprains do not just stretch or rupture the ATFL and CFL. The skin can also be injured, occasionally causing blisters. The superficial peroneal and sural nerve can also be stretched causing dysaesthesia and neuropathic pain that can be particularly bad at night. The peroneal tendons can be torn, snap out of place and dislocate. Avulsion fractures and osteochondral injuries to the talus are also possible. If a patient has general joint hypermobility or inherited collagen disorders such as Ehlers-Danlos and Marfan’s, this can manifest as or predispose to ankle instability. Other predisposing factors include a tight Achilles tendon, anterior impingement and various anatomical variations such as a varus heal or cavus foot.

The essential starting point for assessment of all ankle instability is a good history. I spend a lot of

time working out what when wrong and when. I pay particular attention to identifying sites of pain, stiffness and exact descriptions of instability. It is important to ascertain how much treatment the patient has had as there is good evidence that lack of treatment of the primary injury increases the chances of it recurring.With all patients, I look at their alignment and how they walk. I perform a full and thorough examination of the foot, ankle and lower limb in general. I pay particular attention to the anterior drawer test to assess the ATFL and the varus stress test to assess the CFL, both good indicators of mechanical instability. I do a variation of the proprioceptive Romberg test to assess for functional instability. I also perform the usual tests for generalised joint hypermobility

(Beighton).An MRI scan is essential and an ultrasound is often helpful to delineate all pathology. The commonest cause of recurrent problems is missing and not treating all pathological lesions. I divide ankle sprain

treatment into the three phases of healing. In the first inflammatory phase I keep the ankle as still as possible to limit the amount of pain and swelling. The patient should be immobilized for up to ten days. Putting them in plaster should be considered. Clinical examination five to seven days after an injury is the best time to identify all pathology accurately.During the proliferative phase, when healing tissue is being laid down it is important that the ankle is put through a functional range and that proprioceptive exercises are introduced. There is good eveidence

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FEATURE | Chronic ankle InstabilityLecture by Mr Nick Savva Orthopaedic Foot and Ankle Surgeon

Dr Jonathan Rees FRCP, FFSEM, MDConsultant in Rheumatology and Sport and Exercise Medicine

“Hypermobility or inherited collagen disorders such as

Ehlers-Danlos and Marfan’s, can cause ankle instability.”

What exactly is chronic ankle instability? There’s a huge spectrum, all the way from an ankle that regularly gives way painlessly, to a very painful ankle which locks, clicks and collapses. The unifying factor is that almost all patients with chronic ankle instability have experienced a significant ankle injury at some point.

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that gentle functional movement during this phase aids differentiation of collagen in tendons and ligaments into the correct subtypes.Finally, in the remodelling phase, which lasts between 12 and 18 months, functional bracing is recommended to avoid further injury – a stirrup-type brace for example. With every case, before I consider surgery, I make sure the patient has had full rehabilitation. If surgery is being contemplated for ankle instability arthroscopy has an important role. Pathologies such as osteochondral lesions of the talus, anterior impingement, syndesmosis injury, loose bodies or peroneal tendon disorders can be the sole cause of instability and can all be treated during ankle arthroscopy.Considering the mechanical element of instability I repair or reconstruct the damaged ligaments. The classic repair technique was described by Brostrom and modified by Gould. This involves imbricating the middle of the ATFL and the CFL to make them shorter, which has both a functional and proprioceptive effect (Brostrum). Imbricatation of part of the inferior extensor retinaculum into the repair (Gould) augments this.Non-anatomic reconstruction is more complex. The traditional methods use part or all of one of the peroneal tendons. These are dynamic stabilizers of the lateral side of the joint in their own right and therefore not entirely sacrificable. The second problem with these techniques is that they are non-anatomical and so result in abnormal joint kinematics, which may result in premature degenerative changes in the long term.

Anatomical reconstruction of ATFL and CFL with hamstring tendon is a useful option for revision cases. It can also be considered as a primary option in particularly heavy patients, those who do heavy work and athletes. Patients with generalised hypermobility and collagen disorders such as Marfan’s and Ehlors Danlos syndrome present a particular problem. As all of their tendons and ligaments are of poorer quality repairing them with native tissue is less likely to be successful. This of course includes autograft such as the patients own hamstrings. In this situation I tend to offer the usual repair but explain that failure is more likely than usual. I consider using some form of artificial material to augment the repair. If this does fail then I consider anatomical reconstruction with allograft.All arthroscopic techniques to reconstruct the ATFL and CFL are under development.Treatment of primary sprains in elite athletes is controversial. This of course depends upon their exact pathology. There is some limited evidence that primary repair of the lateral ligaments reduces the risk of chronic instability. In an ideal world of course we prevent the development of chronic instability. In my opinion, the best way to prevent chronic ankle instability is a thorough diagnosis and treatment as soon after the initial injury as possible. The most common causes of failure of surgery for chronic ankle instability is failing to identify and treat all pathology.

Mr Nick Savva Orthopaedix Foot and Ankle SurgeonConsultant Orthopaedic Surgeon specialising in foot and ankle injuries, arthroscopy, bunions and lesser toe deformities.

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June lecture: The Wimbledon Effect

Lectures by:

Mr Callum ClarkConsultant Foot & Ankle Surgeon

Mr Damian FahyConsultant Spinal Surgeon

Ms Alice Bremner-SmithConsultant Hand and Wrist Surgeon

To be added to the attendance list please email: RSVP@fortiusclinic.com

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For further information or to book an appointment, please contact us:

t: +44 (0) 203 195 2442 f: 0203 070 0106 e: appointments@fortiusclinic.comw: www.fortiusclinic.com

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How to find us:Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

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