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I have a colleague who has recently sustained the following injury. What is the recommended surgical / non surgical treatments available?
CLINICAL HISTORY: inversion injury two months ago

REPORT:

RIGHT ANKLE ULTRASOUND

There is evidence of fluid beneath the anterior talofibular ligament, as well as almost complete loss of definition of the anterior talofibular ligament with no definite remaining fibres seen. The left side had a comparatively normal appearance.

The peroneal tendons as well as the anterior compartment tendons have normal appearances.

RIGHT ANKLE CT

Anon contract MD CT was acquired through the right ankle. Multiplanar and high resolution reformatted images were generated.

There is evidence of some thickening of the anterior talofibular ligament corresponding to the change seen on the recent ultrasound. No associated fracture is seen. There is normal bony alignment. The ankle mortise appears preserved. No degenerative changes are seen.

CONCLUSION

The changes on the ultrasound are consistent with the significant tear of the anterior talofibular ligament. No associated fracture is seen.


Examination Date: 27/7/2007

XRAY RIGHT FOOT

There is normal boney alignment. No fracture or dislocation is seen. There are significant degenerative changes involving the great toe MTPJ.


Examination Date: 6/6/2007

XRAY RIGHT FOOT Morning after I fell over.

No broken bones shown.

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Hi Domhogan:
Given what you've told us, the patient is 8 weeks post injury.
How is the patient doing? Improving? Limping?
How old? Occupation? Active? Healthy?
An isolated ATF lig injury does not always necessitate primary repair. I would suggest P.T. and possible temporary orthotic control. In my experience these isolated injuries heal fairly well without surgical intervention, however, the patients often develop painful ankle synovitis which can be removed via arthoscopy. This may be months or even years post injury.
If the patient continues to have pain/swelling and surgery is indicated there are several ways to repair these.
Most recently ( 1 year) I have been using Wright Medical’s Graft Jacket as a graft rather than attempting to mobilize adjacent soft tissue.
I hope some of this helps. Good luck
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

she is a mother of four (all under 7 years), aged 33 years, healthy, and is a stay at home mum, and she is able to function to care for her children,lifting, carrying etc..., and when walking there is no visible limp, but the area does grab her, and is certainly not improving. Admittedly she has taken the "she'll be right mate..." attitude, which in hind sight this wasn't the best decision. When she first told me I identified the pain in the shaft of the fifth metatarsal, hence was suprised to read the report, unless this is an old unrelated injury?

Hi Domhogan:
I have found the interpretation of MRI findings in this area of the ankle fairly subjective. If her pain is in the 5th Metatarsal and not the anterio-lateral ankle, then I would put more credence on the clinical picture. She may have an occult injury to the 5th metatarsal which, as you know, are common in inversion injuries.

What exactly is her chief complaint? Ankle or lat. foot?

As somewhat of a side-note: When I am unsure as to whether a patient's ankle symptoms are intra or extra articlular, I'll inject 3cc's or so of .5% Marcaine into the ankle. If their pain is dramatically improved for a day then I'm pretty sure it's intra articular.

I would not schedule any surgery until you are sure of the diagnosis.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA