Bandverletzungen am oberen Sprunggelenk

Zusammenfassung

Verletzungen des lateralen Kollateralbandapparats sind die häufigsten Sportverletzungen. Die Feststellung des Schweregrads sowie der Ausschluss relevanter Begleitverletzungen erfordern eine subtile und gezielte apparative Diagnostik. Die Therapie ist in der überwiegenden Mehrzahl der Fälle konservativ-funktionell, wobei auf ein konsequentes Tragen supinationshemmender Orthesen und ein anschließendes Eigenreflex- und Pronatorentraining Wert zu legen ist, um chronische Instabilitäten zu vermeiden. Bei rezidivierenden Umknickereignissen ist zwischen funktioneller und mechanischer Instabilität zu unterscheiden. Letztere lässt sich in über 80 % der Fälle erfolgreich mittels anatomischer Bandrekonstruktion bzw. ‐plastik therapieren. Extraanatomische Tenodesen sind für kombinierte Instabilitäten von oberem und unterem Sprunggelenk reserviert. Mediale Kollateralbandrupturen treten selten isoliert auf, sodass nach knöchernen Begleitverletzungen bzw. zugrunde liegenden Deformitäten zu suchen ist. Isolierte Deltabandverletzungen können konservativ-funktionell behandelt werden. Verletzungen der distalen tibiofibularen Syndesmose werden bei manifester oder latenter Diastase mittels offener Reposition und vorzugsweise doppelter Stellschraubenosteosynthese versorgt. Die korrekte Einpassung der distalen Fibula in die Tibiainzisur ist hierbei der entscheidende Prognosefaktor; sie sollte mit einem 3-D‐Bildwandler oder postoperativem CT kontrolliert werden. Bei chronischer Syndesmoseninstabilität wird eine anatomische Bandplastik mittels halber M.-peroneus-longus-Sehne empfohlen.

Abstract

Injuries to the lateral ankle ligaments are the most common sports injuries. Determination of their severity and exclusion of relevant accompanying injuries requires a subtle clinical and a focussed radiological assessment. Treatment is non-operative and functional in the majority of cases. Consequent application of orthoses limiting supination and proprioceptive training are essential to avoid chronic instability. With recurrent ankle sprains one has to distinguish between functional and mechanical instability. The latter can be treated successfully with anatomic reconstruction and ligamentoplasty in more than 80 % of cases. Extraanatomic tenodeses should be reserved for cases of combined ankle and subtalar instability. Isolated injuries to the medial collateral ligaments are rare. Therefore, osseous injuries or underlying deformities have to be excluded. Isolated deltoid ligament ruptures may be treated non-operatively. Unstable injuries to the distal tibiofibular syndesmosis resulting in a manifest or latent diastasis are treated with open reduction and fixation with two tibiofibular set screws. Anatomic reduction of the distal fibula into the tibial groove is of utmost prognostic relevance and therefore should be reliably proved with either intraoperative 3D fluoroscopy or postoperative CT scanning. For chronic syndesmotic instability an anatomic ligamentoplasty using half the peroneus longus tendon is recommended.

Schlüsselwörter

Sprunggelenk - Bandruptur - Außenbänder - Lig. deltoideum - distaler Syndesmosenkomplex - anatomische Rekonstruktion

Key words

ankle - instability - lateral ligaments - deltoid ligament - distal tibiofibular syndesmosis - anatomic reconstruction

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