Page 27 - ISAKOS 2020 Newsletter Volume 2

CURRENT CONCEPTS
Return-to-Play Protocol and Survey Results
Return to Play
There is no consensus on a return-to-play protocol for athletes following syndesmotic injury. D’Hooghe et al., in a registry-based study involving 110 professional soccer players with Grade-IIb and III syndesmotic injuries, evaluated the time to return to sport-specific rehabilitation, the time to return to team training, and the time to the first official soccer match after injury.5 The authors found that none of the athletes had participated in an official match at 1 month after surgery and that only 4% had done so within 2 months after surgery. The mean time to begin on-field / sport-specific rehabilitation was 37 ± 12 days, and the mean time of to the first match after syndesmotic stabilization was 103 ± 28 days.
Global Perspective
The ISAKOS LAF committee recently surveyed >500 orthopaedic surgeons specializing in ankle injuries from across the globe, including members of ISAKOS and all major orthopaedic sports medicine societies. Survey participants answered questions focused on their indications for the treatment of syndesmotic injuries, the information that they used during their decision-making process, and their preferred technique (either suture-buttons or syndesmotic screws) for the operative repair of indicated syndesmotic injuries. Six hypothetical athlete scenarios were constructed to assess the preferred duration of rehabilitation and graduation to activity in each variation of syndesmotic injury. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%), and other (6%). There was a higher preference for flexible devices among providers who were trained in sports medicine (58%) relative to those who were not (44%).
03 Graph illustrating the percentage of surveyed surgeons who would clear each athlete for full participation over time. Six hypothetical elite athlete scenarios were constructed with varying degrees of injury: moderate-impact injury with and without a complete deltoid tear (Athletes 1 and 2, respectively), high-impact injury with and without a complete deltoid tear (Athletes 3 and 4, respectively), and very-high- impact injury with and without a complete deltoid tear (Athletes 5 and 6, respectively). The moderate-impact athlete was described as a 180-pound tennis player (Athletes 1 and 2), the high-impact athlete was described as a 220-pound wide receiver (Athletes 3 and 4), and the very-high-impact athlete was described as a 300-pound defensive lineman (Athletes 5 and 6).
Sixty-two percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was noted with regard to the anticipated timing before full return to sport, ranging from immediately following the injury to 6 months postoperatively (Fig. 3). On the basis of the results of our survey, we inferred that regardless of the severity of the injury to the syndesmosis, device choice and return-to-play protocol were not consistent internationally, and thus no consensus has been made among providers that treat syndesmotic injuries.
04 Graph illustrating the number of surveyed surgeons who would clear each athlete for full participation at each of the specified times. Six hypothetical elite athlete scenarios were constructed with varying degrees of injury: moderate-impact injury with and without a complete deltoid tear (Athletes 1 and 2, respectively), high-impact injury with and without a complete deltoid tear (Athletes 3 and 4, respectively), and very-high-impact injury with and without a complete deltoid tear (Athletes 5 and 6, respectively). The moderate-impact athlete was described as a 180-pound tennis player (Athletes 1 and 2), the high- impact athlete was described as a 220-pound wide receiver (Athletes 3 and 4), and the very-high-impact athlete was described as a 300- pound defensive lineman (Athletes 5 and 6).
Alabama Experience and the Media
Recently, the medical team with the University of Alabama football program (Tuscaloosa, Alabama, USA) began implementing an accelerated postoperative protocol for patients undergoing syndesmosis-stabilization surgery with the Tightrope technique (which involves drilling quadricortical tunnels through the fibula and tibia and then implanting the Tightrope device to reduce the syndesmotic gap and repairing the injured ligaments). According to media reports, athletes in that program who have undergone such treatment can return to sport-specific training within 12 days and are able to compete in games once they can perform 15 single- leg hops (https://www.si.com/college/2019/10/20/tua- tagovailoa-ankle-injury-alabama-lsu-outlook). Aggressive rehabilitation has been a staple in their injury protocol and has successfully allowed the medial staff to get impact players back on the field and performing at a high level at a quicker rate than ever before.
ISAKOS NEWSLETTER 2020: VOLUME II 25