Ankle ankylosis and its importance in chronic venous insufficiency

Abstracts

CONTEXTO: O desenvolvimento de anquilose em pacientes com insuficiência venosa crônica (IVC) pode ser evidenciado em diversos estágios da patologia através de medidas da amplitude de movimento da articulação do tornozelo tomadas com a utilização de um goniômetro. OBJETIVO: Relacionar a diminuição da amplitude de movimento da articulação tíbio-társica na IVC dos membros inferiores (MMII) medida por goniometria com a gravidade da IVC, utilizando-se a classificação CEAP. MÉTODOS: No período de março de 2003 a agosto de 2004, 86 pacientes (67 mulheres e 19 homens) com média de idade de 50,6 anos foram submetidos à goniometria do tornozelo. Os indivíduos foram divididos conforme a gravidade da IVC de seus MMII (121 avaliados) de acordo com a classificação CEAP. Quarenta membros foram caracterizados como C0 (grupo-controle), 40 como C3, e 41 como C4. As medidas obtidas nos diferentes grupos foram comparadas entre si. RESULTADOS: A média da amplitude de movimento da articulação tíbio-társica do grupo C0 foi de 42,4º (variação de 26-54); a do grupo C3 foi de 37,9º (variação de 10-61); e a do grupo C4 foi de 24,5º (variação de 8-50). A diferença das médias de C4 e C3 foi de 36%, e a de C3 comparada com o grupo-controle (C0), de 11%, caracterizando a maior diferença entre C3 e C4. CONCLUSÃO: A goniometria do tornozelo auxilia a graduar a hipertensão venosa crônica, pois demonstra a existência de correlação entre a gravidade da anquilose e a severidade da IVC.

Insuficiência; venosa crônica; anquilose tíbio-társica; goniometria

ORIGINAL ARTICLE

Ankle ankylosis and its importance in chronic venous insufficiency

Jorge Ribas Timi^I; Sergio Quilici Belczak^II; Aline Yoshimi Futigami^III; Fernando Morandini Pradella^IV

^ICirurgião vascular e endovascular. Coordenador, Núcleo Integrado de Cirurgia Endovascular do Paraná (NICEP), Curitiba, PR, Brazil. Professor adjunto, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil

^IIResidente, Cirurgia Vascular, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil

^IIIMédica residente, Cirurgia Geral, Hospital do Servidor Público Estadual Francisco Morato de Oliveira (HSPE-FMO), São Paulo, SP, Brazil

^IVMédico residente, Oftalmologia, Hospital de Clínicas, UFPR, Curitiba, PR, Brazil

Correspondence

ABSTRACT

Background: Development of ankylosis in patients with chronic venous insufficiency (CVI) can be observed in different stages of the disease as the ankle range of motion is measured by a goniometer.

Objective: To relate a reduced ankle range of motion in patients with CVI of the lower limbs measured by goniometry and the severity of CVI according to the CEAP classification.

Methods: From March 2003 to August 2004, 86 patients (67 females and 19 males) with a mean age of 50.6 years had their ankles assessed by a goniometer. Patients were classified into three groups according to the severity of the CVI of the lower limbs (121 were assessed) using the CEAP classification. There were 40 limbs classified as C0 (control group), 40 limbs as C3 and 41 limbs as C4. Measurements of all groups were compared.

Results: The average ankle range of motion was 42.4º (from 26º to 54º) in C0 group, 37.9º (from 10º to 61º) in C3 group and 24.5º (from 8º to 50º) in group C4. The difference between C4 and C3 average values was 36% and that between C3 and the control group (C0) was 11%; thus, the contrast between C3 and C4 was more significant.

Conclusion: Ankle goniometry may be used to assess chronic venous hypertension, as it reveals a correlation between the severity of ankylosis and the severity of CVI.

Keywords: Chronic venous insufficiency, ankle ankylosis, goniometry.

Introduction

Ankle ankylosis is considered as an aggravating factor of chronic venous insufficiency (CVI). It can be considered as of paramount importance in the pathophysiology of patients with CVI since total and permanent ankle ankylosis prevents patients from being healed. In general, ankylosis is not a spontaneous complaint of patients with lower limb ulceration¹, even when it causes deformities and limitations. It has been observed that important current CVI classifications do not mention ankylosis and, in other classifications, it is included only as an update.²

Goniometry is the measurement of angles (Greek gonos = angle and metria = measurement) and it can be used to assess joint motion. It enables both patient and physician to identify and quantify the decrease in the range of motion of a particular joint.^3-6 Goniometry is rarely used because it poses a number of difficulties, from the identification of anatomical nomenclature for movements to the imprecision of the method, which limits its use in the daily angiological practice.

Ankle motion depends on an efficient contraction of the triceps surae muscle,^7,8 which is considered a fundamental part of the calf muscle pump⁹ for the venous return from the lower limbs. Therefore, the motion of this joint is important for the efficiency of the calf muscle pump in order to prevent venous stasis and its consequences.⁷

The objective of this study is to relate a reduced ankle range of motion with the severity of CVI, using goniometry as an important complement for the clinical assessment of the affected patients.

Patients and method

With the approval of the research ethics committee, 86 patients were selected in the vascular surgery service at Hospital das Clínicas de Curitiba from March 2003 to August 2004. A written consent form was obtained from all patients. Patients were classified according to the severity of the venous insufficiency of their lower limbs (121 were assessed) according to the C category of CEAP⁵ (in which C = clinical, E = etiologic, A = anatomic and P = pathophysiologic) into: C0, no visible or palpable sign of venous disease; C1, reticular veins or telangiectasias; C2, varicose veins; C3 edema; C4, skin changes (pigmentation, varicose eczema, lipodermatosclerosis); C5, skin changes and healed ulcerations; C6, skin changes and active ulcerations.

Patient selection was based on the following criteria:

- patients within the C0, C3 and C4 groups, according to the CEAP classification;

- patients who have or have not undergone previous clinical treatment;

- patients who agreed to participate in the study and signed the consent form.

After medical history and physical examination, the following patients were not included in the study:

- patients with orthopedic and/or neurological diseases in the lower limbs;

- patients with rheumatologic diseases in the lower limbs;

- patients with history of lower limb fracture and/or sprains with ruptured ligaments;

- patients who underwent previous surgical treatments in lower limbs;

- patients who refused to participate in the study;

- patients with lower limb venous insufficiency within the C1, C2, C5 and C6 groups, according to the CEAP classification.

The limbs were classified as follows: 40 limbs classified as C0 (control group), 40 limbs as C3 and 41 limbs as C4. All the limbs were assessed based on medical history and physical examination and underwent goniometry with a specific goniometer (Figure 1) built with:

- two metal bars on a cylinder with 1.5 cm in height and 1 cm in radius for localizing the fulcrum;

- two articulated platforms for plantar support;

- cushion support to avoid hyperextension of the triceps surae;

- a folded metal lamina to enable angle measurement;

- a velcro strap;

- a common protractor.

After the limb was adjusted to the goniometer (Figure 2), the joint angle was marked on paper and measured with the protractor (Figure 3).

This goniometer was created by Dr. João Belczak Neto and has been used for physical examination of patients with vascular disease in the Vascular Surgery Service at Centro Vascular João Belczak in the municipality of Maringá, in the state of Paraná, Brazil.⁷ There are few literature reports of goniometers for the measurement of ankle ankylosis; thus, a comparison of this goniometric method with others available is not possible.

Results

C3 and C4 groups were compared with the control group (C0) and with each other.

For all variables of the study, descriptive statistics were presented; to evaluate the relation between dichotomic variables, the ANOVA test (analysis of variance) and the t test (level of significance of 5%) were used.

Of the 86 patients included in the study, 67 were females (77.9%) and 19 were males (22.1%). Their mean age was 50.6 years (Tables 1 and 2). Results of the range of motion (ankle angle) are presented in Table 3.

A sharp decrease in the range of motion is observable among the groups.

The comparison of C4 and C3 reveals that the difference between their average values was 36%, whereas the difference between C3 and the control group (C0) was 11%. Thus, the most significant difference in the range of movement was found between C3 and C4 groups, which are the phases during which the patient presents the first trophic lesions. Assuming that the range of movement corresponds to the efficiency of the calf muscle pump, a decrease in its efficiency would lead to percentage values similar to the ones described here, thus causing an early progression of the disease.

Discussion

Several studies have already been reported on the relation between ankle ankylosis and the severity of CVI. In 1995, Back¹ assessed normal limbs and limbs with CVI and concluded that the severity of symptoms increased as the ankle range of motion decreased, because it contributed to a poor calf pump function (Table 4). Based on his study, the author claimed that this also occurs in phases of chronic venous hypertension with no ulceration.

In 1990¹⁰, Schmeller investigated the ankle range of motion and concluded that older patients have the most limited ankle range of movement, that patients with venous disease have a reduced dorsiflexion when compared to normal patients and that females have a more limited dorsiflexion range of movement than males. Browse et al.¹¹ claim that patients with a stiff and painful ankle have reduced motion and strength in calf muscle contractions, suggesting that "the correction of the joint problem could have a more significant effect on the calf muscle pump function than the correction of the venous anomaly itself".

In patients with superficial venous hypertension, especially in the saphenous trunk, ankle ankylosis leads to a dysfunction in the previously normal or abnormal deep venous system because of impairment of the calf muscle pump. This limitation of the joint motion results in venous stasis because the ejection power of the gastrocnemius and soleus muscles is reduced, with muscle hypotrophy, thus causing or aggravating CVI.^8,9,12

Limbs with edema secondary to lymphatic stasis have a limited range of motion, which is proportional to the progression of the disease. Based on this, lymphedema patients have functional changes in the ankle joint, and its measurement can be an important tool to assess their impairment, to enable their classification and to check the efficacy of the treatment.²

One of the causes for the incurability of some lower limb ulcerations is joint stiffness, which culminates in ankle ankylosis. The consequences of total ankylosis are observable in the walking dynamics, canceling the action of the calf muscle pump and of the foot.^12,13

In this study, patients who still did not present with ulcerations were analyzed, and comparison was established between patients with skin changes and those who did not develop skin changes yet. Results revealed that the most significant differences were found in the comparison of patients with edema (C3) and patients with skin changes.

Considering the results reported here, it is concluded that a preventive treatment should be adopted; and it is possible only if ankylosis is studied as part of the progression of lower limb ulcer.

Thus, new treatments could be suggested aiming at increasing the ankle range of motion and, consequently, improving calf pump function. Within this context, in our service, we conducted a comparative study with patients with ankle ankylosis; five of them with recently healed ulcerations (up to 2 months before the study) and five with healed ulcerations (for more than 3 years). They performed exercises to stimulate an increased joint motion for more than 30 days, and we observed an improvement in the ankle range of motion, which was more intense and faster for those patients who started the treatment earlier.² Therefore, a low-cost, fast and easily repeatable alternative would be to adopt physical therapy in early stages of the venous disease, i.e., up to the C4 level. This could retard or even prevent ulcerations and other complications of venous disease.

Acknowledgements

We thank Dr. João Belczak Neto and Dr. Cleusa Ema Quilici Belczak for having provided us with the goniometer used in this study.

References

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• 2. Belczak J, Belczak CE. Reabilitação cinesiofisiátrica do flebopata crônico. In: Thomaz JB, Belczak CE, editores. Tratado de flebologia e linfologia. Rio de Janeiro: Rubio; 2006. p. 469-483.
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• 8. Belczak CE. Relação entre a mobilidade da articulação talocrural e a úlcera venosa. J Vasc Bras. 2007;6:149-55.
• 9. Barros Jr N. Insuficiência venosa crônica. In: Pitta GB, Castro AA, Burihan E, editores. Angiologia e cirurgia vascular: guia ilustrado. Maceió: UNCISAL/ECMAL; 2000.
• 10. Schmeller, W. Uber den bewegungsumfang im oberen spruggelenk bei venengesunden und venen kraken. Eim beitrag zum arthrogenen staunngssyndrom. Phlebol Proktol. 1990;19:100-10.
• 11. Browse NL, Burnand KG, Irvine AT, et al. Síndrome da falência contrátil da panturrilha. In: Browse NL, Burnand KG, Irvine AT, et al. Doenças venosas. 2Ş ed. Rio de Janeiro: DiLivros; 2001. p. 433-42.
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Publication Dates

• Publication in this collection
  05 Jan 2010
• Date of issue
  Sept 2009

History

• Accepted
  03 Aug 2009
• Received
  11 Mar 2008