Arthroscopic anatomical reconstruction of the lateral ankle ligaments

Quantitative Evaluation of Tunnel Positions for Anatomic Lateral Ankle Ligament Reconstruction: Based on a Cadaveric and Radiographic Study

BACKGROUND

Previous studies reported the ligament attachments with regard to anatomic landmarks. However, these absolute distances may differ in size and anatomic variability.

PURPOSE

To develop radiologic methods for assessing the tunnel placements of anatomic lateral ankle ligament reconstruction with a single common fibular tunnel and provide quantitative data on radiography and 3-dimensional computed tomography (3D CT).

METHODS

Sixteen ankle specimens were used to identify the attachment centers of the anterior talofibular ligament and calcaneofibular ligament. Subsequently, bone tunnels were created at these sites, with their positions evaluated via lateral radiographs and CT scans. Reference lines such as the anterior distal fibular line from the inferior tip of the fibula to the anterior tubercle on the fibula and the anterior lateral malleolar line from the apex of the lateral talar process to the anterolateral corner of the trochlea on the talus were employed for accurate tunnel positioning. For the calcaneal tunnel, the posterior subtalar line and its orthogonal line form the basis for a structured square measurement frame. The tunnel entries were orthogonally projected onto these references, enabling a percentage-based description of their locations. The interobserver and intraobserver reliability of the radiographic measurements were assessed using intraclass correlation coefficients (ICCs).

RESULTS

The fibular tunnel was projected at 35.9% on lateral radiography and 35.0% via 3D CT along the anterior distal fibular line. The talar tunnel was recorded at 62.4% on radiography and 63.5% on 3D CT along the anterior lateral malleolar line. There were no significant differences in the length of the posterior subtalar line (34.6 vs 31.4 mm, P = .140), distance a to the calcaneal tunnel (16.1 vs 14.7 mm, P = .100), and distance b to the calcaneal tunnel (27.9 vs 25.1 mm, P = .233) between the lateral roentgenogram and 3D CT. The calcaneal tunnel was observed at 80.6% on lateral radiography and 79.7% on 3D CT along the posterior subtalar line and at 46.4% on radiography and 46.3% on 3D CT along the orthogonal line. No significant differences were observed in the locations of the fibular, talar, and calcaneal tunnels between lateral radiography and 3D CT. Good interobserver agreement and intraobserver reproducibility were achieved, as indicated by ICCs.

CONCLUSION

This study describes reproducible radiographic measuring techniques and provides quantitative data for intraoperative positioning and postoperative assessment of tunnel locations for anatomic lateral ankle ligament reconstruction. Both lateral radiography and 3D CT were effective modalities for evaluating the bone tunnels.

CLINICAL RELEVANCE

By offering reproducible measurement strategies and critical quantitative data on tunnel positioning for anatomic lateral ankle ligament reconstruction, this research significantly aids in optimizing intraoperative tunnel placement and postoperative evaluation, particularly for procedures involving a single common fibular tunnel and limited exposure methodologies.

Return to sport and satisfaction after arthroscopic anatomic reconstruction of the lateral ligaments of the ankle in athletes

INTRODUCTION

Ankle sprains, one of the most frequent accidental injuries in traumatology, can lead to chronic instability. Although arthroscopic anatomic ankle ligament reconstruction seems to provide good results, very few studies have specifically examined the outcomes of this procedure. The main goal of this study was to evaluate the rate of and delay to return to sport (RTS) at the preinjury level after anatomic ligament reconstruction and the predictive factors of a RTS in an athletic population. The secondary objectives were to report postoperative satisfaction and functional and psychological scores.

MATERIAL AND METHODS

This retrospective multicenter study included 92 athletes who underwent ankle ligament reconstruction between 2015 and 2022 at three different centers with a minimum follow-up of one year. The primary outcome measurement was the percentage, quality and time to RTS. Secondary outcome measurements included the ALR-RSI, FAAM functional scores, satisfaction, and complications rates at the final follow-up. The effect of different variables (age, sex, preoperative level of play, circumstances of the first accident) on RTS was assessed.

RESULTS

Forty-six men (50%) and 46 women (50%), mean age 36.6 years old (SD = 12), were included. Mean follow-up was 37.5 (SD = 23.9) months. At the final follow-up, 85.9% patients had RTS. The analysis did not reveal any factors significantly associated with a RTS at the preinjury level of play except for a trend towards a higher percentage of RTS at the preinjury level in patients with a higher preoperative level of sports activity (p = 0.052). The mean ALR-RSI score at the final follow-up was 67.7% (SD = 24.1), the FAAM sport score was 79.9% (SD = 26.2) and the FAAM adl score was 89.6% (SD = 16.9). Nine patients had postoperative complications, usually discomfort on the endobutton, requiring removal.

CONCLUSION

This study shows that arthroscopic anatomic ankle ligament reconstruction is associated with high rate of RTS (85.9%) after a mean 7.5 (6.9) months as well as a high rate of satisfaction. Although this study did not identify any predictive factors for the RTS, the preoperative level of sports might play a role. In addition, this study once again confirms that functional and psychological scores are practical tools to assess a patient's postoperative readiness to RTS.

LEVEL OF EVIDENCE

IV; retrospective study.

Concomitant Chronic Lateral Ankle Instability Affects Postoperative Functional Outcomes in Patients With Osteochondral Lesions of the Talus but Does Not Affect Cartilage Repair After Restoration of Ankle Stability

PURPOSE

To investigate the effect of concomitant chronic lateral ankle instability (CLAI) on postoperative clinical outcomes in patients with osteochondral lesions of the talus (OLTs).

METHODS

Patients who underwent surgery for OLTs between January 2018 and May 2022 were retrospectively evaluated. OLT patients underwent debridement, microfracture, or bone grafting, whereas patients with concomitant CLAI underwent lateral ligament repair or reconstruction. Functional assessments included the visual analog scale score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), and Tegner score, with a minimum follow-up of 24 months. Cartilage repair was evaluated using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 1 and MOCART 2.0 scores based on postoperative magnetic resonance imaging. Additionally, multiple linear regression analysis was performed to explore the effects of potential factors, and Spearman correlation coefficients (rs) were calculated to assess the relationship between these factors and outcome scores.

RESULTS

A total of 85 patients were included, with 39 in the OLT group and 46 in the OLT-CLAI group. The mean follow-up times were 46.95 ± 17.00 months (range, 24-76 months) and 41.80 ± 15.10 months (range, 24-76 months), respectively (P = .347). Compared with the OLT group, the OLT-CLAI group showed lower postoperative AOFAS and FAOS scores, with a significantly smaller overall improvement in the AOFAS score (P < .05). There was no significant difference in the number of patients achieving the minimal clinically important difference in functional scores between the groups. Multiple linear regression analysis showed that CLAI surgery negatively affected postoperative AOFAS (standardized β = -0.344, P = .001) and FAOS (standardized β = -0.332, P = .001) scores, with Spearman analysis indicating a moderate correlation (rs = -0.442 [P < .001] and rs = -0.339 [P = .002], respectively). No significant differences were observed between the groups in terms of MOCART 1 (61.52 ± 12.38 vs 65.89 ± 14.47) or MOCART 2.0 (68.70 ± 16.53 vs 73.75 ± 14.76) scores (P > .05), and multiple linear regression as well as Spearman analysis did not yield positive results.

CONCLUSIONS

OLT patients with concomitant CLAI had lower postoperative functional outcomes than those without CLAI. However, after surgical treatment of CLAI, cartilage repair in OLT patients was not affected.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Ultrasound of Postoperative Ankle Instability: How to Manage with Arthroscopic Reparation or Anatomical Reconstruction of Lateral Ankle Ligaments

Surgical repair or reconstruction of lateral ankle ligaments is indicated in patients with persistent ankle instability, with arthroscopic/endoscopic treatment becoming more frequent. Although presurgical imaging of the ankle is always standard procedure, more is needed to understand the evolution of the repaired ligament or the tendinous graft to help improve length of postoperative time and functional results. This review describes the normal ultrasound aspects and possible complications of repaired/reconstructed ankle ligaments after an all-inside endoscopic repair/reconstruction of the anterior talofibular ligament and the calcaneofibular ligament.

Which tendon graft to choose for anatomical ligament reconstruction in chronic lateral ankle instability? A biomechanical study

BACKGROUND

The need for anatomic lateral ligament reconstruction of the ankle continues to grow. This procedure usually requires a gracilis autograft or in some cases an allograft. Siegler et al. reported the mechanical characteristics of the collateral lateral ligaments of the human ankle: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL. The objective of this study was to evaluate the mechanical properties of different tendon grafts available for ATFL and CFL reconstruction. We hypothesized that the properties of the tested grafts are not inferior to the published values of those of the original ligaments on the lateral side of the ankle.

METHODS

This was a comparative biomechanical study using 6 cadaver specimens (108 grafts): The biomechanical properties of nine types of grafts were determined using validated tensile testing methods: Gracilis, SemiT, EHL, FHL, Plantaris, Peroneus longus and brevis, TA and TP. The main outcome measure was the comparison of the mechanical properties of each single-stranded tendon with each other and with the known values ​​for the ATFL and CFL, during a uniaxial static rupture test.

RESULTS

The mean load to failure for the gracilis was 257.5 ± 52.9 N. The groups had similar mean values in terms of the maximum load that they could withstand before failing except for the plantaris (137.9 ± 33.7 N) which was statistically lower than all other tested tendons (p < 0,01). The mean load to failure values of the grafts tested were equal or higher than that of the ATFL and CFL reported by Siegler et al. [14]: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL, while the grafts tested here had mean failure load between 258 ± 53 N and 464 ± 136 N.

CONCLUSION

The gracilis, peroneus longus/brevis, EHL, FHL, TA, TP and semiT are legitimate grafts for combined ATFL and CFL reconstruction in the ankle. These tendons have mechanical properties (load to failure, maximum strain at failure and stiffness) that are equal to or higher than the native ligaments on the lateral side of the ankle, except the plantaris.

CLINICAL RELEVANCE

This study validates the current use of the gracilis autograft for the anatomical reconstruction of the ATFL and CFL, and even provides proof that other tendons would be suitable for this anatomical reconstruction of the lateral ankle ligament by auto or even allograft under certain conditions.

LEVEL OF EVIDENCE

Descriptive laboratory study.

Broström ankle ligament repair augmented with suture tape : Results of magnetic resonance imaging evaluation

BACKGROUND

The Broström procedure is an established procedure in cases of primary lateral ankle ligament repair (LALR). To improve postoperative stability an augmentation device, InternalBrace™ (Arthrex, Naples, FL) has been introduced. This study evaluates remodelling of the anterior talofibular ligament (ATFL) in patients undergoing a tape augmented Broström technique as well as clinical outcomes.

METHODS

In this study 32 patients with chronic lateral ankle instability (CLAI) receiving augmented LALR were included. Clinical outcomes were evaluated at a one-time postoperative visit between 12 and 18 months. A 3 T magnetic resonance imaging (MRI) was done to evaluate the morphology of the ATFL. Statistical analysis was completed with the free software and environment R version 3.6.3 (Bell Laboratories, Murray Hill, NJ, USA) and P-values < 0.05 were considered statistically significant.

RESULTS

The mean follow-up time was 15.3 ± 1.8 months with a return to sport time of 4.0 ± 2.4 months. The average AOFAS (American Orthopaedic Foot and Ankle Society Score) score was 94.4 ± 7.2, the FAOS (Foot and Ankle Outcome Score) demonstrated 87.3 ± 10.4 points and the FFI (Foot Function Index - 2 scores (pain and function score)) was 22.9 ± 20.1 and 15.4 ± 10.4, respectively. The MRI findings demonstrated an average length of the ATFL of 18.6 ± 4.3 mm and the width was 3.6 ± 0.9 mm. A clear differentiation between the ATFL and the augmentation device could be shown in 28 cases. The Fisher's exact test could not depict a significant correlation between the presence of a bone marrow edema and the tension of the augmentation device with a level of significance of α = 0.05.

CONCLUSION

An anatomical healing tendency of the ligament repair and good integrity of the augmentation device could be shown based on MRI findings. The lateral ligament repair augmented with suture tape is an effective and safe procedure regarding surgical treatment in chronic lateral ankle instability producing good clinical outcome.

Arthroscopic Anatomic Reconstruction of the Anterior Talofibular and Calcaneofibular Ligaments Through a 2-Portal Technique

Arthroscopic anatomic lateral ligament reconstruction of the ankle joint has proven to be a safe option in the treatment of chronic ankle instability (CAI), with good functional results as well as allowing simultaneous management of associated lesions. We described an arthroscopic technique for anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament using only 2 arthroscopic portals. This surgical technique to treat CAI is technically less demanding than other described techniques that use 3 or 4 arthroscopic portals. Moreover, as an anatomic technique, it has the advantage of preserving the biomechanics and kinematics of the ankle joint.

MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?

BACKGROUND

No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction.

PURPOSE

To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence.

RESULTS

The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months.

CONCLUSION

The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

The Distal Fascicle of the Anterior Inferior Tibiofibular Ligament: A Potential Landmark for Lateral Ankle Ligament Reconstruction

BACKGROUND

A reliable landmark and precise distances from the ligament attachments are needed for lateral ankle stabilization surgery. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) has been used to locate the anterior talofibular ligament (ATFL) or calcaneofibular ligament (CFL) centers on the fibula. However, there is no anatomic study to validate the distal fascicle of the AITFL as a landmark of lateral ankle ligament stabilization, and more importantly, the exact distances from the ATFL or CFL attachments to the distal fascicle of the AITFL are unknown.

METHODS

Sixteen frozen cadaveric specimens (8 paired specimens) with no previous history of ankle injury were used in this study. Whether the distal fascicle of AITFL was present in each specimen was confirmed. Then, the distances from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL and CFL on the fibula were measured. All measurements were performed by 2 observers, and the intraobserver and interobserver reliabilities were analyzed by intraclass correlation coefficients (ICCs).

RESULTS

The distal fascicle of the AITFL was found in all specimens (100%). The mean distance from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL, CFL, and the intersection center of the 2 ligaments on the fibula was 6.0 to 7.1 mm, 11.5 to 13.2 mm, and 9.0 to 10.0 mm, respectively. Excellent interobserver and intraobserver agreement (all ICCs > 0.9, P < .01) was shown in the anatomic measurements of these distances.

CONCLUSION

In this cadaveric study, we found that the distal fascicle was a constant structure of the AITFL in the lateral ankle. The distances from the most distal insertion of the AITFL's distal fascicle to the ligamentous footprint centers were reliable and may be used to identify the origins of the ATFL and CFL for lateral ankle ligament reconstruction.

CLINICAL RELEVANCE

This anatomic study validates the AITFL's distal fascicle as a potential landmark and, more importantly, determines the range of distances from AITFL's distal fascicle to the attachment centers of lateral ankle ligaments by anatomic measurements. The data may be used to identify the ATFL and CFL for lateral ankle stabilization surgery and become particularly valuable for endoscopic or arthroscopic techniques.

Allogeneic tendons in the treatment of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability

BACKGROUND

The aim of this study is to report our institution's experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability.

METHODS

This retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints.

RESULTS

Thirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24-35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01).

CONCLUSION

In this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.

Both Open and Arthroscopic All-Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability

PURPOSE

To compare the return to sports and short-term clinical outcomes between the arthroscopic all-inside and the open anatomic reconstruction with gracilis tendon autograft for chronic lateral ankle instability (CLAI) patients.

METHODS

From March 2018 to January 2020, 57 CLAI patients were prospectively included with arthroscopic all-inside anatomic reconstruction (n = 31) or open anatomic reconstruction (n = 26) with gracilis tendon autograft. The patients were evaluated before operation and at 3 months, 6 months, 12 months, and 24 months after surgery. The American Orthopaedic Foot and Ankle Society score (AOFAS), visual analog scale (VAS), and Karlsson-Peterson score were evaluated at each time point, and stress radiography with a Telos device was performed before surgery and at final follow-up. The time to return to full weightbearing walking, jogging, sports, and work, Tegner activity score, and complications were recorded and compared.

RESULTS

All the subjective scores significantly improved after surgery from the preoperative level. Compared with the open group, the arthroscopic group demonstrated significantly earlier return to full weightbearing walking (8.9 vs 11.7 weeks, P < .001), jogging (17.9 vs 20.9 weeks, P = .012), and recreational sports (22.4 vs 26.5 weeks, P = .001) with significantly better AOFAS score and Karlsson score at 3 to 6 months, and better VAS score at 6 months after surgery. The 2 groups demonstrated no significant difference in the surgical duration or surgical complications. No significant difference was found in the clinical scores or stress radiographic measurements at 24 months after surgery (P > .05).

CONCLUSION

Compared with the open procedure, the arthroscopic all-inside anatomic lateral ankle ligament reconstruction with autologous gracilis tendon could achieve earlier return to full weightbearing, jogging, and recreational sports with less pain and better ankle functional scores at 3 to 6 months after surgery. Similar favorable short-term clinical outcomes were achieved for both techniques at 2 years after surgery.

STUDY DESIGN

Level I, randomized controlled trial.

Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.

Ultrasonography vıew for acute ankle ınjury: comparison of ultrasonography and magnetic resonance ımaging

INTRODUCTION

We aim to asses the diagnostic performance of ankle ultrasonography in patients presenting with acute ankle sprain injury, with comparison to MRI (Manyetik Rezonans İmaging).

MATERIALS AND METHODS

The study included patients who applied to the hospital within 48 h after an ankle sprain, and who presented with signs of pain, swelling, and tenderness in the ankle. Ankle ultrasonography examination was performed and an ankle MRI took place the same day.

RESULTS

30 patients were included in the study. 53.3% (n = 16) were female. The mean age was 30 ± 6.4 years. The ultrasonography examination determined 76.6% (n = 23) of the patients to have anterior talofibular ligament (ATFL) injury, 33.3% to have (n = 10) CFL injury, and 33.3% to have (n = 10) anterior inferior tibia-fibular ligament (AITFL) injury. The MRI of the patients determined 73.3% (n = 22) of the patients to have ATFL injury, 43.3% (n = 13) to have calcaneal fibular ligament (CFL) injury, and 33.3% to have (n = 10) AITFL injury. The ATFL, CFL, and AITFL injuries diagnosed on ultrasonography correlated with the MRI results (ICC = 0.875, ICC = 0.879, and ICC = 0.858). However, among the ATFL injuries observed on MRI, 26.6% (n = 8) were grade I, 26.6% (n = 8) were grade II, and 20% (n = 6) were grade III injuries. Of the ATFL injuries observed on ultrasonography, 46.6% (n = 14) were grade I, 8.6% (n = 2) were grade II, and 30.4% (n = 7) were grade III injuries.

CONCLUSIONS

Findings on all types of ATFL, CFL and AITFL appear to have a higher degree of correlation. Ultrasonography could have an added role as a triaging tool, to fast-track MRI.

Reconstruction of the cervical ligament in patients with chronic subtalar instability

PURPOSE

Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI.

METHODS

This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score.

RESULTS

After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ± 13.5 (median 37, range 10-55) to a mean postoperative Karlsson score was 89.6 ± 8.5 (median 90, range 72-100) (P < 0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3).

CONCLUSION

Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability.

LEVEL OF EVIDENCE

Level III.

Lateral endoscopy of the sinus tarsi: Anatomy, technique and current indications

Numerous pathologies are reported in the lateral mid- and hind-foot. Access to the sinus tarsi is difficult, making lateral endoscopy the preferred approach. The present technical note describes the anatomy, technique and current indications for lateral endoscopy of the sinus tarsi.

Comparison arthroscopic reconstruction and percutaneous reconstruction of ankle lateral ligament for chronic ankle lateral instability: A protocol for a meta-analysis of comparative studies

BACKGROUND

Ankle sprains occur very frequently in daily life, but people who do not pay attention to them and do not receive proper diagnosis and treatment are very prone to develop chronic ankle lateral instability (CALI) at a later stage. For CALI where conservative treatment has failed, reconstruction of the lateral collateral ligament of the ankle can achieve satisfactory results, but there are various and controversial ways of ligament reconstruction. While percutaneous reconstruction of ankle lateral ligament (PLCLR) needs to be performed repeatedly under fluoroscopy, total arthroscopic reconstruction of ankle lateral ligament (ALCLR) is increasingly recognized by experts and scholars for its minimally invasive and precise characteristics, and has achieved good clinical results. Therefore, it is imperative that a meta-analysis be performed to provide evidence as to whether there is a difference between ALCLR and PLCLR in the treatment of CALI.

METHODS

We will search articles in 7 electronic databases including Chinese National Knowledge Infrastructure, Wanfang Data, Chinese Scientific Journals Database, Chinese databases SinoMed, PubMed, Embase, and Cochrane Library databases. All the publications, with no time restrictions, will be searched without any restriction of language and status, the time from the establishment of the database to September 2022.We will apply the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials to assess the methodological quality. Risk-of-Bias Assessment Tool for Non-randomized Studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software.

RESULTS

This systematic review will evaluate the functional outcomes and radiographic results of ALCLR in the treatment of CALI.

CONCLUSION

The conclusion of this study will provide evidence for judging whether ALCLR is superior to PLCLR for treatment of CALI.

TRIAL REGISTRATION NUMBER

CRD42022362045.

Return to sports: Rate and time after arthroscopic surgery for chronic lateral ankle instability

BACKGROUND

Arthroscopic surgery for treating ankle instability is increasingly popular. Several studies showed similar functional outcomes to those seen after open surgery, with no increase in complications. The objective of this study was to evaluate the return-to-sports (RTS) rate and time after arthroscopic surgery to treat chronic lateral ankle instability.

HYPOTHESIS

The rate and time of RTS are satisfactory after arthroscopic surgery to treat chronic lateral ankle instability.

MATERIAL AND METHODS

This single-centre retrospective study included patients managed arthroscopically for chronic lateral ankle instability, with no other procedures, between February 2014 and May 2017. We evaluated the time and rate of RTS, as well as factors associated with RTS such as motivation, athletic level before surgery and whether the injury was work-related. Follow-up was at least 1 year.

RESULTS

Of the 40 included patients, 30 (75%) returned to their main sport, after a median of 6 months. Moreover, 22 (55%) patients resumed their main sport at the same or a higher level within 12 months after surgery, their median postoperative follow-up being 29 months (range, 13-61). The AOFAS score improved significantly, from 67 (30-90) before surgery to 88.5 (39-100) at last follow-up (p<0.001). The numerical pain score decreased significantly between these two timepoints, from 6 (0-10) to 1 (0-10) (p<0.001). By multivariate analysis, a high level of motivation before surgery was the main factor significantly associated with RTS at the same or a higher level within 12 months after surgery (odds ratio, 16.47; 95%CI, 3.33-81.20; p=0.007). Persistent pain was more common in patients with work-related injuries (p=0.016).

CONCLUSION

At 12 months, the RTS rate was 75% overall, with 55% of patients returning to the same or a higher level. Median time to RTS was 6 months (4-8). Both the rate of and the time to RTS were independently associated with greater preoperative motivation.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

The L-shaped tunnel technique showed favourable outcomes similar to those of the Y-graft technique in anatomic lateral ankle ligament reconstruction

PURPOSE

To compare the mid- to long-term clinical and radiological outcomes of the confluent L-shaped tunnel technique with the Y-graft technique for anatomic lateral ankle ligament reconstruction.

METHODS

This retrospective study involved 41 patients who underwent lateral ankle ligament reconstruction between 2013 and 2018. Based on the tunnel direction and tendon fixation method at the fibula side, patients were divided into two groups, with 17 patients in the L-shaped tunnel group and 24 patients in the Y-graft group. The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner score, and Karlsson score were evaluated and compared preoperatively and at follow-up. Anterior talar translation and talar tilt at stress radiographs, postoperative sprain recurrence, range of motion (ROM) restriction, sensory disturbance, etc., were also collected and compared.

RESULTS

The mean follow-up times were 72 and 42 months for the L-shaped group and Y-graft group, respectively. The median VAS pain score, Tegner score, AOFAS score, Karlsson score significantly improved from a preoperative level in both groups (all with p < 0.01). No significant difference was found between the two groups regarding the changes from preoperatively to postoperatively except for the VAS pain score reduction (1.58 ± 1.58 in the L-shaped group vs. 2.53 ± 1.29 in the Y-graft group, p = 0.035). The incidence of flexion-extension ROM restriction (≥ 5°) was significantly higher in the Y-graft group (41.2%) than in the L-shaped group (12.5%) (p = 0.035).

CONCLUSIONS

Both the confluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability (CLAI) at mid- to long-term follow-up. The confluent L-shaped tunnel technique resulted in lower rates of flexion-extension ROM restriction, while the Y-graft technique showed better VAS pain reduction. This result could provide further evidence for the surgical treatment of CLAI.

LEVEL OF EVIDENCE

III.

No tunnel widening following arthroscopic anatomical reconstruction of the lateral ankle ligaments

INTRODUCTION

Arthroscopic anatomical reconstruction of the lateral ankle ligaments is an emerging technique for treating chronic ankle instability. One of the known complications of arthroscopic anterior cruciate ligament reconstruction is tunnel widening; this makes revision more complicated. The aim of this study was to look for tunnel widening in the postoperative course of arthroscopic ankle ligament reconstruction. We hypothesized that significant widening of the bone tunnels is present 1 year after anatomical ankle ligament reconstruction.

MATERIALS AND METHODS

Twenty-one patients who underwent arthroscopic anatomical reconstruction of the lateral ankle ligaments with a gracilis graft were included prospectively. A CT-scan with 1-mm thick slices with multiplanar reconstruction was done 1 year after the surgery. The size and shape of the tunnels was analyzed, and the ratio of the preoperative to postoperative diameter was calculated. Based on this ratio, the tunnels were given a grade as described by Struewer. Tunnel widening was defined as a grade III tunnel, thus a ratio ≥ 1.3. The tunnel shape was classified as described by Peyrache as cone type, cavity type, line type.

RESULTS

None of the tunnels had widened 1 year after arthroscopic anatomical reconstruction of the lateral ankle ligaments. At the fibula, 81% of tunnels were grade I and 19% were grade II; 57% were cone type and 43% were line type. At the talus, 86% of tunnels were grade I and 14% were grade II. All were line type. At the calcaneus, 86% of tunnels were grade I and 14% were grade II; 57% were cone type and 43% were line type.

DISCUSSION

The main finding of this study was the absence of tunnel widening 1 year after arthroscopic reconstruction of the lateral ankle ligaments.

LEVEL OF EVIDENCE

IV; retrospective study.

Magnetic Resonance Accuracy in the Diagnosis of Anterior Talo-Fibular Ligament Acute Injury: A Systematic Review and Meta-Analysis

BACKGROUND

The studies about injury to the anterior talo-fibular ligament (ATFL) are focused mainly on chronic symptoms and chronic instability, and the literature about the accuracy of magnetic resonance imaging (MRI) in acute injuries is quite lacking.

METHODS

This systematic review with meta-analysis analyzes the diagnostic accuracy of MRI on acute ATFL injury. Relative studies were retrieved after searching three databases (MEDLINE, SCOPUS, and Cochrane Central Register of Controlled Trails). Eligible studies were summarized. The quality of the included articles was assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were extracted to calculate pooled sensitivity and specificity of MRI.

RESULTS

Seven studies met our inclusion and exclusion criteria. For MRI, the pooled sensitivities and specificity in diagnosing acute ATFL injury were respectively 1.0 (95% CI: 0.58-1) and 0.9 (95% CI: 0.79-0.96). Pooled LR+ and LR- were respectively 10.4 (95% CI: 4.6-23) and 0 (95% CI: 0-0.82).

CONCLUSION

This systematic review with meta-analysis investigated the accuracy of imaging for the diagnosis of acute ATFL injury. Our results demonstrated that MRI shows high diagnostic accuracy in the diagnosis of acute ATFL lesions. These results suggest that routine MRI in the case of suspected ATFL acute injury may be clinically useful, although this is not done in clinical practice due probably to high cost.

Quantitative Evaluation of Ankle Instability Using a Capacitance-Type Strain Sensor

BACKGROUND

Manual evaluation is an important method for assessing ankle instability, but it is not quantitative. Capacitance-type sensors can be used to measure the distance on the basis of the capacitance value. We applied the sensor to the noninvasive device for measuring ankle instability and showed its utility.

METHODS

First, 5 ankles embalmed by Thiel's method were used in an experiment using a cadaver. The capacitance-type sensor was fixed alongside the anterior talofibular ligament (ATFL) of a specially made brace, and the anterior drawer test was performed. The test had been performed for the intact ankle, with the ATFL transected and with both the ATFL and calcaneofibular ligament (CFL) transected. The anterior drawer distance was calculated by the sensor. Intra- and interinvestigator reliability were also analyzed.Next, as a clinical study, a brace with a sensor was fitted to 22 ankles of 20 patients with a history of ankle sprain. An anterior drawer test at a load of 150 N was conducted using a Telos stress device. The anterior drawer distances measured by the sensor and based on radiographic images were then compared.

RESULTS

The mean anterior drawer distances were 3.7 ± 1.0 mm for the intact cadavers, 6.1 ± 1.6 mm with the ATFL transected (P < .001), and 7.9 ± 1.8 mm with the ATFL and CFL transected (P < .001). The intrainvestigator intraclass correlation coefficients (ICCs) were 0.862 to 0.939, and the interinvestigator ICC was 0.815. In the experiments on patients, the mean anterior drawer distance measured by the sensor was 2.9 ± 0.9 mm, and it was 2.7 ± 0.9 mm for the radiographic images. The correlation coefficient between the sensor and the radiographic images was 0.843.

CONCLUSION

We quantitatively evaluated anterior drawer laxity using a capacitance-type sensor and found it had high reproducibility and strongly correlated with stress radiography measurements in patients with ankle instability. Capacitance-type sensors can be used for the safe, simple, and accurate evaluation of ankle instability.

Strain patterns in normal anterior talofibular and calcaneofibular ligaments and after anatomical reconstruction using gracilis tendon grafts: A cadaver study

Background

Inversion ankle sprains, or lateral ankle sprains, often result in symptomatic lateral ankle instability, and some patients need lateral ankle ligament reconstruction to reduce pain, improve function, and prevent subsequent injuries. Although anatomically reconstructed ligaments should behave in a biomechanically normal manner, previous studies have not measured the strain patterns of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) after anatomical reconstruction. This study aimed to measure the strain patterns of normal and reconstructed ATFL and CFLs using the miniaturization ligament performance probe (MLPP) system.

Methods

The MLPP was sutured into the ligamentous bands of the ATFLs and CTLs of three freshly frozen cadaveric lower-extremity specimens. Each ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N m force was applied to the ankle and subtalar joint complex.

Results

The normal and reconstructed ATFLs exhibited maximal strain (100) during supination in three-dimensional motion. Although the normal ATFLs were not strained during pronation, the reconstructed ATFLs demonstrated relative strain values of 16–36. During the axial motion, the normal ATFLs started to gradually tense at 0° plantar flexion, with the strain increasing as the plantar flexion angle increased, to a maximal value (100) at 30° plantar flexion; the reconstructed ATFLs showed similar strain patterns. Further, the normal CFLs exhibited maximal strain (100) during plantar flexion-abduction and relative strain values of 30–52 during dorsiflexion in three-dimensional motion. The reconstructed CFLs exhibited the most strain during dorsiflexion-adduction and demonstrated relative strain values of 29–62 during plantar flexion-abduction. During the axial motion, the normal CFLs started to gradually tense at 20° plantar flexion and 5° dorsiflexion.

Conclusion

Our results showed that the strain patterns of reconstructed ATFLs and CFLs are not similar to those of normal ATFLs and CFLs.

All-inside endoscopic anatomic reconstruction leads to satisfactory functional outcomes in patients with chronic ankle instability

PURPOSE

Ankle sprain is a common injury that can be treated conservatively, though many injured patients do not seek treatment or are not adequately managed, both of which can lead to subsequent chronic ankle instability (CAI). The purpose of this study was to evaluate the functional scores and complication rates of an all-inside anatomic reconstruction technique to treat CAI at a minimum follow-up of 24 months.

METHODS

The authors retrospectively collected the records of 41 patients that underwent all-inside endoscopic anatomic reconstruction of the ATFL and CFL including demographics, complications, satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson score, and ankle activity score (AAS), at a minimum follow-up of 24 months.

RESULTS

The study cohort, comprised 34 patients aged 35.6 ± 10.8 years, were assessed at 48.7 ± 19.0 months. AOFAS scores improved from 60.3 ± 11.9 to 94.3 ± 6.2 postoperatively. Karlsson scores improved from 49.0 ± 10.9 to 87.2 ± 10.1 postoperatively. Thirty-three (97%) patients returned to the same AAS (5.6 ± 3.1) and rated their overall satisfaction ≥ 7. One patient (3%) was reoperated to treat a hematoma, while five patients (15%) were reoperated to remove the cortical fixation device that caused discomfort.

CONCLUSION

The novel all-inside endoscopic technique for anatomic reconstruction of the ATFL and CFL grants satisfactory functional outcomes at a minimum of 24 months, and the improvements in AOFAS and Karlsson scores compared favourably to those reported for other techniques in the literature.

LEVEL OF EVIDENCE

IV.

Hybrid Ankle Reconstruction of Lateral Ligaments

Open anatomic reconstruction of the lateral ligament (AntiRoLL) of the ankle with a gracilis Y graft and the inside-out technique are commonly used and have evolved to minimally invasive surgery, including arthroscopic AntiRoLL (A-AntiRoLL) and percutaneous AntiRoLL procedures. A-AntiRoLL allows assessment and treatment of intra-articular pathologies of the ankle concurrently with stabilization. However, the A-AntiRoLL technique is technically demanding, especially in the process of calcaneofibular ligament reconstruction under subtalar arthroscopy. In contrast, the percutaneous AntiRoLL procedure is a simple concept that does not require the skill of an experienced arthroscopist but requires an extra skin incision to assess and treat intra-articular pathologies of the ankle. This study describes the application of a minimally invasive anatomic reconstruction technique-hybrid AntiRoLL-for chronic instability of the ankle that does not require advanced arthroscopic technique to assess and treat intra-articular pathology simultaneously.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.

Editorial Commentary: Arthroscopic Treatment of Ankle Instability Is the Emerging Gold Standard

Arthroscopic techniques for the treatment of ankle instability are increasing. The possibility of treating concomitant ankle pathology and ankle instability in the same procedure with similar outcomes and minor complications is making foot and ankle surgeons rethink the role of the current gold standard technique, the open Broström-Gould procedure. The improvement of arthroscopic procedures in the ankle joint, as has happened before in other joints, is forcing the evolution of the classic open gold standard techniques toward an arthroscopic approach. A nondistraction and ankle dorsiflexion procedure is the key arthroscopic technique. The anterior talofibular ligament's superior fascicle, an intra-articular structure, is located on the floor of the lateral gutter, and distraction detrimentally narrows the view and access to this space.

Autograft versus allograft tenodesis for chronic ankle instability: a single-center retrospective comparative study

Aim: To compare the outcomes of patients who underwent autograft tenodesis with those who underwent allograft tenodesis for the treatment of chronic mechanical ankle instability. Patients & methods: Ten patients who underwent allograft lateral tenodesis were compared with 15 patients who underwent lateral tenodesis using a split peroneus brevis tendon. Patients were followed up after an average time of 10.5 years. Results: No statistically significant differences concerning American Orthopaedic Foot and Ankle Society and Karlsson-Peterson scores were reported (p = n.s.). A reduced average radiographic anterior talar translation was observed in the autograft group compared with the allograft group (1.4 and 4.0 mm respectively, p < 0.001). Conclusion: Both surgical techniques significantly improved subjective and objective outcomes in patients suffering from chronic ankle instability compared with pre-operatory status. Autograft stabilization provided reduced post-operative anterior talar translation compared with allograft tenodesis.

The ankle ligament reconstruction-return to sport after injury (ALR-RSI) is a valid and reproducible scale to quantify psychological readiness before returning to sport after ankle ligament reconstruction

PURPOSE

Chronic ankle instability is the main complication of ankle sprains and requires surgery if non-operative treatment fails. The goal of this study was to validate a tool to quantify psychological readiness to return to sport after ankle ligament reconstruction.

METHODS

The form was designed like the anterior cruciate ligament-return to sport after injury scale and "Knee" was replaced by the term "ankle". The ankle ligament reconstruction-return to sport after injury (ALR-RSI) scale was filled by patients who underwent ankle ligament reconstruction and were active in sports. The scale was then validated according to the international COSMIN methodology. The AOFAS and Karlsson scores were used as reference questionnaires.

RESULTS

Fifty-seven patients (59 ankles) were included, 27 women. The ALR-RSI scale was strongly correlated with the Karlsson score (r = 0.79 [0.66-0.87]) and the AOFAS score (r = 0.8 [0.66-0.87]). A highly significant difference was found in the ALR-RSI between the subgroup of 50 patients who returned to playing sport and the seven who did not: 68.8 (56.5-86.5) vs 45.0 (31.3-55.8), respectively, p = 0.02. The internal consistency of the scale was high (α = 0.96). Reproducibility of the test-retest was excellent (ρ = 0.92; 95% CI [0.86-0.96]).

CONCLUSION

The ALR-RSI is a valid, reproducible scale that identifies patients who are ready to return to the same sport after ankle ligament reconstruction. This scale may help to identify athletes who will find sport resumption difficult.

LEVEL OF EVIDENCE

III.

The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis

Chronic ankle instability predominantly occurs due to multiple exercise-related diseases. Conservative treatment methods regarding this condition have not effectively improved in recent years, which is why more focus has been put on exploring different novel reconstruction procedures of the lateral ankle ligament for the treatment of chronic ankle instability.

OBJECTIVES

This study aims to obtain the overall effectiveness of various lateral ankle ligament reconstruction methods for chronic ankle ligament instability.

METHODS

We gathered data from PubMed and EMBASE databases using the keywords: ankle, malleolar, and reconstruction. Newcastle - Ottawa quality assessment was carried out for the obtained studies; effect volume combination and image drawing were performed by Stata14, and Excel was used for data statistics.

RESULTS

A total of 12 articles were included in the quantitative analysis by performing full-text reading and data inclusion. Among them, 476 patients (485 ankle joints) were treated. The results showed that the overall valid efficiency of "excellent" was 59% and "good" lateral ligament reconstruction was 26%, I²=87.3%, P = 0.000; the subgroup analysis anatomic reconstruction group I²=0.0%, P = 0.993; the autograft group I²=0.0%, P = 1.000; allograft group I²=0.0%, P = 0.993.

CONCLUSION

Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability.

Outcomes After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for Chronic Ankle Instability: A Systematic Review and Meta-analysis

The purpose of this study was to systematically review the current evidence in the literature to ascertain whether the anatomic ankle ligament reconstruction procedure with allograft resulted in improved patient outcomes after ≥2 years of follow-up. A literature search of Medline, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Clinical studies investigating anatomic lateral ankle ligament reconstruction procedures for chronic ankle instability with a mean of >2 years' follow-up were included. Means were calculated for population size, age, follow-up duration, and postoperative Tegner scores. Pooled estimates were calculated for postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion, return to sports, risk of postoperative instability, and complications. Six clinical trials with 153 patients were included. The pooled estimated mean for the postoperative AOFAS score was 89.4 points (95% confidence interval [CI], 86.0 to 92.9; I² = 88.7%). The pooled proportion of patients who returned to sports after surgery was 80% (95% CI 57.0% to 100%; I² = 88.7%). The pooled total risk of recurrent instability after surgery was 6% (95% CI 1% to 12%; I² = 0%). No rejection was reported. Anatomic lateral ankle ligament reconstruction procedure results in significant improvements in patient function and outcome scores, with low rates of recurrent instability.

Operative Approaches to Ankle and Hindfoot Arthroscopy

The role of arthroscopy in the management of ankle and hindfoot pathology management has increased greatly in recent years with the potential for lower complication rates, faster recovery, improved access, and improved outcomes when compared to open techniques. Procedural variations exist as techniques aim to optimize lesion access, decrease operative time, and improve patient safety. Our goal is to summarize the described approaches and patient positionings common in minimally invasive arthroscopic surgery for anterior, lateral, and posterior ankle pathologies. A survey of pathology organized by arthroscopic approach and a review of recent advances in concomitant lesion management may be useful when planning arthroscopic foot and ankle surgery.

LEVEL OF EVIDENCE

Level V, expert opinion.

Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability

PURPOSE

When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability.

METHODS

Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique.

RESULTS

During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up.

CONCLUSION

Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

3D MRI evaluation of morphological characteristics of lateral ankle ligaments in injured patients and uninjured controls

BACKGROUND

With ultrasonography or 2D magnetic resonance imaging (MRI) of the lateral ankle ligament, it is particularly difficult to show the entire calcaneofibular ligament (CFL). The purpose of this study was to evaluate the morphological characteristics of the lateral ankle ligaments in injured patients and uninjured controls using 3D MRI.

METHODS

A total of 64 ankles of 59 healthy volunteers and lateral ligament injury patients (mean age of 32.4 years) were examined. The 64 ankles included a healthy group of 11 ankles, an acute injury group of 12 ankles that underwent MRI a month after injury, and a chronic injury group of 41 ankles that underwent MRI more than 3 months after injury. Using a 3.0-T MRI system, imaging was done with fast imaging employing steady-state acquisition cycled phases. Oblique sagittal images that most clearly depicted the entire anterior talofibular ligament (ATFL) and CFL were prepared manually and evaluated using a workstation.

RESULTS

In the healthy group, both the ATFL and CFL were clearly and entirely visualized. The mean width in the central portion was 4.0 ± 1.0 mm in the ATFL and 4.8 ± 0.6 mm in the CFL. 3D MRI in the acute injury group showed findings of diffuse swelling with hyperintensity in the ATFL of all patients. The CFL in 7 of 12 ankles showed findings of diffuse swelling with hyperintensity. In the chronic injury group, morphological abnormalities of the ATFL were seen in 19 of 41 ankles. The ligament signal disappeared in 2 ankles, thinned in 4 ankles, and showed swelling in 13 ankles. Morphological abnormalities of the CFL were seen in 17 of 41 ankles. The ligament signal disappeared in 1 ankle, thinned in 2 ankles, and showed swelling in 14 ankles.

CONCLUSION

3D MRI may be a useful modality to visualize both the ATFL and the CFL.

Ultrasound-Guided Ankle Lateral Ligament Stabilization

PURPOSE OF REVIEW

Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

RECENT FINDINGS

To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.

No Difference between Percutaneous and Arthroscopic Techniques in Identifying the Calcaneal Insertion during Ankle Lateral Ligament Reconstruction: A Cadaveric Study

Background. Both percutaneous and arthroscopic techniques have been introduced in anatomic ankle lateral ligaments reconstruction. The purpose of this study was to compare these two techniques in identifying the calcaneal insertion of the calcaneofibular ligament (CFL). Methods. Fifteen fresh-frozen human ankle cadaver specimens were used in this study. Each specimen was tested in three stages. For stage 1, each specimen was evaluated under arthroscopy. After debridement was performed, the insertion of the CFL on the calcaneus was identified, and a 1.5mm Kirschner wire was drilled at the center of the insertion. For stage 2, a percutaneous technique was used to identify the center of the insertion of the CFL. A second 1.5 mm Kirschner wire was drilled through the skin marker. For stage 3, the ankle was dissected, the footprint of the CFL was identified under direct vision, and the distances between the center of the CFL insertion on the calcaneus and the two Kirschner wires were measured, respectively. Results. In the arthroscopic technique group, the mean distance from the Kirschner wire to the center of the CFL insertion in the calcaneus was 3.4 ± 1.3 mm. In the percutaneous technique group, the mean distance from the Kirschner wire to the center of the CFL insertion was 3.2 ± 1.4 mm. No significant difference was found between the two groups. Conclusion. No difference in identifying the calcaneal insertion of the CFL was found between the percutaneous and the arthroscopic ankle lateral ligaments reconstruction technique. Both techniques can be used during anatomic ligaments reconstruction in treatment of chronic ankle instability.

Kinematics and Laxity of the Ankle Joint in Anatomic and Nonanatomic Anterior Talofibular Ligament Repair: A Biomechanical Cadaveric Study

BACKGROUND

Although it is crucial to accurately identify the anterior talofibular ligament (ATFL) attachment site, it may not be feasible to fully observe the ATFL attachment site during arthroscopic surgery. As a result, the repair position might often be an unintentionally nonanatomic ATFL attachment site.

HYPOTHESIS

Anatomic ATFL repair restores kinematics and laxity to the ankle joint, while nonanatomic ATFL repair does not.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven normal fresh-frozen human cadaveric ankles were used. The ankles were tested with a 6 degrees of freedom robotic system. The following ankle states were evaluated: intact, ATFL injured, ATFL anatomic repair, and ATFL nonanatomic repair. The ATFL nonanatomic repair position was set 8 mm proximal from the center of the ATFL attachment site of the fibula. For each state, a passive plantarflexion (PF)-dorsiflexion (DF) kinematics test and a multidirectional loading test (anterior forces, inversion moment, and internal rotation moment) were performed.

RESULTS

The kinematics and laxity of the anatomic repair were not significantly different from those of the intact state. In nonanatomic repair, the inversion-eversion angle showed significant inversion (3.0°-3.4°) from 5° to 15° of DF, and the internal rotation-external rotation angle showed significant internal rotation (2.0°) at neutral PF-DF versus the intact state. In addition, internal rotation laxity was significantly increased (5.5°-5.8°) relative to the intact state in the nonanatomic repair at 30° and 15° of PF. There were no significant differences in anterior-posterior translation between the repairs.

CONCLUSION

Although the anatomic ATFL repair state did not show significant differences in kinematics and laxity relative to the intact state, the nonanatomic ATFL repair state demonstrated significant inversion and internal rotation kinematics and internal rotation laxity when compared with the intact state.

CLINICAL RELEVANCE

Nonanatomic repair alters kinematics and laxity from the intact condition.

Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases

INTRODUCTION

Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results.

HYPOTHESIS

We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately.

MATERIALS AND METHODS

Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs.

RESULTS

The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability.

DISCUSSION

Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination.

LEVEL OF EVIDENCE

IV, Case-series.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal

BACKGROUND

Anatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström-Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability.

METHODS

We reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months.

RESULTS

The mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture.

CONCLUSIONS

Chronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients

BACKGROUND

Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques.

MATERIAL AND METHODS

Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports.

RESULTS

The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients.

DISCUSSION

Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery.

CONCLUSION

Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.

Arthroscopic Treatment of Ankle Instability - Allograft/Autograft Reconstruction

Inversion ankle sprains represent one of the most common traumatic injuries in the active sports population. Although most respond well to conservative treatment, some hide important lesions. Lateral ankle ligament injuries occur in more than 80% of all ankle sprains, with one-third of these developing chronic ankle instability (CAI). Lateral ankle ligament repair or reconstruction procedures aim to restore normal ankle anatomy and function in patients with CAI. Arthroscopic reconstruction techniques allow the surgeon to reach surgery objectives with minimal soft tissue injury. When the indications and surgical steps are respected, this arthroscopic technique seems to be safe and reproducible.

Ankle Arthroscopic Surgery

Ankle arthroscopy is a diagnostic and therapeutic surgical procedure which was first attempted on cadavers by Dr Burman in 1931 and first successfully described in patients by Dr Takagi in 1939. Two general approaches to ankle arthroscopy currently exist: (1) anterior ankle arthroscopy and (2) posterior ankle arthroscopy. The indications for ankle arthroscopy have expanded as increased experience has been obtained treating various pathologic entities and as the surgical results have been reported in the literature. There has been significant progress in ankle arthroscopic surgery over the past decades, notably allowing surgical procedures to be performed with fewer complications and with quicker return to work and play. We anticipate that expanding indications for arthroscopic ankle surgical procedures combined with further development of biomedical devices to enhance these procedures will result in improved patient outcomes in the future.

Arthroscopic reconstruction of the lateral ankle ligaments: Radiological evaluation and short-term clinical outcome

PURPOSE

The purpose of this study was to describe the positioning of bone tunnels of arthroscopic anatomical reconstruction of lateral ankle ligaments (AAR-LAL) and identify radiological measurements associated with short-term clinical outcome one year after surgery.

MATERIALS AND METHODS

A total of 61 patients were included in this IRB-approved retrospective study. There were 52 men and 9 women, with a mean age of 36.3 ± 10.8 (SD) years. AAR-LAL was performed to treat chronic instability secondary to strain sequelae after failure of conservative treatment. Good short-term clinical outcome was defined by Karlsson-score≥80 (n=40) one year after surgery. Sixteen radiological measurements were studied to characterize the positionings of fibular, talar and calcaneal tunnels (FT, TT and CT, respectively). Feasibility and inter-observer agreement were calculated for each measurement. Receiver operating characteristic curves were used to identify optimal thresholds for measurements associated with outcome at univariate analysis. A binary logistic regression was used to identify independent predictors.

RESULTS

Two measurements were associated with good outcome: distance from the proximal FT entrance to the distal end of the fibula on anteroposterior (AP) view (called 'AP distal FT', P=0.005), and the ratio between the distance from TT entrance to the talo-navicular joint and the talus length on lateral view (P=0.009). Optimal thresholds were of >35mm and<0.445, respectively. At multivariate anlysis, only 'AP distal FT'>35mm remained independent predictor of good outcome (P=0.002).

CONCLUSION

Radiological evaluation of bone tunnels following AAR-LAL is feasible, reproducible, and helps predict short-term outcome after reconstruction of lateral ankle ligaments.

The distal margin of the lateral malleolus visible under ankle arthroscopy (articular tip) from the anteromedial portal, is separate from the ATFL attachment site of the fibula: A cadaver study

PURPOSE

The purpose of this study was to evaluate the relationship between the lateral malleolus view under ankle arthroscopy and the anterior talofibular ligament (ATFL) attachment site.

METHODS

Seven normal ankles from Thiel-embalmed cadavers were investigated. Ankle arthroscopy was performed using a 2.7 mm-diameter, 30-degree, oblique-viewing endoscope. An antero-medial portal (AM), a medial midline portal (MML), and an antero-central portal (AC) were created in order, and the ankle arthroscope was inserted. The lateral malleolus was visualized as distally as possible, and the site that appeared to be the distal margin was marked with a 1.5 mm-diameter K-wire. Visualization with arthroscopy was carried out from all portals to mark the distal margin, and the ankle was subsequently exposed to directly measure the distance from the center of the ATFL attachment site at the fibula to each marking.

RESULTS

The distances from the ATFL attachment site to the markings made under arthroscopy from the AM, MML, and AC portals were 10.4 ± 2.6 mm, 7.4 ± 1.9 mm, and 7.3 ± 1.9 mm, respectively. Compared to markings made from the MML or AC portal, the marking made from the AM portal was significantly further away from the ATFL attachment site.

CONCLUSIONS

A typical ankle arthroscopy portal may not allow complete visualization of the tip of the lateral malleolus, indicating that it may not be feasible to thoroughly observe the ATFL attachment site. It is necessary to perform arthroscopic surgeries with the understanding that the distal margin of the lateral malleolus that appears under ankle arthroscopy is 7-10 mm proximal to the ATFL attachment site.

An Ultrasound Classification of Anterior Talofibular Ligament (ATFL) Injury

Background:

To develop a classification of ATFL injury based on the ultrasonography.

Methods:

The ultrasound images of 560 cases that had chronic ankle instability were studied from May 2012 to May 2015. All the patients accepted ultrasonography to type the ATFL injury.

Results:

The ATFL injuries could be divided into six subtypes based on ultrasound imaging: I: Intact ligament; II: Injury at the fibular side; III:Injury at the talar side; IV: Tear at the midsubstance; V:Ligament absorbed; VI:Combined injury.

Conclusion:

Ultrasound could be used to evaluate and type the injury of ATFL. This kind of classification could be helpful in the preoperative decision of ATFL procedure.

All Arthroscopic Remnant-Preserving Technique to Reconstruct the Lateral Ankle Ligament Complex

Arthroscopic lateral ankle ligament reconstruction has been recently advocated. But this technique has not been popularized because of the technical complexity and potential iatrogenic injury. Because the talocalcaneal and calcaneofibular ligaments are extra-articular structures, how to efficiently view and address them is a difficult task. Limited dissection outside the capsule to form a working space is required, but aggressive dissection is harmful for tissue healing although it is helpful for visualization and instrumentation. Because almost the entire talar body is covered by articular cartilage, it is very difficult to safely make a bone tunnel without damaging the cartilage. The remnants of the lateral ankle ligament have proprioceptive sensors that are important for functional stability, but it is difficult to perform anatomical reconstruction arthroscopically while preserving them because of the narrow working space. Furthermore, how to properly tension the reconstructed ligaments in such a narrow working space is also a very difficult task. We have designed a technique that preserves the remnants of lateral ankle ligaments, and all of the above-mentioned problems have been successfully addressed. We have used this technique clinically, and only minor complications occurred.