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Beaudet P, Giunta JC, Agu C, van Rooij F, Saffarini M, Nogier A. Accuracy of Cutaneous Landmarks Compared to Ultrasound to Locate the Calcaneal Footprint of the CFL. J Foot Ankle Surg 2024; 63:353-358. [PMID: 38218343 DOI: 10.1053/j.jfas.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/05/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
The purpose was to determine the accuracy of the techniques of Lopes et al. and Michels et al., compared to ultrasound, to locate the center of the calcaneal footprint of the CFL in healthy volunteers. The authors recruited 17 healthy adult volunteers at 1 center with no current ankle pathologies and no previous surgical antecedents on either ankle. The authors recorded the age, sex, height, BMI, and ankle side for each volunteer. Measurements were made on both ankles of the 17 volunteers to increase the sample size and ensure less dispersion of data, independently by 2 surgeons: 1 senior surgeon with 15 years' experience and 1 junior with 3 years' experience. The location of the center of the calcaneal footprint of the CFL was determined by each surgeon using 3 methods: (1) the cutaneous technique of Lopes et al., (2) the cutaneous technique of Michels et al., and (3) ultrasound imaging. The 17 volunteers (34 feet) had a mean age of 26.3 ± 8.7 and a BMI of 21.7 ± 2.9. The Michels point was significantly closer (4.6 ± 3.7 mm) than the Lopes point (11.1 ± 5.4 mm) to the true center of the calcaneal footprint of the CFL determined by ultrasound, notably in the vertical direction. The Michels point was located significantly closer to the true center of the calcaneal footprint of the CFL and demonstrated less dispersion than the Lopes point, indicated by significantly lower absolute mean deviation from the true center of the calcaneal footprint of the CFL, and that ultrasound is therefore preferred to locate the footprint the CFL.
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Guyonnet C, Vieira TD, Wackenheim FL, Lopes R. Arthroscopic Modified Broström Repair with Suture-Tape Augmentation of the Calcaneofibular Ligament for Lateral Ankle Instability. Arthrosc Tech 2024; 13:102887. [PMID: 38584641 PMCID: PMC10995735 DOI: 10.1016/j.eats.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/04/2023] [Indexed: 04/09/2024] Open
Abstract
Surgical repair of acute or chronic lateral instability of the ankle may be unsuccessful in the presence of associated anterior fibulotalar ligament (AFTL) and calcaneofibular ligament (CFL) injury. This Technical Note presents an arthroscopic double-row repair technique of the AFTL associated with suture tape augmentation of the CFL. The patient is in the supine position with the ankle hanging over the edge of the surgical table. The anteromedial portal is created inside the anterior tibial tendon, and the anterolateral portal is created under arthroscopic control. The ATFL is released from the capsule with a beaver blade. The calcaneal tunnel is created percutaneously at the footprint of the CFL. A soft anchor is impacted at the tip of the lateral malleolus with thread and tape. With the foot in the neutral position, the tape is then passed into the calcaneal tunnel and attached with an interference screw to strengthen the CFL. The ATFL is grasped with a Mini-Scorpion suture passer and pressed against the anchor with the foot in neutral position. A knotless anchor is impacted 5 mm above with the threads of the soft anchor, creating double-row fixation. This technique is indicated in proximal tears of the AFTL associated with a stretched CFL.
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Affiliation(s)
- Clément Guyonnet
- Institut Médical Pérignat, Pérignat-lès-Sarliève, France
- Hôpital Privé la Châtaigneraie, Beaumont, France
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Beldame J, Charpail C, Sacco R, Lalevée M, Duparc F. Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions. Surg Radiol Anat 2023:10.1007/s00276-023-03189-6. [PMID: 37369810 DOI: 10.1007/s00276-023-03189-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.
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Affiliation(s)
- Julien Beldame
- Clinique Megival, 1328 Avenue maison blanche, 76550, Saint aubin sur scie, France.
- , Clinique Blomet, Ramsay Santé, 136 Rue Blomet, 75015, Paris, France.
| | - Christel Charpail
- SOS pied/cheville, Clinique Merignac, 4 rue Georges Negrevergne, 33700, Merignac, France
| | - Riccardo Sacco
- Department of Orthopedic Surgery, Rouen University Hospital, 37 Boulevard Gambetta, 76000, Rouen, France
| | - Matthieu Lalevée
- Department of Orthopedic Surgery, Rouen University Hospital, 37 Boulevard Gambetta, 76000, Rouen, France
| | - Fabrice Duparc
- Department of Orthopedic Surgery, Rouen University Hospital, 37 Boulevard Gambetta, 76000, Rouen, France
- Laboratory of Anatomy, Faculty of Medicine-Pharmacy, Rouen Normandy University, 22 boulevard Gambetta, 76183, Rouen, France
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Chen L, Xie X, Cao P, Guo Q, Jiang D, Jiao C, Pi Y. Arthroscopic and Open Procedures Result in Similar Calcaneal Tunnels for Anatomical Reconstruction of Lateral Ankle Ligaments. Arthrosc Sports Med Rehabil 2023; 5:e687-e694. [PMID: 37388872 PMCID: PMC10300538 DOI: 10.1016/j.asmr.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 03/29/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose The purpose of this study was to validate the accuracy and reliability of arthroscopic markers of distal insertion of the calcaneofibular ligament (CFL), and to compare the calcaneus bone tunnels of the CFL that were made under arthroscopy and open procedures. Methods Fifty-seven patients who underwent lateral ankle ligament reconstruction procedures were enrolled and divided into open (n = 24) and arthroscopic groups (n = 33). Lateral ankle radiography was performed postoperatively, and the calcaneus bone tunnels referenced to several landmarks, including the subtalar joint, calcaneus superior edge, fibular tip, angulation with fibula axis, cross point of the fibular and tangential line of the fibular obscure tubercle cross point of the tangential lines of the talar posterior edge and deepest point of the subtalar joint, and cross point of the fibular axis and perpendicular line across fibular tip. These results were compared between the two groups. Results No significant intergroup differences were observed between the parameters. When the bone tunnels of the CFL were referenced to the cross point of tangential lines of the talar posterior edge and deepest point of the subtalar joint, and the cross point of the fibular axis and perpendicular line across fibular tip, the coefficient variations were very high, which indicated that the locations of the bone tunnels were scattered over a large area in both groups. Conclusions Arthroscopic and open procedures achieved similar results for calcaneus bone tunnel making of the CFL. However, large variations were observed in both groups. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Linxin Chen
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Xin Xie
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Peng Cao
- Orthopedics Dept. 1, CangZhou Hospital of Integrated TCM-WM, Cangzhou City, Hebei Province, People’s Republic of China
| | - Qinwei Guo
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Dong Jiang
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Chen Jiao
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Yanbin Pi
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
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Ghasemi SA, Murray BC, Lipphardt M, Yin C, Shaffer G, Raphael J, Vaupel Z, Fortin P. Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery. Surg Radiol Anat 2023:10.1007/s00276-023-03162-3. [PMID: 37198438 DOI: 10.1007/s00276-023-03162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Grade III ankle sprains that fail conservative treatment can require surgical management. Anatomic procedures have been shown to properly restore joint mechanics, and precise localization of insertion sites of the lateral ankle complex ligaments can be determined through radiographic techniques. Ideally, radiographic techniques that are easily reproducible intraoperatively will lead to a consistently well-placed CFL reconstruction in lateral ankle ligament surgery. PURPOSE To determine the most accurate method to locate the calcaneofibular ligament (CFL) insertion radiographically. METHODS MRIs of 25 ankles were utilized to identify the "true" insertion of the CFL. Distances between the true insertion and three bony landmarks were measured. Three proposed methods (Best, Lopes, and Taser) for determining the CFL insertion were applied to lateral ankle radiographs. X and Y coordinate distances were measured from the insertion found on each proposed method to the three bony landmarks: the most superior point of the postero-superior surface of the calcaneus, the posterior most aspect of the sinus tarsi, and the distal tip of the fibula. X and Y distances were compared to the true insertion found on MRI. All measurements were made using a picture archiving and communication system. The average, standard deviation, minimum, and maximum were obtained. Statistical analysis was performed using repeated measures ANOVA, and a post hoc analysis was performed with the Bonferroni test. RESULTS The Best and Taser techniques were found to be closest to the true CFL insertion when combining X and Y distances. For distance in the X direction, there was no significant difference between techniques (P = 0.264). For distance in the Y direction, there was a significant difference between techniques (P = 0.015). For distance in the combined XY direction, there was a significant difference between techniques (P = 0.001). The CFL insertion as determined by the Best method was significantly closer to the true insertion compared to the Lopes method in the Y (P = 0.042) and XY (P = 0.004) directions. The CFL insertion as determined by the Taser method was significantly closer to the true insertion compared to the Lopes method in the XY direction (P = 0.017). There was no significant difference between the Best and Taser methods. CONCLUSION If the Best and Taser techniques can be readily used in the operating room, they would likely prove the most reliable for finding the true CFL insertion.
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Affiliation(s)
- S Ali Ghasemi
- Department of Orthopaedic Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA.
| | | | - Matthew Lipphardt
- Royal Oak Beaumont Department of Orthopaedic Surgery, Royal Oak, MI, USA
| | - Clark Yin
- Royal Oak Beaumont Department of Orthopaedic Surgery, Royal Oak, MI, USA
| | - Gene Shaffer
- Department of Orthopaedic Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - James Raphael
- Department of Orthopaedic Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Zachary Vaupel
- Royal Oak Beaumont Department of Orthopaedic Surgery, Royal Oak, MI, USA
| | - Paul Fortin
- Royal Oak Beaumont Department of Orthopaedic Surgery, Royal Oak, MI, USA
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Michels F, Vereecke E, Matricali G. Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice. Front Bioeng Biotechnol 2023; 11:1047134. [PMID: 36970618 PMCID: PMC10036586 DOI: 10.3389/fbioe.2023.1047134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 02/28/2023] [Indexed: 03/12/2023] Open
Abstract
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.
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Affiliation(s)
- Frederick Michels
- Orthopaedic Department AZ Groeninge, Kortrijk, Belgium
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
- ESSKA-AFAS Ankle Instability Group, Kortrijk, Belgium
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
- EFAS European Foot and Ankle Society, Brussels, Belgium
- *Correspondence: Frederick Michels,
| | - Evie Vereecke
- Department Development and Regeneration, Faculty of Medicine, University of Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Giovanni Matricali
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Orthopaedics, Foot and Ankle Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Guyonnet C, Lopes R. Re-injury after arthroscopic anatomical reconstruction of the lateral ankle ligaments treated by a new arthroscopic anatomical reconstruction: A case report. Int J Surg Case Rep 2023; 105:107994. [PMID: 37003231 PMCID: PMC10091021 DOI: 10.1016/j.ijscr.2023.107994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Lateral ankle ligament reconstruction failures are increasingly frequent. To our knowledge no reports of using a new arthroscopic anatomical reconstruction with a gracilis autograft to treat an ankle re-injury have been described. CASE PRESENTATION A 19-year-old man presented with a right ankle injury resulting in isolated lateral ankle instability. The clinical examination showed significant laxity. The MRI confirmed a grade 3 tear of the lateral ligament complex. Arthroscopic anatomical reconstruction with a gracilis autograft was performed and the patient was able to return to all of his activities. Eighteen months after the primary reconstruction, he had another high-energy injury. Despite rehabilitation, he experienced isolated lateral instability. Arthrography confirmed graft failure. The patient underwent a new anatomical reconstruction with the controlateral gracilis autograft, with no difficulties. At 6 months, he had returned to all of his activities, with no limitations or discomfort. CLINICAL DISCUSSION Articular hypermobility, hindfoot varus and/or excess weight should be looked for or treated to explain the graft failure. Other therapeutic options are possible for revision surgery such as non-anatomical tenodesis, allografts or artificial ligaments. CONCLUSION Arthroscopic anatomical reconstruction of the lateral ligaments of the ankle with a new arthroscopic anatomical reconstruction procedure seems to be feasible. Other studies are needed to define the therapeutic strategy for ligament reconstruction graft failures.
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Needle arthroscopy in anatomical reconstruction of the lateral ankle: a report of three cases with a parallel comparison to the standard arthroscopy procedure. J Exp Orthop 2022; 9:75. [PMID: 35907091 PMCID: PMC9339066 DOI: 10.1186/s40634-022-00510-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study evaluates the use of the needle arthroscopy in anatomical reconstruction of the lateral ankle. We hypothesized that the needle arthroscopy would allow anatomical reconstruction to be performed under arthroscopy. Methods Three patients underwent treatment of chronic ankle instability. The comparative procedure was performed in the following four steps: 1) anteromedial articular exploration (medial/lateral gutter/anterior chamber/syndesmosis); 2)creation of the talar tunnel via the anteromedial arthroscopic approach; 3) anterolateral fibular tunneling; and 4) positioning of the graft by the anteromedial arthroscopic approach. For each of these steps, the planned procedure using the needle arthroscope was compared to the standard arthroscope. For each step, the planned procedure using the needle arthroscopy was compared to the standard arthroscope and the act was classified based on level of difficulty: facilitated, similar, complicated and impossible. Results The exploration of the medial and lateral gutter, the creation of the tunnel of the talus and graft positioning were not accomplished using the needle arthroscope. While the syndesmosis visualization was facilitated by the needle arthroscope in comparison to the standard arthroscope. Conclusion The anatomical reconstruction of the lateral ankle, using the needle arthroscopy-only approach, was impossible in all three cases, regarding: ankle joint exploration, creation of the tunnel of the talus and graft positioning. The needle arthroscope should not be considered as a "mini arthroscope" but as a new tool with which it is necessary to rethink procedures to take advantage of the benefits of this instrument.
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Lopes R, Andrieu M, Molinier F, Colin F, Morin V. PT4: New arthroscopic technique for isolated reconstruction of the anterior talofibular ligament using a quadrupled plantaris tendon. Orthop Traumatol Surg Res 2021; 107:102995. [PMID: 34198006 DOI: 10.1016/j.otsr.2021.102995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/01/2020] [Accepted: 03/11/2020] [Indexed: 02/03/2023]
Abstract
The strategy for surgical treatment of chronic ankle instability is becoming increasingly refined. In instances of isolated symptomatic non-repairable anterior talofibular ligament (ATFL) injury, there is a surgical indication for isolated ATFL reconstruction. However, we feel that the typical gracilis tendon graft is not always appropriate. Interest in using the plantaris tendon as a graft has picked up since a biomechanics study found the tensile strength of a quadrupled plantaris tendon is comparable to that of the ATFL. Here, we describe an original arthroscopic technique for isolated ATFL reconstruction using a quadrupled plantaris tendon (PT4) graft.
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Affiliation(s)
- Rony Lopes
- Clinique Brétéché, 3, rue de la Béraudière, 44000 Nantes, France; Santé Atlantique, Avenue Claude Bernard, 44800 Saint-Herblain, France.
| | - Mickaël Andrieu
- Clinique du Pont de Chaume, 330 Avenue Marcel Unal, 82017 Montauban cedex, France
| | | | - Fabrice Colin
- Clinique Mutualiste Catalane, 60, rue Louis Mouillard, 66000 Perpignan, France
| | - Vincent Morin
- Clinique Médipôle de Savoie, 300, Avenue des Massettes, 73190 Challes-les-Eaux, France
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Pereira BS, Andrade R, Espregueira-Mendes J, Marano RPC, Oliva XM, Karlsson J. Current Concepts on Subtalar Instability. Orthop J Sports Med 2021; 9:23259671211021352. [PMID: 34435065 PMCID: PMC8381447 DOI: 10.1177/23259671211021352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/23/2021] [Indexed: 12/19/2022] Open
Abstract
Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.
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Affiliation(s)
- Bruno S. Pereira
- Facultad de Medicina, University of Barcelona, Casanova, 143, 08036
Barcelona, Spain
- Clínica Espregueira - FIFA Medical Centre of Excellence, Porto,
Portugal
- Dom Henrique Research Centre, Porto, Portugal
- Hospital Privado de Braga, Lugar da Igreja Nogueira, Braga,
Portugal
| | - Renato Andrade
- Clínica Espregueira - FIFA Medical Centre of Excellence, Porto,
Portugal
- Dom Henrique Research Centre, Porto, Portugal
- Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports,
University of Porto, Porto, Portugal
- Porto Biomechanics Laboratory (LABIOMEP), University of Porto,
Porto, Portugal
| | - João Espregueira-Mendes
- Clínica Espregueira - FIFA Medical Centre of Excellence, Porto,
Portugal
- Dom Henrique Research Centre, Porto, Portugal
- School of Medicine, Minho University, Braga, Portugal
- 3B’s–PT Government Associate Laboratory, Braga/Guimarães,
Portugal
- 3B’s Research Group– Biomaterials, Biodegradables and Biomimetics,
University of Minho, Headquarters of the European Institute of Excellence on Tissue
Engineering and Regenerative Medicine, Barco, Guimarães, Portugal
| | | | - Xavier Martin Oliva
- Facultad de Medicina, University of Barcelona, Casanova, 143, 08036
Barcelona, Spain
- Orthopedic Surgery Department, Clínica Ntra. Sra. Del Remei,
Barcelona, Spain
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, Sahlgrenska
University Hospital, Gothenburg University, Gothenburg, Sweden
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Michels F, Matricali G, Wastyn H, Vereecke E, Stockmans F. A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity. Knee Surg Sports Traumatol Arthrosc 2021; 29:1325-1331. [PMID: 32613335 DOI: 10.1007/s00167-020-06134-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/26/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. METHODS The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. RESULTS For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. CONCLUSION Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.
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Affiliation(s)
- Frederick Michels
- Orthopaedic Department, AZ Groeninge, President Kennedylaan 4, 8500, Kortrijk, Belgium. .,GRECMIP-MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France. .,ESSKA-AFAS Ankle Instability Group, Luxembourg, Luxembourg. .,Institute of Orthopaedic Research and Training, KU Leuven, Leuven, Belgium.
| | - Giovanni Matricali
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Orthopaedics, Foot and Ankle Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Institute of Orthopaedic Research and Training, KU Leuven, Leuven, Belgium
| | - Heline Wastyn
- Department Development and Regeneration, Faculty of Medicine, University of Leuven Campus Kortrijk, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium
| | - Evie Vereecke
- Department Development and Regeneration, Faculty of Medicine, University of Leuven Campus Kortrijk, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium
| | - Filip Stockmans
- Orthopaedic Department, AZ Groeninge, President Kennedylaan 4, 8500, Kortrijk, Belgium.,Department Development and Regeneration, Faculty of Medicine, University of Leuven Campus Kortrijk, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium
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Kakegawa A, Mori Y, Tsuchiya A, Sumitomo N, Fukushima N, Moriizumi T. Independent Attachment of Lateral Ankle Ligaments: Anterior Talofibular and Calcaneofibular Ligaments - A Cadaveric Study. J Foot Ankle Surg 2019; 58:717-722. [PMID: 31130481 DOI: 10.1053/j.jfas.2018.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 02/03/2023]
Abstract
Anatomic knowledge of lateral ligaments around the lateral malleolus is important for repair or reconstruction of ankle instability. The detailed structure of the connective fibers between the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is unknown. To clarify the anatomic structure of ATFL and CFL and the connective fiber between the 2 ligaments, the lateral ligament was dissected in 60 ankles of formalin-fixed cadavers, and the distance was measured between bony landmarks and fibular attachment of ATFL and CFL using a digital caliper. All ankles had connective fibers between ATFL and CFL. The structure of connective fibers consisted of a thin fiber above the surface layer of ATFL and CFL; it comprised thin fibrils of the surface layer covering the lower part of ATFL and the front part of CFL. Both ATFL and CFL were independent fibers, and both attachments of the fibula were isolated. Single bands of ATFL were noted in 14 of 60 (23.3%) ankles, double bands that divided the superior and inferior bands were observed in 42 of 60 (70.0%) ankles, and multiple bands were observed in 4 of 60 (6.7%) ankles. A cord-like and a flat and fanning type of CFL was noted in 22 (36.7%) and 38 (63.3%) of the 60 ankles, respectively. Distances between ATFL/CFL and articular and inferior tips of the fibula were 4.3 ± 1.1 mm/7.6 ± 1.6 mm and 14.3 ± 1.9 mm/7.4 ± 1.7 mm, respectively (mean ± standard deviation). The results of this study suggest that knowledge of more anatomic structures of ATFL, CFL, and connective fiber will be beneficial for surgeons in the repair or reconstruction of the lateral ligament of the ankle.
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Affiliation(s)
- Akira Kakegawa
- Associate Professor, Faculty of Health Care, Teikyo Heisei University, Tokyo, Japan; Lecturer, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan.
| | - Yusuke Mori
- Orthopedic Surgeon, Toyohashi Ezaki Orthopedic Hospital, Aichi, Japan
| | | | - Norimi Sumitomo
- Technological Assistant, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
| | - Nanae Fukushima
- Professor, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
| | - Tetsuji Moriizumi
- Professor, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
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No Difference between Percutaneous and Arthroscopic Techniques in Identifying the Calcaneal Insertion during Ankle Lateral Ligament Reconstruction: A Cadaveric Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2128960. [PMID: 30834256 PMCID: PMC6375008 DOI: 10.1155/2019/2128960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/07/2019] [Accepted: 01/17/2019] [Indexed: 11/17/2022]
Abstract
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.
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Lopes R, Andrieu M, Cordier G, Molinier F, Benoist J, Colin F, Thès A, Elkaïm M, Boniface O, Guillo S, Bauer T. Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients. Orthop Traumatol Surg Res 2018; 104:S199-S205. [PMID: 30245066 DOI: 10.1016/j.otsr.2018.09.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/03/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Ronny Lopes
- Polyclinique de l'atlantique (PCNA), avenue Claude-Bernard, 44800 Saint-Herblain, France
| | - Michael Andrieu
- Clinique Pont-de-Chaume, 330, avenue Marcel-Unal, 82000 Montauban, France
| | - Guillaume Cordier
- Clinique du Sport Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France
| | - François Molinier
- Clinique des Cèdres, route de Mondonville, 31700 Cornebarrieu, France
| | - Jonathan Benoist
- CHP Saint-Grégoire, 7, boulevard de la Boutière, 35760 Saint-Grégoire, France
| | - Fabrice Colin
- Clinique Mutualiste Catalane, 60, rue Louis-Mouillard, 66000 Perpignan, France
| | - André Thès
- Hôpital privé d'Eure-et-Loir, 2, rue Roland-Buthier, 28300 Mainvilliers, France; Service de chirurgie orthopédique et traumatologique, CHU Ambroise-Paré, AP-HP, groupe hospitalier universitaire Paris Île-de-France Ouest, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Marc Elkaïm
- Clinique de Tournan, 2, rue Jules-Lefebvre, 77220 Tournan-en-Brie, France
| | - Olivier Boniface
- Clinique Générale-Annecy, 4, chemin de la Tour-la-Reine, 74000 Annecy, France
| | - Stéphane Guillo
- Clinique du Sport Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France
| | - Thomas Bauer
- Service de chirurgie orthopédique et traumatologique, CHU Ambroise-Paré, AP-HP, groupe hospitalier universitaire Paris Île-de-France Ouest, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
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- 15, rue Ampère, 92500 Rueil Malmaison, France
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Mizia E, Pękala PA, Chomicki-Bindas P, Marchewka W, Loukas M, Zayachkowski AG, Tomaszewski KA. Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study. Clin Anat 2018; 31:870-877. [PMID: 29737558 DOI: 10.1002/ca.23205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 04/30/2018] [Indexed: 12/19/2022]
Abstract
When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. The study involved 40 healthy volunteers (n = 80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. Clin. Anat. 31:870-877, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Ewa Mizia
- Department of Anatomy, Jagiellonian University Medical College, Poland
| | - Przemysław A Pękala
- Department of Anatomy, Jagiellonian University Medical College, Poland.,International Evidence-Based Anatomy Working Group, Krakow, Poland
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada
| | | | - Krzysztof A Tomaszewski
- Department of Anatomy, Jagiellonian University Medical College, Poland.,International Evidence-Based Anatomy Working Group, Krakow, Poland
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