Clinical outcomes of concurrent surgery with weight bearing after modified lasso-loop stitch arthroscopic ankle stabilization

All-inside arthroscopic procedures for chronic lateral ankle instability: evidence-based clinical practice guidelines

BACKGROUND

All-inside arthroscopic procedures are now frequently employed to manage chronic lateral ankle instability (CLAI) with satisfactory functional outcomes. Currently, no evidence-based guidelines exist for all-inside arthroscopic procedures for CLAI. Many surgical decisions remain uncertain and challenging.

SOURCES OF DATA

Published scientific literature in PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

AREAS OF AGREEMENT

All-inside arthroscopic repair and reconstruction procedures are reliable treatments for CLAI.

AREAS OF CONTROVERSY

The all-inside arthroscopic procedures for CLAI present significant challenges, particularly in the following aspects.

GROWING POINTS

Given the lack of guidelines for the all-inside arthroscopic procedures for CLAI, this evidence-based clinical practice guideline provides 11 recommendations to address the controversy.

AREAS TIMELY FOR DEVELOPING RESEARCH

In patients with CLAI undergoing all-inside arthroscopic procedures, comparative studies are urgently needed to establish the optimal timing for weight-bearing, as well as return to work and sports.

Directly measured strain patterns of the anterior talofibular and calcaneofibular ligaments after isolated ATFL repair in a combined ATFL and CFL injury: A cadaver study

BACKGROUND

Even though 20% of chronic lateral ankle instability results from a combined anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, only the ATFL is sutured using arthroscopic ligament repair techniques. Although some biomechanical and clinical studies have proved that isolated ATFL repair yields excellent results, previous biomechanical studies were performed using systems that only allow indirect estimations. The purpose of this study was to clarify strain patterns by directly measuring repaired ATFL and CFL strain patterns on cadaveric models that underwent isolated ATFL repair of a combined ATFL and CFL injury.

METHODS

The miniaturization ligament performance probe (MLPP) system was used for directly measuring the strain patterns to insert the strain gauges into the mid-substance of normal and repaired ATFL and CFL fibers in five cadaveric specimens to allow measurement of strain patterns in the axial and three-dimensional motion of the ankle.

RESULTS

The normal and repaired ATFL showed similar strain patterns in axial and three-dimensional motions. During the axial range of motion of the ankle, the repaired CFL showed a strain pattern almost similar to that of normal CFL, but the strain increased as the plantar flexion or dorsiflexion angle increased to the maximum value of 100 at 30° plantarflexion or strain values of 17-55/100 at 15°dorsiflexion. During three-dimensional motion, the repaired CFL was under the maximum value of 100 during dorsiflexion-inversion and exhibited less strain (7-38/100) during plantar flexion-eversion.

CONCLUSION

The repaired CFL did not show a strain pattern that was completely consistent with a normal strain pattern; however, it did have some degree of tension similar to a normal strain pattern, even though it was not directly repaired.

Ultrasound Imaging for the Evaluation of Anterior Talofibular Ligament Remnants in 547 Ankles With Chronic Lateral Ankle Instability

BACKGROUND

There are few reports on the intra- and interobserver agreement and parameters for the diagnostic accuracy of ultrasound (US) imaging for chronic lateral ankle instability (LAI). The purpose of this study was to investigate the reliability and validity of US imaging for identifying anterior talofibular ligament (ATFL) remnants in patients with LAI.

METHODS

A total of 547 ankles from 406 patients underwent surgery for LAI between 2019 and 2022. If ligament fibers remained in US images, they were evaluated as positive. If the ligament was not visualized, it was evaluated as negative. Two observers performed repeated measurements. Arthroscopic findings were considered the "gold standard" for validity and diagnostic test accuracy purposes. The intra- and interobserver agreements and parameters for diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative US imaging as intraoperative arthroscopic findings were used as reference standards.

RESULTS

The intraobserver agreement was substantial, with an agreement of 98.54% and a kappa coefficient of 0.76. The interobserver agreement was also substantial, with an agreement of 98.72% and a kappa coefficient of 0.75. The sensitivity, specificity, and accuracy of preoperative US imaging were 98.7%, 100%, and 98.7%, respectively. The PPV and NPV of US imaging were 100% and 61.1%, respectively. In the arthroscopic evaluation of the 7 cases in which US imaging showed false negative results, the ATFL ruptured at the fibular attachment and ran in contact with the talus.

CONCLUSION

A US examination finding of an intact ATFL is highly likely to be correct. An US examination finding of a ruptured ATFL can be false and may require arthroscopic confirmation.

Functional Outcomes of Immediate Weightbearing After Arthroscopic Lateral Ankle Ligament Repair: A Prospective Randomized Single-Center Trial

BACKGROUND

Previous studies have revealed that early postoperative rehabilitation of chronic lateral ankle instability is just as crucial as surgical intervention. Immediate weightbearing has yielded good clinical results; however, randomized controlled studies have been limited.

PURPOSE

To compare the clinical outcomes of patients with immediate weightbearing after lateral ankle ligament repair with those with delayed weightbearing after 2 weeks in a prospective randomized controlled study.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Patients who underwent arthroscopic anterior talofibular ligament repair between August 2021 and December 2022 were randomized into 2 groups-immediate weightbearing with a hard ankle brace and nonweightbearing casting for 2 weeks followed by cast removal and weightbearing. Primary outcomes were the ankle function scores as assessed using the visual analog scale at rest and during activities, the American Orthopaedic Foot & Ankle Society (AOFAS) score, and the Karlsson Ankle Functional Score (Karlsson score). Secondary outcomes were the time to return to unsupported walking, jogging, work, and exercise and change in the ankle range of motion (ROM) at 3-, 6-, and 12-month follow-ups.

RESULTS

A total of 88 participants were included, consisting of 58 men and 30 women, with a mean age of 30.26 years. Computerized randomization resulted in 44 patients per group. These 2 groups displayed no difference in the AOFAS score, Karlsson score, and ankle ROM at all follow-ups. Patients who underwent immediate weightbearing had a significantly shorter time of returning to unsupported walking (P < .001). No differences were observed in the time of returning to work, jogging, and sports exercise.

CONCLUSION

For patients with chronic ankle instability after arthroscopic anterior talofibular ligament repair, immediate weightbearing allowed patients to return to unsupported walking more quickly and had no negative effects on the AOFAS score, Karlsson score, times of returning to normal life, jogging, sports exercise, and ankle ROM at 3-, 6-, and 12-month follow-ups compared with cast fixation.

REGISTRATION

ChiCTR2100049612 (Chinese Clinical Trial Registry; https://www.chictr.org.cn/).

Clinical Outcomes for Arthroscopic Anterior Talofibular Ligament Repair After Suture Anchor Insertion Through the Anterolateral Portal vs the Lateral Accessory Portal

BACKGROUND

Two types of suture anchor insertion pathways (anterolateral portal vs lateral accessory portal) are used in arthroscopic anterior talofibular ligament (ATFL) repair. However, it is not clear which one is the better choice. This study aims to compare the clinical outcomes of these 2 suture anchor insertion pathways when performing arthroscopic ATFL lasso-loop repair for the treatment of chronic lateral ankle instability (CLAI).

METHODS

From 2019 to 2021, patients with CLAI who underwent arthroscopic ATFL lasso-loop repair were retrospectively reviewed and divided into the anterolateral portal (ALP) group and the lateral accessory portal (LAP) group. A 1:1 propensity score matching was used to control confounding factors based on age, sex, body mass index, follow-up duration, preoperative visual analog scale (VAS) score, and Tegner score (ALP group, n = 26; LAP group, n = 26). Karlsson score, VAS score, Tegner score, operation time, anterior drawer test results, patient symptoms, and magnetic resonance (MR) evaluation of ATFL quality were used to describe the outcomes.

RESULTS

The patient characteristics and follow-up durations were similar between the 2 groups. After a mean follow-up duration of 28.8 ± 2.3 months, the ALP group had significantly better Karlsson score, VAS score, and Tegner score improvement than the LAP group, with fewer symptoms. Seven patients in the LAP group still had a feeling of ankle instability, and 3 of them exhibited ankle laxity.

CONCLUSION

In this study, we found that inserting the suture anchor through the anterolateral portal was associated with better outcomes compared to that through the lateral accessory portal when performing arthroscopic ATFL lasso-loop repair for CLAI patients. The improvement was greater for pain relief and function and was associated with a lower frequency of subjective ankle instability.

Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes

BACKGROUND

Posterior ankle impingement syndrome (PAIS) is sometimes complicated by bilateral cases and lateral ankle ligament injuries. Reports on bilateral surgery for PAIS and simultaneous surgery for lateral ankle ligament injury are scarce in the literature.

METHODS

We present a 2-year follow-up of 76 athletic patients who underwent endoscopic hindfoot surgery for PAIS. Patients were divided into those who underwent unilateral or simultaneous bilateral surgery and PAIS surgery alone or simultaneous bilateral PAIS surgery without arthroscopic ankle lateral ligament repair.

RESULTS

All patients returned to full athletic activities postoperatively. There was no difference in all subscales of the SAFE-Q score between groups except for mean days after surgery for full return to athletic activities.

CONCLUSION

Simultaneous bilateral surgery and simultaneous arthroscopic lateral ankle ligament repair had no negative effect on subjective clinical evaluation 2 years after surgery in hindfoot endoscopic surgery for PAIS.

LEVEL OF EVIDENCE

III, retrospective case-control study.

Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients

BACKGROUND

In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients.

METHODS

Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated.

RESULTS

Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively.

CONCLUSION

We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain: A systematic review and meta-analysis

BACKGROUND

Lateral ankle sprains are the most common traumatic musculoskeletal injuries of the lower extremity, with an incidence rate of 15%-20%. The high incidence and prevalence highlights the economic impact of this injury. Ankle sprains lead to a high socioeconomic burden due to the combination of the high injury incidence and high medical expenses. Up to 40% of patients who suffer from an ankle sprain develop chronic ankle instability. Chronic instability can lead to prolonged periods of pain, immobility and injury recurrence. Identification of factors that influence return to work (RTW) and return to sports (RTS) after a lateral ankle sprain (LAS) may help seriously reduce healthcare costs.

AIM

To explore which factors may potentially affect RTW and RTS after sustaining an LAS.

METHODS

EMBASE and PubMed were systematically searched for relevant studies published until June 2023. Inclusion criteria were as follows: (1) Injury including LAS or chronic ankle instability; (2) Described any form of treatment; (3) Assessment of RTW or RTS; (4) Studies published in English; and (5) Study designs including randomized controlled clinical trials, clinical trials or cohort studies. Exclusion criteria were: (1) Studies involving children (age < 16 year); or (2) Patients with concomitant ankle injury besides lateral ankle ligament damage. A quality assessment was performed for each of the included studies using established risk of bias tools. Additionally quality of evidence was assessed using the GRADEpro tool in cases where outcomes were included in the quantitative analysis. A best evidence synthesis was performed in cases of qualitative outcome analysis. For all studied outcomes suitable for quantitative analysis a forest plot was created to calculate the effect on RTW and RTS.

RESULTS

A total of 8904 patients were included in 21 studies, 10 randomized controlled trials, 7 retrospective cohort studies and 4 prospective cohort studies. Fifteen studies were eligible for meta-analysis. The overall RTS rate ranged were 80% and 83% in the all treatments pool and surgical treatments pool, respectively. The pooled mean days to RTS ranged from 23-93 d. The overall RTW rate was 89%. The pooled mean time to RTW ranged from 5.8-8.1 d. For patients with chronic ankle instability, higher preoperative motivation was the sole factor significantly and independently (P = 0.001) associated with the rate of and time to RTS following ligament repair or reconstruction. Higher body mass index was identified as a significant factor (P = 0.04) linked to not resuming sports or returning at a lower level (median 24, range 20-37), compared to those who resumed at the same or higher level (median 23, range 17-38). Patients with a history of psychological illness or brain injury, experienced a delay in their rehabilitation process for sprains with fractures and unspecified sprains. The extent of the delayed rehabilitation was directly proportional to the increased likelihood of experiencing a recurrence of the ankle sprain and the number of ankle-related medical visits. We also observed that 10% of athletes who did return to sport after lateral ankle sprain without fractures described non-ankle-related reasons for not returning.

CONCLUSION

All treatments yielded comparable results, with each treatment potentially offering unique advantages or benefits. Preoperative motivation may influence rehabilitation after LAS. Grading which factor had a greater impact was not possible due to the lack of comparability among the included patients.

Return to Sport After Anatomic Lateral Ankle Stabilization Surgery for Chronic Ankle Instability: A Systematic Review and Meta-analysis

BACKGROUND

Chronic lateral ankle instability that develops after ankle sprains has a severe, negative influence on the patient's lower extremity function. Anatomic repair or reconstruction of the lateral ankle ligament is an effective treatment for people with chronic lateral ankle instability who want to regain their preinjury levels of work and sport.

PURPOSE

To determine the rate of return to sport (RTS) and related factors after anatomic lateral ankle stabilization (ALAS) surgery.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Electronic databases including Medline, Embase, the Cochrane Library, and EBSCO Rehabilitation & Sports Medicine Source were searched from the earliest feasible entrance until August 2021. Articles reporting the number of patients who returned to sport after ALAS surgery and analyzing the relevant factors were included. The results were combined using proportion meta-analyses.

RESULTS

A total of 25 publications were reviewed, with a total of 1384 participants. Results showed that 95% of patients (95% CI, 91%-99%) returned to any sport, 83% (95% CI, 73%-91%) returned to their preinjury level of sport, and 87% (95% CI, 71%-98%) returned to competitive sport after surgery. The mean time to RTS was 12.45 weeks (95% CI, 10.8-14.1 weeks). Each decade of age increased the likelihood of RTS failure by 6%, and increases in body mass index (BMI) of 5 kg/m2 raised the risk of RTS failure by 4%. The rate of RTS was higher in professional and competitive athletes (93%; 95% CI, 73%-100%) than in recreational athletes (83%; 95% CI, 76%-89%). Analysis showed no differences for arthroscopy versus open surgery, repair versus reconstruction, and early versus late weightbearing.

CONCLUSION

In most cases, patients may return to some kind of sport after ALAS surgery, and some patients RTS at their preinjury level. The relative risk of RTS failure increases according to the magnitude of the increase in age and BMI. Elite athletes are more likely to return compared with nonelite athletes.

Hindfoot Alignment and Ankle Stability Following Arthroscopic Lateral Ankle Ligament Repair

BACKGROUND

Hindfoot varus deformity is a known risk factor for chronic lateral ankle instability (CLAI). The impact of this deformity on clinical results following arthroscopic lateral ankle ligament repair (ALLR) for CLAI has not been studied.

METHODS

Sixty-three ankles from 62 patients who received ALLR for CLAI were retrospectively examined. Preoperative plain radiographs were used to measure tibial articular surface (TAS) angles, and long axial hindfoot alignment radiographs were used to measure tibiocalcaneal angles (TCAs) pre- and postoperatively. Results included ratings on the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and recurrent ankle instability (respraining of the operated ankle following surgery).

RESULTS

Recurrent ankle instability, defined as incidence of any new ankle sprain after surgery reported in the follow-up period, occurred in 13 ankles. The TAS angles of these patients were significantly low, and their preoperative TCA was significantly high. Multivariate analysis showed that preoperative TCA was an independent risk factor for recurrent ankle instability. The threshold values for preoperative TCA for recurrent instability were determined via the receiver operating characteristic curve analysis to be 3.4 degrees. Patients were assigned to a low- or high-TCA group based on the reported average TCA (2.7 degrees) of healthy patients. In the high-TCA group, recurrent instability was significantly more frequent, and the scores on the pain subscale of the postoperative SAFE-Q were significantly lower.

CONCLUSION

Hindfoot varus alignment was associated with pooreroutcomes after ALLR.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair

PURPOSE

To compare the clinical outcomes of the lasso-loop and simple suture techniques in arthroscopic anterior talofibular ligament (ATFL) repair for the treatment of chronic lateral ankle instability (CLAI).

METHODS

From 2018 to 2020, patients with CLAI who underwent arthroscopic ATFL repair using the lasso-loop or simple suture technique were matched 1:1 (arthroscopic lasso-loop [AL] group, n = 29; simple arthroscopic suture [AS] group, n = 29) based on age, sex, affected side, body mass index, and follow-up duration using propensity score matching and retrospectively evaluated. Karlsson score, visual analogue scale (VAS) score, Tegner score, anterior drawer test (ADT) results, complications, patient-reported satisfaction, and magnetic resonance (MR) re-evaluation findings of ATFL quality were used to describe the outcomes.

RESULTS

The patient characteristics or follow-up durations did not significantly differ between the two groups. The Karlsson score, VAS score, and Tegner score improved significantly in both groups after a mean follow-up duration of 29.6 ± 2.8 months. The postoperative clinical scores, ADT results, satisfaction rates, complication rates and MR re-evaluation findings were not significantly different between the two groups at the latest follow-up.

CONCLUSION

The lasso-loop technique was equivalent to the simple suture technique in arthroscopic ATFL repair for the treatment of CLAI after a minimum follow-up of 2 years, suggesting that the simple suture technique is sufficient for arthroscopic ATFL repair in most patients without the need to add a lasso loop.

LEVEL OF EVIDENCE

Level III.

Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability

OBJECTIVE

To introduce the surgical technique and clinical outcomes of arthroscopic anterior talofibular ligament (ATFL) repair using the Internal Brace and lasso-loop technique for chronic ankle lateral instability.

METHODS

A retrospective study was performed on 29 patients who underwent all-arthroscopic ATFL repair with the Internal Brace and lasso-loop technique from January to August 2020. The patients included 24 males and five females, with a mean age of 30.17 years. Through the accessory anterolateral (AAL) portal, we drilled the bone tunnels and fixed the tape with 4.75 mm and 3.5 mm "SwiveLock" anchors and reattached the torn ligament by the lasso-loop technique.

RESULTS

All 29 patients underwent all-arthroscopic procedures smoothly without serious complications, such as infection and important nerve or vessel injuries. There were eight cases of lateral malleolar avulsion fractures and ten cases of talus cartilage injury. The visual analog scale (VAS), Karlsson-Peterson, Tegner, and American Orthopedic Foot and Ankle Society (AOFAS) scores were used to evaluate the clinical consequences. All the patients were followed up for 18.66 ± 4.85 months on average. The average pre-operative VAS score was 4.69 ± 1.04, which was significantly higher than the average post-operative VAS score of 1.14 ± 1.56. At the final follow-up appointments, the averages of Karlsson-Peterson, AOFAS, and Tenger scores were 75.83 ± 9.44, 88.31 ± 6.81, and 6.93 ± 1.79, respectively, which was significantly higher than that before the operation.

CONCLUSION

This arthroscopic anterior talofibular ligament repair with the Internal Brace and lasso-loop technique achieves satisfactory clinical outcomes with the benefits of high safety and reliability for chronic ankle lateral instability.

Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair

PURPOSE

The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair.

METHODS

A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores.

RESULTS

Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy.

CONCLUSION

Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality.

LEVEL OF EVIDENCE

IV.

Effect of Accelerated Rehabilitation on Early Return to Sport After Arthroscopic Ankle Lateral Ligament Repair

Background

Although the minimal invasiveness of arthroscopic ankle lateral ligament repair (ALLR) means that an early return to sporting activities can be anticipated, studies have described postoperative cast immobilization and the avoidance of weightbearing for a certain period. Accelerated rehabilitation may be helpful for an early return to sport.

Purpose

To investigate clinical outcomes of ALLR and accelerated rehabilitation with a minimum duration of postoperative ankle immobilization and proactive early weightbearing.

Study Design

Case series; Level of evidence, 4.

Methods

This study investigated 23 ankles of 22 patients (11 men, 11 women; mean age, 38.7 years) who underwent ALLR for chronic lateral ankle instability. Postoperative management included the avoidance of weightbearing until postoperative day 3, after which full weightbearing walking with a brace was permitted. The objective was to return to competitive sport 8 weeks after surgery. The following were evaluated: pre- and postoperative instability and pain symptoms, ankle range of motion, anterior drawer distance on stress radiograph, anterior translation measured with a capacitance-type strain sensor, the Ankle-Hindfoot Scale from the Japanese Society for Surgery of the Foot, and the SAFE-Q (Self-Administered Foot Evaluation Questionnaire).

Results

Two male patients dropped out and were excluded from analysis. Postoperatively, instability and pain resolved or improved in all patients. There was no significant postoperative change in range of motion. There were significant pre- to postoperative improvements in talar tilt angle (from 12.2°-5.6°, P < .01), anterior drawer distance (8.2-4.4 mm, P < .01), and anterior translation (10.5-4.6 mm, P < .01) as well as the Ankle-Hindfoot Scale score (68.8-96.8, P < .01) and all subscales of the SAFE-Q (P ≤ .01 for all). Complete return to sport was achieved by 75% of the patients at 8 weeks postoperatively.

Conclusion

When accelerated rehabilitation with proactive weightbearing exercises was implemented from postoperative day 3 without ankle immobilization after ALLR, there were significant improvements in objective assessments of ankle stability and clinical scores, and as many as 75% of the patients were able to make a complete return to sport within 8 weeks.

Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques

Background

There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability.

Methods

Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24—36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded.

Results

At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77—100), 90.17 ± 4.64 (range, 85—100) and 0.53 ± 0.63 (range, 0—2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered.

Conclusions

The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization.

Varus-Tilted Distal Tibial Plafond Is a Risk Factor for Recurrent Ankle Instability After Arthroscopic Lateral Ankle Ligament Repair

BACKGROUND

Although varus-tilted distal tibial deformity is an established risk factor for chronic lateral ankle instability (CLAI), no studies have reported whether this deformity influences ankle instability after arthroscopic lateral ankle ligament repair (ALLR) for CLAI.

METHODS

A total of 57 ankles from 57 patients who underwent ALLR for CLAI were retrospectively analyzed. Tibial articular surface (TAS) angles were measured on preoperative plain radiograph. After 12 months of follow-up, recurrent ankle instability and talar tilt angles on stress radiograph were evaluated as outcomes. Relationships between the TAS angle and these outcomes were assessed.

RESULTS

Recurrent ankle instability was observed in 10 ankles. The TAS angles of patients with recurrent instability were significantly lower (85.2 degrees vs 87.9 degrees). The receiver operating characteristic curve analysis revealed that the cutoff value of TAS angle for recurrent instability was 86.2 degrees. Based on this cutoff value, our patients were divided into 2 groups: low-TAS and high-TAS group. Univariate and multivariate analysis revealed that low TAS was an independent risk factor for recurrent ankle instability and greater postoperative talar tilt angles.

CONCLUSION

Varus-tilted distal tibial plafond appears to be a risk factor for recurrent ankle instability after ALLR.

Nonunion of a medial malleolar stress fracture in an adolescent athlete secondary to lateral ankle instability: A case report

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A 13-year-old male football player presented with chronic medial left ankle pain.

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Radiographic examination showed nonunion of the medial malleolar stress fracture and chronic lateral ankle instability.

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Internal fixation with the arthroscopic modified Broström procedure was performed.

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The Self-Administered Foot Evaluation Questionnaire improved in all parameters.

•

The method is useful for medial malleolar stress fractures due to chronic lateral ankle instability.

Introduction

Medial malleolar stress fractures are relatively uncommon. This report describes the successful treatment of nonunion of a medial malleolar stress fracture due to chronic lateral ankle instability.

Presentation of case

A 13-year-old middle school student who belonged to a football club presented to our clinic with chronic medial left ankle pain lasting over a year. He had sprained his left ankle several times 6 years earlier. A plain anteroposterior ankle radiograph showed a vertical fracture line in the medial malleolus involving the epiphyseal plate, and computed tomography demonstrated the vertical fracture seen on the plain radiographs and bone sclerosis at the fracture site. We performed internal fixation for nonunion of the medial malleolar stress fracture with arthroscopic modified Broström for lateral ankle instability. Two years after surgery, the Self-Administered Foot Evaluation Questionnaire improved in all parameters, and both the anterior drawer and varus stress tests were negative.

Discussion

Early diagnosis of medial malleolar stress fracture is important for a rapid return to sports. Magnetic resonance imaging is helpful for early diagnosis. Because lateral ankle instability can cause medial malleolar stress fracture, arthroscopic modified Broström procedure is meaningful for medial malleolar stress fracture with lateral ankle instability.

Conclusion

Internal fixation and the arthroscopic modified Broström procedure could achieve good clinical outcomes for medial malleolar stress fractures with lateral ankle instability.