Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace

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.

Internal brace augmentation improves the biomechanical properties of trapeziometacarpal joint dorsoradial ligament repair

This study investigated whether dorsoradial ligament repair with internal brace augmentation provided more immediate stability in the trapeziometacarpal joint than dorsoradial ligament repair alone. Seven matched pairs of cadaveric hands were used. One specimen from each pair was assigned to the repair-only group and the other to the repair + internal brace augmentation group. Trapeziometacarpal joint range of motion and translation were quantified under different conditions for both groups: (1) intact, (2) transected dorsoradial ligament, and (3) repaired dorsoradial ligament or repaired dorsoradial ligament plus internal brace augmentation. Load-to-failure tests were performed after repair. Range of motion and translation were increased by dorsoradial ligament transection and were decreased by dorsoradial ligament repair; however, compared to the intact condition, the repair-only group demonstrated greater flexion/extension range, while the repair + internal brace group showed no significant difference in range of motion. Mean loads at 2- and 3-mm displacements were greater in the repair + internal brace group than in the repair-only group (18.0 ± 1.8 N vs. 10.8 ± 1.3 N for 2 mm displacement and 35.3 ± 3.7 N vs. 23.1 ± 2.9 N for 3 mm displacement, respectively). Internal brace augmentation improved the load-to-failure characteristics of dorsoradial ligament repair without compromising range of motion. LEVEL OF EVIDENCE: IV.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Comparison of Knot-Tying Techniques During the Arthroscopic Broström-Gould Procedure: Semiconstrained Freehand Versus Knot Pusher Techniques

Background

The arthroscopic Broström technique with or without Gould modification has been used to treat patients with anterior talofibular ligament injury who failed nonoperative management and progressed to chronic lateral ankle instability. However, some patients develop limited range of motion over the ankle joint postoperatively.

Purpose/Hypothesis

To compare the clinical outcomes and midterm functional performance of knot-tying techniques between using a knot pusher and a semiconstrained freehand tie during arthroscopic Broström-Gould procedure with inferior extensor retinaculum (IER) augmentation. It was hypothesized that the semiconstrained freehand tie would provide better plantarflexion of the ankle joint compared with the knot pusher.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 135 consecutive patients with mild-to-moderate lateral ankle instability (mean age, 42.7 years; range, 16-78 years) who underwent an arthroscopic Broström-Gould procedure from March 1, 2016, to April 30, 2022. The patients were divided into 2 groups according to the tying technique used in the Gould modification: surgical tie using a knot pusher (KP group; n = 30) or a semiconstrained freehand tie (FT group; n = 105). Radiographic parameters and ultrasound dynamic testing were examined during the preoperative assessment. Preoperative and 2-year postoperative assessments comprised American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale for pain, and 12-Item Short Form Survey (SF-12) scores.

Results

The 2 groups had no differences in age, sex, or severity distribution in the preoperative assessment. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale pain, and SF-12 scores were significantly better at the postoperative evaluation (all P < .05) in both groups. No significant difference was noted between groups in outcome scores. In the KP group, however, 7 out of 30 patients (23.3%) developed ankle stiffness with tightness when performing plantarflexion movement. No patients in the FT group reported similar symptoms.

Conclusion

For mild-to-moderate chronic lateral ankle instability, we propose an arthroscopic Broström procedure with the addition of IER augmentation using a semiconstrained freehand tie to avoid overtightening the IER. This ensures favorable patient satisfaction and clinical outcomes without limitation of plantarflexion of the ankle joint and avoids the possible complication of stiffness with plantarflexion.

Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability

PURPOSE

Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair.

MATERIALS AND METHODS

Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed.

RESULTS

The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05).

CONCLUSIONS

Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

LEVEL OF EVIDENCE: 4

Successful Return to Sport and Daily Activities After Suture Augmentation of Both the Anterior Talofibular Ligament and Calcaneofibular Ligament

Purpose

To evaluate the return to sport and daily activities in addition to clinical outcomes after modification of the Brostöm repair, specifically using suture augmentation for concomitant fixation of both the anterior talofibular ligament and calcaneofibular ligament.

Methods

Patients who had grade III ankle sprains and lateral ankle instability, all of whom failed supervised conservative management, were included. Patients underwent a modified Broström procedure consisting of suture augmentation for both the anterior talofibular ligament and calcaneofibular ligament. For clinical outcome evaluation, Foot and Ankle Ability Measure (FAAM) and Karlsson-Peterson Scoring System for Ankle Function questionnaires coupled with questions regarding time of return to sport and level of sports activity were used.

Results

Thirty-one patients were included. The differences in preoperative and postoperative FAAM scores for both the Activities of Daily Living subscale and Sports subscale were significant (P < .001). The FAAM Activities of Daily Living score improved from an average of 46.06 preoperatively to 77.49 postoperatively (P < .001, 99% confidence interval, 26.4-36.4). The FAAM Sports score improved from an average of 4 preoperatively to 19.31 postoperatively (P < .001, 99% confidence interval, 11.6-19.0). For the Karlsson-Peterson Scoring System for Ankle Function, the surveyed population reported a mean of 82.74 points out of 100 post-op (standard deviation 20.14). The mean time to return to sport activity was 5.72 months. Mean follow-up time was 24.12 months.

Conclusions

This variant Broström procedure with suture anchors and augmentation of both the anterior talofibular ligament and calcaneofibular ligament was effective in helping patients return to their preinjury functionality level in both daily life and sports activity.

Level of Clinical Evidence

Level IV, therapeutic case series.

Anterior Talo-Fibular Ligament Reconstruction With InternalBrace™ for Chronic Lateral Ankle Instability in Pediatric Patients

INTRODUCTION

Ankle injuries and instability in a pediatric age group are common problems and often underreported. The injuries can range from a relatively benign ankle sprain to pain-limiting ankle instability that can inhibit the child from participating in sporting activities. However, conservative management and physiotherapy are the mainstay of treatment; a small group of patients present with persistent instability and benefit from surgical intervention in lateral ligament reconstruction. Our study looked at pediatric patients who had instability following failed conservative management.

METHODS

Retrospective analysis of 14 patients with Chronic lateral Ankle instability (CLAI) who underwent Modified Brostrom-Gould repair( MBG) with or without Internal brace augmentation between January 2015 and October 2020. Patients were evaluated for the visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), subjective satisfaction, and return to preinjury activity level.

RESULTS

Pain score improved from 8 (average 5-9) to 1 (average 0-3) following surgery. Functional assessment was made by assessing the Manchester Oxford questionnaire pre-and postoperatively. MOxFQ scores improved from 64 (8 SD) to 7 (15 SD). Thirteen of fourteen patients returned to normal sporting activities at the final follow-up.

CONCLUSION

Modified Brostrom-Gould with InternalBrace™ augmentation is an excellent procedure for chronic lateral ligament injuries in the Paediatric population. It can be safely performed if we respect the anatomy and the physeal growth plate. It allows faster rehabilitation and return to preinjury activity level.

Cohort study of short-term outcomes after ACL-reconstruction using autograft with internal brace reinforcement versus isolated autograft demonstrating no significant difference

Background

The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. Few studies have examined these techniques, in particular when compared to non-augmented grafts. This study assesses the short-term outcome of ACL-R using augmented and non-augmented hamstring tendon autografts.

Methods

This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes.

Results

There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82 mm versus 8.44 mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width.

Conclusion

No statistically significant difference was demonstrated in the short-term functional outcome of ACL reconstruction using an augmented or non-augmented hamstring graft. Augmented ACL-R may achieve superior graft diameters, failure rates and patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons

OBJECTIVES

To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR.

METHODS

We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence.

RESULTS

Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p ​= ​0.005).

CONCLUSION

LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population.

LEVEL OF EVIDENCE

Level V.

Isolated Anterior Talofibular Ligament (ATFL) vs Combined ATFL and Calcaneofibular Ligament Suture Tape Augmentation for the Treatment of Lateral Ankle Instability: Are Outcomes Equivalent?

Background

The Broström procedure with suture tape augmentation has become commonplace for surgical treatment of chronic lateral ankle instability. However, there is no consensus among surgeons whether internal bracing of the ATFL alone or a combined ATFL and calcaneofibular ligament (CFL) internal brace produces superior clinical outcomes. This retrospective study aims to investigate whether isolated internal bracing of the ATFL has comparable outcomes to combined ATFL and CFL brace.

Methods

There were 85 patients from a single tertiary medical center's electronic medical record identified who underwent an ATFL or ATFL and CFL reconstruction between January 2017 and December 2020. Postoperative outcomes including patient satisfaction, ankle instability, ankle pain, and the need for revision surgery at 1-year follow-up were evaluated.

Results

Forty-eight patients underwent isolated ATFL reconstruction, and 37 underwent combined ATFL and CFL reconstruction. The choice was made between the 2 options based on surgeon preference. At 1-year follow-up, postoperative outcomes were statistically indistinguishable between the 2 treatment groups.

Conclusion

The modified Broström reconstruction with ATFL and CFL reconstruction with an internal brace did not produce superior functional outcomes measured at 1 year compared to isolated ATFL reconstruction. Further investigation of long-term functional outcomes is needed to evaluate the long-term efficacy of combined or single-ligament reconstruction.Level of Evidence: Level III, retrospective study.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.

METHODS

The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.

DISCUSSION

This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

Acute Distal Rupture of the Calcaneus-Fibular Ligament Near the Calcaneus Insertion: Magnetic Resonance Imaging for Diagnostic Value and Comparison to Surgical Findings-A Retrospective Case Series Study

Distal rupture of the calcaneus-fibular ligament (CFL) was unique and important, because it is crucial to diagnose this type of injury before surgical intervention. In the present study, we collected several imaging characteristics based on MRI and tried to determine whether those clues can be used to diagnose distal rupture of CFL specifically and sensitively. Several imaging characteristics based on MRI were collected and used to diagnose and determine the location of CFL injury. All these clues on preoperative MRI were verified by operative findings and postoperative roentgenography. The interobserver agreement for the quality of the MRI images had a p value of .6 (McNemar test) and a Cohen's kappa of 65.2% (confidence interval, 50.5%-79.9%), and the agreement of the 2 observers was categorized as substantial. The sensitivity and specificity of distal rupture of CFL between 2 observers were 76.3%, 91.4% and 72.2%, 85.55%, respectively. The sensitivity and specificity of MRI clues were calculated as follows: hyperintense signal changes (86.1%, 38.6%), peroneal sheath fluid (63.9%, 74.7%), wave or laxity of the ligament (80.6%, 51.8%), fluid exudation around the ligament (80.6%, 51.8%), bone marrow edema on the calcaneus insertion (2.8%, 91.6%), avulsion fracture of the calcaneus (0%, 96.4%), incongruency or disruption of the ligament (69.4%, 77.1%), and exudation on the subtalar joint (52.8%, 71.1%). Preoperative MRI scans are a useful tool to diagnose distal injury of the CFL.

Biomechanical Effect of Differential Tensioning on Suture-Augmented Ulnar Collateral Ligament Reconstruction of the Elbow

BACKGROUND

Medial ulnar collateral ligament (mUCL) reconstructions are becoming increasingly prevalent among the overhand throwing population. Suture tape augmentation has the potential to provide biomechanical advantages over standard docking reconstruction. However, the optimal tensioning of the suture augmentation technique has not yet been evaluated.

PURPOSE

To compare the subfailure biomechanical performance and graft strain of a standard docking mUCL reconstruction to an mUCL reconstruction using suture tape augmentation tensioned with 1 mm or 3 mm of laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 18 cadaveric elbows were dissected to the mUCL anterior band and biomechanically assessed via a valgus torque protocol to failure. Elbows were randomly assigned to be reconstructed via (1) a standard docking technique, (2) a suture-augmented reconstruction with 1-mm laxity, or (3) a suture-augmented reconstruction with 3-mm laxity. Reconstructed elbows were then subjected to the same loading protocol. Subfailure mechanical properties, failure mode, and mUCL/palmaris strain were assessed.

RESULTS

All reconstruction groups had decreased rotational stiffness, torque at 5° of angular rotation, and resilience compared with matched native controls. There were no differences in transition torque between groups. The failure mode of suture-augmented specimens was most often due to bone tunnel failure or reaching the maximum allowable angular displacement. In native controls or docking reconstructions, the primary failure mechanism was in the ligament or graft midsubstance. There were no significant differences in strain on the reconstructed or suture-augmented groups at any laxity compared with native controls.

CONCLUSION

Suture augmentation results in similar subfailure joint biomechanical properties as the standard docking reconstruction procedure at both laxity levels in a cadaveric model. There are improvements in the failure mode of suture-augmented specimens compared with standard docking. Graft strain may be modestly reduced in the 1-mm laxity group compared with other reconstruction groups.

CLINICAL RELEVANCE

Suture augmentation at both 1-mm and 3-mm laxity appears to offer similar advantages in subfailure biomechanics to standard docking reconstruction of the mUCL, with some improvements associated with failure mode. Strain data suggest a potential avoidance of graft stress shielding when tensioning the suture augmentation to 3-mm laxity, which is not as apparent with 1-mm laxity.

Are Prospective Criteria or Objective Clinical Measures Utilized in Return to Play (RTP) Decision Making After Ankle Surgery? A Scoping Review

Background

Manuscripts discussing return to play (RTP) following ankle surgery are common. However, the definition for RTP and the method by which it is determined remains unclear. The purpose of this scoping review was to clarify how RTP is defined following ankle surgery in physically active patients, to identify key factors informing RTP decision making (such as objective clinical measures), and make recommendations for future research.

Methods

A scoping literature review was performed in April 2021 using PubMed, EMBASE, and Nursing and Allied Health databases. Thirty studies met inclusion criteria: original research following ankle surgery reporting at least 1 objective clinical test and documentation of RTP. Data were extracted for study methods and outcomes (RTP definition, RTP outcomes, and objective clinical tests).

Results

The scoping review found studies on 5 ankle pathologies: Achilles tendon rupture, chronic lateral ankle instability, anterior ankle impingement, peroneal tendon dislocation, and ankle fracture. RTP criteria were not provided in the majority of studies (18/30 studies). In the studies that provided them, the RTP criteria were primarily based on time postsurgery (8/12) rather than validated criteria. Objective clinical outcome measures and patient-reported outcome measures (PROMs) were documented for each surgery when available. Both clinical outcomes and PROMs were typically measured >1 year postsurgery.

Conclusion

In physically active patients who have had ankle surgery, RTP remains largely undefined and is not consistently based on prospective objective criteria nor PROMS. We recommend standardization of RTP terminology, adoption of prospective criteria for both clinical measures and PROMs to guide RTP decision making, and enhanced reporting of patient data at the time of RTP to develop normative values and determine when the decision to RTP is not safe.

Level of Evidence

Level IV, scoping review.

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.

Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement

Background

Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions.

Purpose

To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively.

Results

Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores.

Conclusion

All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.

The Chinese knotting technique assist anatomical anterior cruciate ligament reconstruction for aggressive rehabilitation

Aggressive rehabilitation after anterior cruciate ligament (ACL) reconstruction may result in better clinical outcomes and fewer complications such as knee stiffness and weakness. We explored the effect of the Chinese knotting technique (CKT) for aggressive rehabilitation after ACL reconstruction. Ninety-one anatomical ACL reconstruction cases from 2016 to 2020 were retrospectively reviewed. All patients were operated by the same senior physician and his team. According to the reconstruction with or without CKT, the patients were divided into 2 groups. Both groups received aggressive rehabilitation. The follow-up time of 91 patients was more than 2 years. In total, 43 out of the 91 patients were in the CKT group, and 48 were in the routine group. The knee joint kinematics recorded by Opti_Knee revealed no significant difference among the CKT group, the routine group, and healthy adults at 3, 6, 12, and 24 months after the operation, respectively. The internal and external rotation angle and the anteroposterior displacement at 3 and 6 months after the operation in the CKT group were smaller than in the routine group and were similar to that of the healthy adults. There was no significant difference in flexion and extension angle, varus or valgus angle, proximal-distal displacement, or the internal or external displacement between the 2 groups. In addition, there was no significant difference in 6 degrees of freedom of the knee between the 2 groups at 12 and 24 months after the operation, respectively, which was similar to healthy adults. Compared to the routine group, the International Knee Documentation Committee scores were significantly higher in the CKT group at the 3, 6, and 12 months, respectively, but no difference was observed at 24 months (P = .749). The Lysholm score was significantly higher in the CKT group at the 3 and 6 months postoperatively, while there was no difference at 12 and 24 months, respectively. In short-term observation, the ACL reconstruction with CKT, which can sustain aggressive rehabilitation and prevent the loosening of ACL graft, can lead to better clinical outcomes and kinematics recovery of the knee compared to routine technique.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review

Background:

There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle.

Purpose:

To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed.

Results:

There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I² = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, –3.73 to 6.21]; I² = 66%; P = .63), talar tilt angle improvement (MD, –0.07 [95% CI, –0.68 to 0.54]; I² = 0%; P = .42), or anterior talar translation improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I² = 0%; P = .77).

Conclusion:

Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model

Background:

Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity.

Purpose/Hypothesis:

To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation.

Study Design:

Controlled laboratory study.

Methods:

We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test.

Results:

There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site.

Conclusion:

Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model.

Clinical Relevance:

The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.

Treatment of Thumb Metacarpophalangeal Joint Hyperextension by Volar Plate Advancement and Capsulodesis With Suture Tape Augmentation

Basal joint arthritis is commonly associated with attenuation of the volar structures at the thumb metacarpophalangeal (MCP) joint, leading to an initially dynamic, and eventually passive hyperextension deformity. In surgical treatment of basilar thumb disease, intervention at the MCP joint should also be considered to correct deformity and prevent persistent dysfunction. We present a novel technique using suture tape augmentation of the thumb MCP joint volar plate advancement and capsulodesis, with the goal of preventing recurrent instability as a result of tissue attenuation and enabling early functional recovery. We also report a representative case of a 66-year-old woman with symptomatic thumb carpometacarpal osteoarthritis and 50 degrees of MCP passive hyperextension. She underwent trapeziectomy and MCP joint volar plate advancement and capsulodesis with suture tape augmentation. Postoperatively, the patient underwent early mobilization of the affected thumb and at final follow-up of 2 years postsurgery had a painless thumb with full opposition and without hyperextension at the MCP joint during pinch maneuvers.

Modified Broström With and Without Suture Tape Augmentation: A Systematic Review

The Modified Broström has become the gold standard for operative management of chronic lateral ankle instability. Despite overall good clinical outcomes with this procedure, recent biomechanical data have called into question the strength and durability of this technique. Accordingly, the addition of suture tape to the Modified Broström construct has been described in an attempt to more closely recreate the natural biomechanical properties of the ankle lateral ligament complex. We performed a systematic review of the literature was using PubMed, Embase, and CINAHL to identify English-language articles from 2009 to present discussing outcomes with the augmented Modified Broström technique. A total of 4 studies (2 retrospective cohort studies, 2 case series) involving 156 patients with Modified Broström with augmentation met inclusion criteria. Average follow-up time was 13.8 months. Of the 3 studies reporting patient-reported outcome measures both pre- and postoperatively, there was a significant improvement in all measures (p < .05). Two studies compared the Modified Broström directly with and without augmentation, one of which found a statistically significant difference in the Foot and Ankle Ability Measure in favor of the augmentation group (93.1 vs 90.5, p = .027), while American Orthopaedic Foot and Ankle Society score was not significantly different (p > .05) between the 2 procedures across studies. There were no significant differences in complications between techniques. Modified Broström with suture tape augmentation for chronic lateral ankle instability can produce good short-term clinical outcomes with few complications, comparable to the Modified Broström alone.

Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

INTRODUCTION

Modified Brostrom Gould (MBG) repair is widely accepted procedure for chronic lateral ankle instability (CLAI), but there are limitations with regards to strength of repair and risk of reinjury and complications. Internal brace has been recently used as augmentation of standard MBG repair. It provides stronger construct, facilitates early mobilisation and protects repaired ligament with minimal surgical morbidity. The aim of present study is to compare the outcome of MBG repair without and with Internal brace augmentation (IB) in CLAI.

METHODS

Retrospective analysis of 172 patients with CLAI who underwent MBG repair with or without IBA between November 2017 and October 2019. Patients were evaluated for Visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), Patients subjective satisfaction and return to preinjury activity level.

RESULTS

148 patients were included in the study with 87 in MBG group and 61 in IB group. The mean age, average injury-surgery interval and mean follow up duration was 40.6 ± 11.2 vs 37.5 ± 14.7 years, 13.1 ± 10.3 vs 14.1 ± 8 months and mean follow up duration of 24.2 ± 5.1 vs 20.7 ± 6.0 months respectively (p > 0.05). The mean time to return to preinjury activity level was significantly better in IB group compared to MBG group of 12.1 ± 2.3 vs 20.3 ± 3.9 weeks, p < 0.001. 55 (90.2%) patients in IB and 73 (83.7%) in MBG group return to preinjury activity level. Mean postoperative VAS score (1.9 ± 1.5 vs. 1.7 ± 1.4, p = 0.428), Mean MOxFQ score (19.7 ± 22.2 vs. 18.2 ± 15.4, p = 0.674) showed no significant difference between MBG and IB group respectively, at final follow up.

CONCLUSION

The use of IB augmentation with MBG repair showed significantly better outcome in terms of early rehabilitation and return to preinjury activity level compared to isolated MBG repair. The functional outcome and VAS score were better in IB group compared to MBG group with no significant difference.

LEVEL OF EVIDENCE

Level IV retrospective study.

Proprioception and neuromuscular control at return to sport after ankle surgery with the modified Broström procedure

The modified Broström procedure (MBP) is an initial treatment for symptomatic chronic ankle instability (CAI) patients. This study aimed to compare the proprioception and neuromuscular control ability of both affected and unaffected ankles at the time of return to sports after MBP for patients with scores of normal controls. 75 individuals (40 who underwent MBP, 35 normal controls) participated. The dynamic balance test scores were significantly higher in the affected ankle of the patients than in the controls (1.5 ± 0.6° vs. 1.1 ± 0.4°, p < 0.003). The time to peak torque for dorsiflexion (60.8 ± 13.9 ms vs. 52.2 ± 17.5 ms, p < 0.022) and eversion (68.9 ± 19.1 ms vs. 59.3 ± 21.1 ms, p < 0.043) was significantly delayed in the affected ankle of the patients than in the controls. The dynamic balance test and time to peak torque in CAI patients remained significantly reduced at the time of return-to-sport after MBP. Clinicians and therapists should be aware of potential deficits in proprioception and neuromuscular control when determining the timing of return to sports after MBP.

Clinical outcomes of anterior tibiofibular ligament's distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients

PURPOSE

Treatment of chronic ankle instability (CAI) for ankle sprain patients remains a challenge. If initial treatments fail, surgical stabilization techniques including ligament reconstruction should be performed. Anterior tibiofibular ligament (ATiFL) distal fascicle transfer for CAI was recently introduced. The goal of the study is to assess the 1-year clinical effectiveness of ATiFL's distal fascicle transfer versus ligament reconstruction with InternalBrace™ (Fa. Arthrex, Naples).

METHODS

Between October 2019 and February 2021, 25 patients (14 males and 11 females) scheduled for ligament reconstruction treatment of CAI were enrolled after propensity score matching. Twelve underwent ligament reconstruction with InternalBrace™ (InternalBrace™ group) and thirteen underwent ATiFL's distal fascicle transfer (ATiFL's distal fascicle transfer group). We recorded the American Orthopedic Foot & Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), anterior drawer test grade, patient satisfaction and complications. All results of this study were retrospectively analyzed.

RESULTS

Statistically significant (p = 0.0251, independent-samples t test) differences in the AOFAS can be found between the ATiFL's distal fascicle transfer group and the InternalBrace™ group. No substantial changes in the VAS (p = 0.1778, independent-samples t test), patient satisfaction (p = 0.1800, independent-samples t test) and anterior drawer test grade (p = 0.9600, independent-samples t test) were found between the two groups. There was one patient with superficial wound infection and one patient with sural nerve injury in the InternalBrace™ group and ATiFL's distal fascicle transfer group, respectively.

CONCLUSION

This is the first study that assessed a cohort of CAI patients and suggests that the ATiFL's distal fascicle transfer operation has the potential to attain good-to-excellent clinical outcomes after 1-year recovery. The AOFAS scores were significantly higher for patients with ATiFL's distal fascicle transfer, indicating that this technique may be considered a viable option for both patients and their surgeon, while long-term outcomes should be investigated in the future.

Repair of Acute Patellar Tendon Rupture Using an Internal Brace Technique

Acute patellar tendon rupture is a serious injury, resulting in the disruption of the knee extensor mechanism. Many authors recommend augmented repairs of patellar tendon ruptures to allow early active rehabilitation. An internal brace technique, which is a ligament augmentation using high-strength suture tape and knotless anchors, has been used as augmentation for the primary tendon or ligament injury. A case of acute patellar tendon rupture in a Judo player, who was successfully treated with primary repair and augmentation using an internal brace technique, is presented. In this case, the patient regained full function of the knee and returned to full sports activities postoperatively. An internal brace technique provides biomechanical stability of the repaired tendon without donor site morbidity and could be an effective procedure for the treatment of acute patellar tendon rupture.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Ankle instability – review and new trends

Ankle instability is an old topic with increasing importance in Orthopaedics’ world, as we start now realising how underdiagnosed this pathology has been. A lot of effort has been made in recent years to better understand the pathomechanics of this injury, with new surgical techniques being tried and even new anatomic structures being described. The objective of this paper is to review and compile the most important and recent literature on this matter, in an academic way, but oriented to clinical practice, so it can help surgeons keep updated in this so important subject.

Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee

PURPOSE

Medial collateral ligament (MCL) injury is very common and surgical repair is sometimes necessary. Especially in the setting of simultaneous anterior cruciate ligament reconstruction (ACLR) as the ACL is the secondary restraint against valgus stress. The goal of this study was to evaluate knee biomechanics after suture repair of the MCL augmented with suture tape, as compared to MCL repair alone, in the setting of concomitant ACL reconstruction (ACLR).

METHODS

Fifteen fresh-frozen human cadaveric knees were tested using a six-degrees-of-freedom robotic system under four loadings: (a) an 89.0 N anterior tibial load, (b) a 5.0 Nm internal and external rotation torque, (c) a 10.0 Nm valgus load, (d) a 7.0 Nm valgus load combined with 5.0 Nm internal rotation torque as a static simulated pivot-shift. The tested conditions were ACLR with the following states: (1) MCL intact, (2) MCL deficient, (3) MCL Repair, and (4) MCL repair augmented with suture tape (MCL Repair + ST). Under the different knee loadings, the tibial displacement, and the force in either the intact MCL, suture repaired MCL or repaired MCL-suture tape complex was measured.

RESULTS

While neither the MCL Repair nor the MCL Repair + ST restored valgus rotation to the MCL intact state, displacement was significantly smaller after MCL Repair + ST (p < 0.05). The knee rotation under external rotation torque in MCL Repair + ST did not differ MCL intact (n.s.), while with MCL Repair the rotation was significantly greater (p < 0.05). MCL Repair + ST did not cause an over-constraint of the knee in any of the tested loading conditions.

CONCLUSION

In a combined ACL-reconstruction-MCL-repair model, MCL Repair augmented with suture tape improved valgus and external rotation laxity when compared to MCL suture repair alone. Suture tape augmentation may provide this additional means of stabilization and can be added at the time of surgical repair of the MCL. Clinically this may result in lower failure rates and less residual laxity after MCL repair, as well as shorter immobilization times and faster return to play.

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

BACKGROUND

Acute ankle sprains are common injuries. The anterior talofibular (ATFL) and calcaneofibular ligaments (CFL) are the most injured lateral structures. However, controversy exists on the optimal surgical treatment when the injury is both acute and severe or becomes chronic and unstable. Studies have evaluated the biomechanics of these ligaments, but no studies have robotically evaluated injury effects and surgical treatment of ATFL or ATFL and CFL injuries.

PURPOSE

To quantitatively evaluate biomechanical effects of ATFL and CFL lesions, ATFL repair, ATFL and CFL repair, and augmentation of ATFL on ankle stability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten nonpaired cadaveric ankles were tested using a 6 degrees of freedom robot. Each ankle underwent testing in the following states sequentially: (1) intact, (2) ATFL cut, (3) CFL cut, (4) ATFL repair + CFL cut, (5) ATFL repair + CFL repair, and (6) ATFL repair with augmentation with suture tape + CFL repair. Testing included 88 N anterior drawer and 5 N·m varus talar tilt tests at 0° and 30° of plantarflexion, and 88 N Cotton test at 0° of plantarflexion.

RESULTS

After all surgical treatments ankles still had increased laxity compared with intact state testing, except after augmented ATFL repair + CFL repair in anterior drawer testing at 30° of plantarflexion (P = .393). Sectioning the CFL caused a significant increase in talar tilt compared with the ATFL cut state at 0° (P < .001) and 30° of plantarflexion (P < .001), but no increase in anterior drawer or Cotton tests.

CONCLUSION

Complete native stability may not be attainable at time zero repair with the tested treatments. The option that best returned stability in anterior translation was augmented ATFL repair with nonaugmented CFL repair. The importance of the CFL as a primary ligamentous stabilizer for talar tilt was confirmed.

CLINICAL RELEVANCE

Evaluating lateral ankle stability and treatment with a 6 degrees of freedom robot should help delineate optimal treatment options. Findings in this study show that none of the repair methods at time zero restored kinematics to the intact state. Of the tested states, the augmented ATFL repair with CFL repair was the best option for controlling anterior translation at time zero. The importance of addressing the CFL to correct talar tilt instability was suggested as was the importance of a period of immobilization before beginning protected rehabilitation. The benefit of ATFL repair augmentation with suture tape is in limiting the postoperative motion in an anterior drawer motion to just 0.5 to 1 mm, but there was no significant improvement to talar tilt even with CFL repair, suggesting that further consideration should be given to CFL augmentation in future studies.

Postoperative Rehabilitation of Chronic Lateral Ankle Instability: A Systematic Review

Chronic lateral ankle instability often causes adults to require a surgical intervention with subsequent physical therapy to assist with returning to their prior level of function. This systematic review is hoping to provide an up to date understanding of surgical procedures performed to correct chronic lateral ankle instability and establish a protocol for others to follow when treating adults who are status-post chronic lateral ankle instability surgery. This review looked at level I to III research studies that included surgical interventions to correct chronic lateral ankle instability as well as a rehabilitation protocol. This study found implementation of a rehabilitation protocol after surgical intervention could improve balance and subjective functional outcomes. It also determined that early weight-bearing may allow for early strengthening as range of motion returns faster. Further research is required utilizing larger randomized studies to better evaluate the outcomes of specific rehabilitation protocols in this patient population.

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

Arthroscopic Internal Brace Augmentation With Arthroscopic Modified Broström Operation for Chronic Ankle Instability

Lateral ankle sprains are very common injuries that sometimes lead to chronic lateral ankle instability. The modified Broström operation is the gold standard procedure for treatment of chronic lateral ankle instability. Currently, this operation is performed arthroscopically. Broström repair depends on the quality of the remnant ligament. In cases with an insufficient remnant ligament, Gould augmentation or reconstruction using the gracilis tendon is generally performed. Recently, tape augmentation (internal brace) also has been used to support an insufficient ligament. This article introduces arthroscopic tape augmentation with arthroscopic modified Broström operation. This technique consists of creation of a talar anchor hole and fibular anchor hole, reattachment of the remnant ligament to the fibula with tape, and tape fixation to the talus. This technique uses only one knotless anchor screwed to the fibula for both the modified Broström operation and fixation of the tape. This technique is relatively simple and produces similar results as an open procedure.

Evolution in Surgical Management of Ankle Instability in Athletes

Recent concepts are changing the management of ankle instability. These include concurrent medial and lateral instabilities, use of ankle arthroscopy, use of suture anchors, all-arthroscopic stabilization, synthetic augmentation, and early postoperative rehabilitation. Medial sided injuries occur in up to 72% of the lateral ankle sprains, and concomitant repair may provide greater stability. Suture anchors are equally as strong as transosseous tunnels, and the technique is simple, reproducible, and may decrease complications, but anchors do increase costs. Synthetic augmentation demonstrates greater strength than Broström alone in cadaver-based biomechanical testing. Although clinical studies of synthetic augmentation have demonstrated equivocal stability and pain compared with Broström alone, synthetic augmentation may expedite rehabilitation. All-arthroscopic ankle stabilization is gaining popularity with increasing publications. Early findings demonstrate comparable biomechanical and clinical data compared with open techniques. Early postoperative weight-bearing within 2 weeks seems to be safe and may shorten time to return to play. Surgeons may consider using these novel techniques in the management of lateral ankle instability.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

Anterior Talofibular Ligament Repair With Suture Tape Augmentation

The most common injury sustained to the ankle ligaments is a result of inversion of the foot. This mechanism results in injury to the anterior talofibular ligament alone or in conjunction with the calcaneofibular ligament and posterior talofibular ligament. Patients experiencing recurrent ankle sprains despite nonoperative measures often require surgical management. Recent focus has been on augmentation procedures to improve the stability of a lateral ankle ligament repair by protecting it during the healing phase and supporting early mobilization. This article describes, with video illustration, anterior talofibular ligament repair with suture tape augmentation.

High-Strength Suture Tape Augmentation Improves Cyclic Gap Formation in Transosseous Patellar Tendon Repair: A Biomechanical Study

Purpose

To compare gap displacement at various intervals of cyclic testing and biomechanical load to failure of a Krackow patellar tendon repair augmented with high-strength suture tape versus the standard Krackow transosseous technique for inferior pole patellar tendon rupture.

Methods

Twelve matched pairs of cadaveric knees were used (8 males and 4 females; mean age 79.6 years, range 57 to 96). An inferior pole patellar tendon rupture was simulated after random assignment of specimens in each pair to the standard or augmented Krackow technique. Each specimen was then repetitively cycled from 90° to 5° for 1,000 cycles. A differential variable reluctance transducer was used to measure gap displacement. After cyclic loading, load to failure was determined by pulling the tendon at a rate of 15 mm/s until a sudden decrease in load occurred.

Results

Compared with the control repair, specimens with augmented repair demonstrated significantly less displacement at all testing intervals up to 1,000 cycles (P < .05). Two patellar tendons failed before the end of cyclic loading, and 4 specimens had inadequate tendon length for loading. Among the 18 remaining specimens, no significant difference in load to failure was observed between the experimental group (n = 11) and the control group (n = 7) (1,006.5 ± 332.1 versus 932.8 ± 229.1 N, respectively; P = .567).

Conclusions

Significantly greater gap displacement was observed in the standard Krackow repair group compared with the augmented Krackow group at all cyclic loading intervals. This suggests that the Krackow transosseous procedure augmented with high-strength suture tape is biomechanically viable for inferior pole patellar tendon repair.

Clinical Relevance

This biomechanical study supports the use of high-strength suture tape augmentation of Krackow transosseous repair for inferior pole patellar tendon rupture.

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability

Syndesmotic instability is a source of significant pain and disability. Both subtle instability and gross diastasis, whether acute or chronic, require stabilization and may benefit from reconstruction with ligamentous augmentation. The use of nonabsorbable suture-tape has emerged as a promising operative strategy, allowing surgeons to anatomically reconstruct the syndesmosis, in particular the anterior inferior tibiofibular ligament. The current work provides a detailed description of the technique and preliminary results of a patient cohort treated using nonabsorbable suture-tape for syndesmotic augmentation.Level of Evidence: Level V, expert opinion.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability

Background

Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.

Purpose

To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.

Results

A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.

Conclusion

No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Normal Kinematics of the Syndesmosis and Ankle Mortise During Dynamic Movements

Background:

Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space.

Methods:

Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition.

Results:

Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space (P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space (P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively.

Conclusion:

These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics.

Clinical Relevance:

Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.

Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

INTRODUCTION

Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study was to analyze and assess the variability across different rehabilitation protocols for patients undergoing either lateral ankle ligament repair, reconstruction, and suture tape augmentation.

METHODS

Using a web-based search for published rehabilitation protocols after lateral ankle ligament repair, reconstruction, and suture tape augmentation, a total of 26 protocols were found. Inclusion criteria were protocols for post-operative care after an ankle ligament surgery (repair, reconstruction, or suture tape augmentation). Protocols for multi-ligament surgeries and non-operative care were excluded. A scoring rubric was created to analyze different inclusion, exclusion, and timing of protocols such as weight-bearing, range of motion (ROM), immobilization with brace, single leg exercises, return to running, and return to sport (RTS). Protocols inclusion of different recommendations was recorded along with the time frame that activities were suggested in each protocol.

RESULTS

Twenty-six protocols were analyzed. There was variability across rehabilitation protocols for lateral ankle ligament operative patients especially in the type of immobilizing brace, time to partial and full weigh bearing, time to plantar flexion, dorsiflexion, eversion and inversion movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement between protocols. All (12/12) repair, internal brace, and unspecified protocols and 86% (12/14) of reconstruction protocols recommended no ROM immediately postoperatively. Eighty-six percent (6/7) of repair and 78% (11/14) of reconstruction protocols recommended no weight-bearing immediately after surgery, making post-operative ROM and weight-bearing status the most consistent aspects across protocols. Five protocols allowed post-operative weight-bearing in a cast to keep ROM restricted. Sixty-six percent (2/3) of suture tape augmentation protocols allowed full weight-bearing immediately post-operatively. Suture tape augmentation protocols generally allowed rehabilitation to occur on a quicker time-line with full weight-bearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3) protocols. RTS was consistent in repair protocols (100% at week 12-16) but varied more in reconstruction.

CONCLUSION

There is significant variability in the post-operative protocols after surgery for ankle instability. ROM was highly variable across protocols and did not always match-up with supporting literature for early mobilization of the ankle. Return to sport was most likely to correlate between protocols and the literature. Weight-bearing was consistent between most protocols but requires further research to determine the best practice. Overall, the variability between programs demonstrated the need for standardization of rehabilitation protocols.

Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation

Background

Surgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs.

Methods

Cadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation.

Results

Augmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor.

Conclusion

When positioned in neutral forearm rotation and 90^o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.

Arthroscopically Assisted Tape Augmentation for Anterior Talofibular Ligament Repair

In this Technical Note, we describe arthroscopically assisted tape augmentation of a modified Broström repair for chronic lateral ankle instability. Specifically, this technique involves talar anchor placement under direct arthroscopic visualization combined with a minimally invasive approach for anatomic anterior talofibular ligament repair and FiberTape (Arthrex, Naples, FL) augmentation. The primary advantage of our technique compared with open InternalBrace (Arthrex) techniques is that only a 2-cm incision is made and no subcutaneous suture passing and knot tying are required, which bear the danger of superficial peroneal nerve damage. In addition, the risk of nonanatomic anchor placement is diminished owing to direct arthroscopic visualization and preparation of the anterior talofibular ligament remnants.

Biomechanical evaluation of PCL reconstruction with suture augmentation

PURPOSE

The purpose of this study was to compare kinematics and patellofemoral contact pressures of all inside and transtibial single bundle PCL reconstructions and determine if suture augmentation further improves the biomechanics of either technique.

METHODS

Cadaveric knees were tested with a posterior drawer force, and varus, valgus, internal and external moments at 30, 60, 90, and 120° of flexion. Displacement, rotation, and patellofemoral contact pressures were compared between: Intact, PCL-deficient, All-Inside PCL reconstruction with (AI-SA) and without (AI) suture augmentation, and transtibial PCL reconstruction with (TT-SA) and without (TT) suture augmentation.

RESULTS

Sectioning the PCL increased posterior tibial translation (PTT) from intact at 60° to 120° of flexion, p < 0.001. AI PCL reconstruction improved stability from the deficient-state but had greater PTT than intact at 90° of flexion, p < 0.05. Adding suture augmentation to the AI reconstruction further reduced PTT to levels that were not statistically different from intact at all flexion angles. TT reconstructed knees had greater PTT than intact knees at 60, 90, and 120° of flexion, p < 0.01. Adding suture augmentation (TT-SA) improved posterior stability to PTT levels that were not statistically different from intact knees at 30, 60, and 120° of flexion. Patellofemoral pressures were highest in PCL-deficient knees at increased angles of flexion and were reduced after reconstruction, but this was not significant.

CONCLUSION

In this time-zero study, both the all-inside and transtibial single bundle PCL reconstructions effectively reduce posterior translation from the deficient-PCL state. In addition, suture augmentation of both techniques provided further anterior-posterior stability.

Modified Broström Repair With and Without Augmentation Using Suture Tape for Chronic Lateral Ankle Instability

Objective

To compare the clinical and radiological outcome between the modified Broström repair with augmentation using suture tape (MBA) and the modified Broström repair (MB) for patients with chronic lateral ankle instability.

Methods

A retrospective study was performed in Ningbo No. 6 Hospital. The study included 53 patients who underwent surgical treatment from March 2014 to July 2016 and were followed for 2 years. A total of 25 patients underwent modified Broström repair with augmentation using suture tape, and 28 patients were treated with modified Broström repair. Patients were evaluated using the American Orthopedic Foot and Ankle Scale (AOFAS) hindfoot scale, the Foot and Ankle Ability Measure (FAAM) score, range of motion (ROM), and the visual analogue scale (VAS). The talar tilt angle (TTA) and anterior talar translation (ATT) were used to evaluate the mechanical stability. All radiological outcomes were measured by two orthopaedic surgeons, with the measurements repeated 3 days later.

Results

The mean age of the patients was 26.6 ± 17.8 years in the MBA group and 28.1 ± 19.4 years in the MB group, and no statistical difference in preoperative data was found between two groups. There were significant differences before and after the operation within the groups. Both groups achieved satisfactory outcomes, and significant improvements (VAS, FAAM, AOFAS, TTA, and ATT) were observed between the 1‐year follow‐up and final follow‐up (P < 0.05). The MBA group showed significant improvement in the FAAM Sport (87.1 ± 5.4 vs 78.2 ± 12.0, P = 0.001) and total scores (93.1 ± 2.3 vs 90.5 ± 5.1, P = 0.027) at the final follow‐up compared with the MB group, and for the other outcomes, there were no significant differences between the two groups.

Conclusion

The modified Broström repair with augmentation using suture tap for chronic lateral ankle instability achieves a better outcome; however, further research is necessary.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment.

METHODS

Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018.

RESULTS

One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies.

CONCLUSIONS

There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data.

LEVEL OF EVIDENCE

Level IV, review of level I, II, III and IV studies.

Arthroscopic ankle lateral ligament repair with biological augmentation gives excellent results in case of chronic ankle instability

PURPOSE

The open "Broström-Gould" procedure has become the gold standard technique for the treatment of chronic ankle instability. Although arthroscopic techniques treating ankle instability have significantly evolved in the last years, no all arthroscopic Broström-Gould has been described. The aim of the study was to describe the all-arthroscopic Broström-Gould technique [anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER)], and to evaluate the clinical results in a group of patients.

METHODS

Fifty-five patients with isolated lateral ankle instability were arthroscopically treated. Arthroscopic ATFL repair with biological augmentation was performed through a two-step procedure. First, the ligament is reattached through an arthroscopic procedure. Next, the ligament is augmented with the IER that is endoscopically grasped. Both the ligament repair and its augmentation with IER were performed with the help of an automatic suture passer and two soft anchors. Characteristics of the patients, and pre- and postoperatively AOFAS and Karlsson scores were recorded.

RESULTS

The median preoperative AOFAS score increased from 74 (range 48-84) to 90 (range 63-100). According to the Karlsson score, the median preoperative average increased from 65 (range 42-82) to 95 (range 65-100). No major complications were reported. Only one case (1.8%) required a revision surgery at 23 months of follow-up.

CONCLUSION

The arthroscopic all-inside ATFL repair with biological augmentation using the IER is a reproducible technique. Excellent clinical results were obtained. The technique has the advantage of its minimally invasive approach and the potential to treat concomitant ankle intra-articular pathology.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Modified Broström procedure in patients with chronic ankle instability is superior to conservative treatment in terms of muscle endurance and postural stability

PURPOSE

To compare muscle strength, muscle endurance, and postural stability in both the affected and unaffected ankles between patients with chronic ankle instability (CAI) who underwent conservative treatment and those who underwent the modified Broström procedure (MBP).

METHODS

A total of 67 patients (37, conservative treatment; 30, MBP) participated. Muscle strength and muscle endurance were measured using an isokinetic device, and postural stability was tested using a postural stabilometry system. We used the independent t test for continuous variables with a normal distribution and Fisher's exact test for categorical variables.

RESULTS

There was no difference in the muscle strengths of the affected and unaffected ankles between the groups. The muscle endurance of plantarflexion and inversion muscles was significantly lower in the affected ankles of the conservative treatment group than in those of the MBP group (plantarflexion: 209 ± 103.1 vs. 318 ± 162.2, p = 0.001; inversion: 93 ± 58.7 vs. 154 ± 65.9, p < 0.001). Static postural stability testing showed no significant differences between the affected and unaffected ankles of the two groups. In the dynamic postural stability test, the overall, anterior-posterior, and medial-lateral stability indices were all significantly higher in the affected ankles of the conservative treatment group than in those of the MBP group (p < 0.001, p = 0.004, p = 0.004, respectively), with no differences observed in the unaffected ankles.

CONCLUSION

The MBP may significantly improve muscle endurance and dynamic postural stability in CAI patients in whom conservative treatment has failed. Therefore, clinicians should consider using MBP instead of conservative treatment when patients show severe muscle weakness or dynamic postural instability.

LEVEL OF EVIDENCE

Case-control study, Level III.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality

PURPOSE

An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality.

METHODS

Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair.

RESULTS

Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up.

CONCLUSION

Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality.

LEVEL OF EVIDENCE

IV, retrospective case series.