Percutaneous Ankle Reconstruction of Lateral Ligaments

Chronic ankle instability: a cadaveric anatomical and 3D high-resolution MRI study for surgical reconstruction procedures

OBJECTIVES

To quantitatively investigate the anatomy of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) for surgical reconstruction procedures in chronic ankle instability (CAI).

METHODS

3D MRI was performed on five fresh-frozen cadaveric ankles using six different spatial resolutions (0.3 × 0.3 × 0.3 mm3, 0.45 × 0.45 × 0.45 mm3, 0.6 × 0.6 × 0.6 mm3, 0.75 × 0.75 × 0.75 mm3, 0.9 × 0.9 × 0.9 mm3, 1.05 × 1.05 × 1.05 mm3). After comparing the MRI results with cadaver dissection, a resolution of 0.45 × 0.45 × 0.45 mm³ was selected for bilateral ankles MRI on 24 volunteers. Classification of the ATFL and four distances of surgically relevant bony landmarkers were analyzed (distance 1 and 3, the fibular origin of the ATFL and CFL to the tip of fibula, respectively; distance 2, the talar insertion of the ATFL to the bare zone of talus; distance 4, the calcaneal insertion of the CFL to the peroneal tubercle).

RESULTS

In subjective evaluation, the interobserver ICC was 0.95 (95% confidence interval (CI): 0.94-0.97) between two readers. The spatial resolution of 0.3 × 0.3 × 0.3 mm3 and 0.45 × 0.45 × 0.45 mm3 received highest subjective score on average and demonstrated highest consistency with autopsy measurements in objective evaluation. Measurements on the 48 volunteer ankles, distance 1 in type I and II were 12.65 ± 2.08 mm, 13.43 ± 2.06 mm (superior-banded in Type II) and 7.69 ± 2.56 mm (inferior-banded in Type II) (means ± SD), respectively. Distance 2 in type I and II were 10.90 ± 2.24 mm, 11.07 ± 2.66 mm (superior-banded in Type II), and 18.44 ± 3.28 mm (inferior-banded in Type II), respectively. Distance 3 and 4 were 4.71 ± 1.04 mm and 14.35 ± 2.22 mm, respectively.

CONCLUSION

We demonstrated the feasibility of quantifying the distances between bony landmarkers for surgical reconstruction surgery in CAI using high-resolution 3D MRI.

CRITICAL RELEVANCE STATEMENT

High-resolution 3D MRI examination may have a guiding effect on the preoperative evaluation of chronic ankle instability patients.

KEY POINTS

Spatial resolutions of 0.3 × 0.3 × 0.3 mm3 and 0.45 × 0.45 × 0.45 mm3 demonstrated highest consistency with autopsy measurements. The spatial resolution of 0.45 × 0.45 × 0.45 mm3 was conformed more to clinical needs. 3D MRI can assist surgeons in developing preoperative plans for chronic ankle instability.

A novel classification of lateral malleolus morphological characteristics based on three-dimensional computed tomography reconstruction

BACKGROUND

The study was to establish a novel classification of the morphological characteristics of fibula anterior-inferior margin (FAIM), which was reported in few studies.

METHODS

The 501 images with three-dimensional computed tomography (3D CT) reconstruction were reviewed retrospectively. The width, height, thickness, long axis, short axis, and lateral malleolus angle were measured.

RESULTS

The FAIM was divided into Angular, Flat, and Arc. The Flat has no distinct fibular obscure tubercles (FOT). The short axis of Angular and Arc were more significant than the Flat (P < 0. 05). The height of left was larger than the right, but short axis was less than it (P < 0.05). The height and short axis of males were larger than the females (P < 0.05).

CONCLUSIONS

A novel classification (the Angular, Flat and Arc) of FAIM was identified based on lateral malleolus morphology, and it suggested that not all have obvious FOT.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective study.

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

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

Return to sports after ankle reconstruction with tendon grafts in chronic lateral ankle instability: A systematic review and meta-analysis

Purpose

Anatomic reconstruction using grafts is being performed more frequently in athletes experiencing recurrent chronic lateral ankle instability (CLAI). The purpose of the study was to systematically review the current literature to determine the rates of return to sports (RTS) along with timing in patients with CLAI undergoing ligament reconstruction.

Methods

The databases PubMed, Scopus, Cochrane, and Embase were searched based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles quoting on the return to sports rate after lateral ankle reconstruction were included. The rates of return to any sports, return to pre-injury sports, and return to competitive sports along with the timing of return were evaluated and a proportion meta-analysis was performed.

Results

A total of 720 patients in 20 studies met our inclusion criteria. The RTS rates for any sports were 95.3%, and 84.3% for pre-injury sports The average time taken for return to sports was 17 weeks. Postoperative functional outcomes, ankle stability, and ROM were significantly improved in comparison to preoperative status.

Conclusion

The RTS rates following lateral ankle reconstruction in CLAI showed a high return to any sports, but moderate to high rates for the pre-injury or competitive level of sports.

Level of evidence

Level of evidence II.

Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It?

Understanding of the ankle and subtalar joint ligaments is essential to recognize and manage foot and ankle disorders. The stability of both joints relies on the integrity of its ligaments. The ankle joint is stabilized by the lateral and medial ligamentous complexes while the subtalar joint is stabilized by its extrinsic and intrinsic ligaments. Most injuries to these ligaments are linked with ankle sprains. Inversion or eversion mechanics affect the ligamentous complexes. A profound knowledge of the ligament's anatomy allows orthopedic surgeons to further understand anatomic or nonanatomic reconstructions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

CRD42022362045.

Comparison Between the Simultaneous Reconstructions of the Anterior Talofibular Ligament and Calcaneofibular Ligament and the Single Reconstruction of the Anterior Talofibular Ligament for the Treatment of Chronic Lateral Ankle Instability

This study aimed to evaluate the procedures of reconstruction surgery for chronic lateral ankle instability. We compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. From 2015 to 2019, 14 consecutive patients diagnosed with chronic lateral ankle instability underwent arthroscopic anterior talofibular ligament reconstruction with or without calcaneofibular ligament reconstruction after conservative treatment. Seven patients underwent single anterior talofibular ligament reconstruction (group AT), and 7 patients underwent simultaneous reconstructions of the anterior talofibular ligament and calcaneofibular ligament (group AC). The Japanese Society for Surgery of the Foot scale scores and Karlsson scores significantly improved in all patients 1 year postoperatively. The radiographic measurement of the talar tilt angle and the talar anterior drawer distance at 1 year after surgery were also significantly improved compared to preoperative values. The postoperative talar tilt angle was significantly greater in group AT (median 6°, range 3°-7°) than that in group AC (median 3°, range 2°-5°; p = .038). The postoperative talar anterior drawer distance, Japanese Society for Surgery of the Foot scale score, and Karlsson score were not significantly different between the 2 groups. We found that although the clinical outcomes after the anterior talofibular ligament reconstruction with or without the calcaneofibular ligament reconstruction for chronic lateral ankle instability were good, instability of the talar tilt angle at 1 year postoperatively in patients who underwent single anterior talofibular ligament reconstruction was greater than that in patients who underwent simultaneous anterior talofibular and calcaneofibular ligament reconstructions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Imaging of Peritalar Instability

Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.

Arthroscopic Assessment and Treatment of Medial Collateral Ligament Complex

An increased interest in ankle instability has led to description of new concepts such as ankle microinstability or rotational ankle instability and the development of new arthroscopic techniques treating ankle instability. Ankle instability is constantly associated to intraarticular pathologies that contribute to generate pain and dysfunction. Arthroscopy plays an important role in identifying and treating all intraarticular abnormalities including ligament injuries. Despite a few studies are available in literature on arthroscopic treatment of medial collateral ligament injury, an arthroscopic all-inside repair of lateral and medial ankle ligaments has been proposed showing promising clinical results.

The Location of the Fibular Tunnel for Anatomically Accurate Reconstruction of the Lateral Ankle Ligament: A Cadaveric Study

We aimed to describe the location of fibular footprint of each anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), as well as their common origin in relation to bony landmarks of the fibula in order to determine the location of the fibular tunnel. In 105 ankle specimens, the center of the footprints of the ATFL and CFL (cATFL and cCFL, respectively) and the intersection point of their origin (intATFL-CFL) were investigated, and the distances from selected bony landmarks (the articular tip (AT) and the inferior tip (IT) of the fibula) were measured. Forty-two (40%) specimens had single-bundle ATFL, and 63 (60%) had double-bundle patterns. The distance between intATFL-CFL and IT was 12.0 ± 2.5 mm, and a significant difference was observed between the two groups (p = 0.001). Moreover, the ratio of the intATFL-CFL location based on the anterior fibular border for all cadavers was 0.386. The present study suggests a reference ratio that can help surgeons locate the fibular tunnel for a more anatomically accurate reconstruction of the lateral ankle ligament. Also, it may be necessary to make a difference in the location of the fibular tunnel according to the number of ATFL bundles during surgery.

Hybrid Ankle Reconstruction of Lateral Ligaments

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

A modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction: medium-term clinical and radiologic results comparable with open reconstruction

BACKGROUND

The aim of this study was to compare clinical and radiologic outcomes of a modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction with traditional open reconstruction.

METHODS

From January 2012 and March 2016, 60 eligible patients with chronic lateral ankle instability (CLAI) received all arthroscopic remnant-preserving reconstruction or open reconstruction of the anterior talofibular ligament and calcaneofibular ligament using semitendinosus autograft. They were divided into the arthroscopic group (n = 28) and the open group (n = 32). The American Orthopaedic Foot and Ankle Society (AOFAS),visual analog scale (VAS), and Karlsson scores and ankle range of motion (ROM) were used to evaluate clinical outcomes pre-operatively and at six and 12 months and the final follow-up of at least 24 months post-operatively, with SF-36 physical component summary (PCS) and mental component summary (MCS) scores evaluated for quality of life, and the anterior talar translation and talar tilt measurements for radiologic outcomes.

RESULTS

There was no difference in pre-operative demographics between two groups (P > 0.05). At the final follow-up, the AOFAS, VAS, Karlsson, SF-36 PCS, and MCS scores improved significantly in both groups (P < 0.05). However, no significant difference was found in AOFAS (91.9 ± 6.8 vs 91.1 ± 5.5), VAS (2.7 ± 1.7 vs 2.5 ± 1.6), Karlsson (95.3 ± 6.7 vs 94.8 ± 6.5), SF-36 PCS (53.2 ± 6.1 vs 52.9 ± 5.7), and MCS scores (55.7 ± 5.8 vs 54.2 ± 5.4) between the two groups (P > 0.05). There was no significant difference in post-operative operated/non-operated ankle ROM between two groups (P > 0.05). No significant difference was observed in talar tilt angle (7.6 ± 4.1° vs 6.8 ± 3.6°) and anterior talar translation (5.8 ± 1.7 mm vs 5.7 ± 1.5 mm) between the two groups at the final follow-up (P > 0.05), although these two variables improved significantly in both groups (P < 0.05). No severe complications were encountered in both groups during the follow-up period.

CONCLUSIONS

The modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction could produce excellent clinical and radiologic outcomes comparable with open reconstruction.

A New Individualized Three-Dimensional Printed Template for Lateral Ankle Ligament Reconstruction

Background

Anatomical reconstruction using a semitendinosus tendon autograft is one of the most widely-used techniques for chronic lateral ankle instability (CLAI), and it can result in good biomechanical recovery for patients. The purpose of this study was to investigate the outcome of a novel individualized three-dimensional printed guide template for lateral ankle ligament reconstruction compared with the traditional surgical methods.

Material/Methods

We retrospectively studied 34 patients with CLAI who required lateral ankle ligament reconstruction. Patients were randomly divided into 2 cohorts: the template group (18 patients) and the conventional group (16 patients). The average operation duration and number of radiation exposures were compared between the 2 cohorts. The displacement of anterior talar and talar tilt angle were recorded at the last follow-up, and Karlsson-Peterson score and American Orthopedic Foot and Ankle Society Score (AOFAS) were also compared.

Results

All patients had satisfactory ankle stability at the last follow-up. The average operation duration was 51.9±3.6 min and the average number of radiation exposures was 1.34±0.6 in the template group, and the average operation duration was 72.4±12.6 min and the average number of radiation exposures was 6.58±1.7 in the conventional group. Difference between the 2 cohorts was statistically significant. However, in AOFAS (95.2±2.5 vs. 94.9±2.2; P>0.01.) and Karlsson Score (94.7±3.6 vs. 93.8±4.1; P>0.01.), no significant differences were found between the 2 cohorts.

Conclusions

Both the template technique and the conventional method provided satisfactory outcomes for CLAI patients. However, the shorter operation duration and low number of radiation exposures in the template cohort suggest it is the better alternative for treatment of CLAI.