The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact

Corticospinal tract alterations after ankle sprain in adolescence: Insights from the mouse model

Purpose

Lateral ankle sprains (LAS) are associated with corticospinal pathway deficits. Existing evidence is primarily based on cross-sectional investigations and noncausal speculations. This study aims to determine whether maladaptive corticospinal pathway alterations occur pre- and postligament transection in LAS mouse models. Additionally, this study explores whether the alterations are more pronounced in adolescent mice than adults.

Methods

Twenty-four 8-week-old adolescent and twenty-four 24-week-old adult mice were randomly assigned to lateral ankle ligament transection or sham surgery. Diffusion-weighted imaging of the corticospinal pathway was performed presurgery and 8 weeks postsurgery. Fractional anisotropy (FA) values, reflecting fiber integrity within the corticospinal subregions of the medulla, pons, midbrain, and cerebrum, were extracted.

Results

Overall, 41 mice completed repeated image acquisition. Before surgery, no significant group effects on FA within the four corticospinal subregions were detected in either adolescent or adult mice. Two months after surgery, the adolescent cohort displayed a significant reduction in FA in the medulla subregion following ankle ligament transection (β-baseline-adjusted ​= ​-0.083, 95% CI , -0.145 to -0.021, p-corrected ​= ​0.048). Conversely, no significant effects of ankle ligament transection on corticospinal FA were observed in the adult cohort.

Conclusion

The maladaptive alterations in the corticospinal tract could be observed in the adolescent LAS mouse model, characterized by reduced fiber integrity in the medulla subregion. While these results are derived from an animal model, they provide a foundation for future investigations into the mechanisms underlying neurological deficits following musculoskeletal injuries.

Routine 2D MRI identifies the anterior talofibular ligament fascicles and lateral fibulotalocalcaneal ligament complex with moderate to substantial interobserver reliability

PURPOSE

The anterior talofibular ligament (ATFL) consists of two fascicles, with the intra-articular superior fascicle and extra-articular inferior fascicle connected to the calcaneofibular ligament (CFL) via the arciform fibres, forming the lateral fibulotalocalcaneal ligament (LFTCL) complex. Accurate identification of which fascicles have been injured is useful for determining the optimal treatment of patients with lateral ligament injuries. There is a lack of imaging studies demonstrating the distinctive anatomy of these important structures on magnetic resonance imaging (MRI). Hence, the aim of this pilot study is to investigate interobserver reliability in identifying the fascicles of the ATFL and LFTCL complex on routine two-dimensional (2D) MRI scans.

METHODS

This is a single-centre review of 100 consecutive routine 2D MRI ankles performed in our institution for reasons other than ankle sprain. The ATFL fascicles and LFTCL complex were independently reviewed by three clinicians, and interobserver reliability was analysed using Fleiss kappa.

RESULTS

There were 46 males, and the average age was 47.7 years. In terms of the interobserver reliability, there was a substantial level of agreement in determining the number of fascicles for the ATFL (k = 0.688, p < 0.001, 95% confidence interval [CI]: 0.575-0.801) which was similar to the CFL (k = 0.747, p < 0.001, 95% CI: 0.633-0.860) while the arciform fibres had a moderate level of agreement (k = 0.489, p < 0.001, 95% CI: 0.377-0.603). There were 54 MRI scans with bifascicular ATFL, while the rest had a single inferior ATFL fascicle. The LFTCL complex was identified in 99 scans. No differences were noted in age, gender or MRI strength in the ability to visualize these structures on routine 2D MRI scans.

CONCLUSION

Routine 2D MRI can reliably identify the fascicles of the ATFL and LFTCL complex with moderate to substantial levels of agreement. This can help clinicians enhance their diagnostic accuracy and refine treatment strategies without relying on complex or costly imaging techniques.

LEVEL OF EVIDENCE

Level III.

Ligamentous ankle injuries in relation to the morphology of the incisura fibularis: A systematic review

IMPORTANCE

Ligamentous ankle lesions are among the most frequent sports injuries. One of the key intrinsic stabilizers of the ankle joint is the incisura fibularis (IF), as it interlocks the distal tibia and fibula. Despite an abundant amount of studies related to ligamentous ankle injuries, scant attention has been given to the specific role of the IF morphology.

OBJECTIVE

We systematically reviewed all literature focused on the relation between ligamentous ankle lesions and IF morphology.

EVIDENCE REVIEW

A systematic literature search was conducted on PubMed, Embase, and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021282862). In general, search terms were related to ankle and syndesmosis trauma/instability in combination with morphology parameters of the IF. Studies categorizable as original research (randomized controlled trial or observational) were included. Studies concerning degenerative ankle disease and cadavers were excluded.

FINDINGS

Thirteen studies were confirmed eligible and consisted of a prospective cohort (n ​= ​1), retrospective comparative (n ​= ​10), and observational (n ​= ​2) study design. Several studies have found an increased number of ankle ligament injuries and a higher incidence of chronic ankle instability in association with a shallow IF depth. In addition, statistically significant differences in incisura height and angle were also noted: a shorter incisura and more obtuse angle were more present in patients with ankle ligament injuries.

CONCLUSION AND RELEVANCE

Most studies found distinct characteristics of the IF morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. However, not all studies could identify this association and presented a heterogeneous methodological quality. Therefore, further prospective studies are warranted to clarify the relationship between the IF morphology and ligamentous ankle injuries.

LEVER OF EVIDENCE

Level III, systematic review.

Risk factors for the recurrence of instability after operative treatment of chronic lateral ankle instability: A systematic review

Purpose

To identify, review and summarize risk factors for failure of lateral ankle ligament operative treatment for chronic lateral ankle instability (CLAI).

Methods

A Systematic review according to PRISMA guidelines was performed. In July 2023, a bibliographic search of the PubMed, Medline, CINAHL, Cochrane, and Embase databases was performed. Articles were included if they were quantitative studies published in English and reported risk factors for recurrence of instability.

Results

A total of 496 articles were identified using the search strategy, and nine articles were included. All were low-quality cohort studies (level 3 or 4 evidence). These nine studies comprising 762 participants met the criteria for inclusion. Eighty-nine patients (11%) had treatment failure as defined by recurrence of instability, with rates ranging from 5.7% to 28.5%. Six risk factors were divided into three categories: patient demographics (generalized joint laxity [GJL], high-level sports activities and female sex), imaging features (varus hindfoot alignment), and surgical findings (poor quality of the remnant lateral ligaments, intraoperative syndesmosis widening).

Conclusion

The presence of risk factors such as GJL, high-level sports activities, female sex, varus hindfoot alignment, poor ligament quality, and intraoperative syndesmosis widening should guide surgical strategy to reduce the risk of treatment failure in lateral ankle ligament repair for CLAI.

Level of Evidence

Level IV, systematic review.

All-Inside Endoscopic Classic Bröstrom-Gould Technique: Medium-term Results

BACKGROUND

Short-term results after arthroscopic/endoscopic lateral ligament repair for chronic lateral ankle instability have been satisfactory, although medium- to longer-term results are lacking.

PURPOSE/HYPOTHESIS

The purpose of this study was to report the medium-term results of an all-inside endoscopic classic Bröstrom-Gould procedure where both the both lateral ligaments and the inferior extensor retinaculum can be approached directly, interchanging between arthroscopy for intracapsular structures and endoscopy for extracapsular structures. It was hypothesized that the all-inside endoscopic classic Bröstrom-Gould procedure would produce sustainable good outcomes at a medium term of 5 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A prospective database for 43 patients who underwent an all-inside endoscopic classic Bröstrom-Gould repair of the anterior talofibular ligament and calcaneofibular ligament with inferior extensor retinaculum augmentation was reviewed. Patient details, American Orthopaedic Foot & Ankle Society score, Karlsson score, ankle activity score (AAS), and patient satisfaction were collected and analyzed.

RESULTS

The study cohort of 43 patients with a mean age of 29.4 years (SD, 11.9 years) were reviewed at a mean follow-up of 63.1 months (SD, 8.5 months). The American Orthopaedic Foot & Ankle Society scores showed significant improvement from a mean of 69.6 (SD, 13.9) to 93.7 (SD, 10.7), while the Karlsson score improved from 59.7 (SD, 14.5) to 91.5 (SD, 14.5) at the final follow-up. The AAS showed that 32 (74.4%) patients maintained or had improvement in the AAS, from a mean of 5.38 (SD, 2.8) to 5.41 (SD, 2.8), with a mean satisfaction rate of 9.1 (SD, 1.3). Although the remaining 11 patients had a reduced AAS, at a mean of 4.6 (SD, 2.6), they reported a mean satisfaction rate of 7.4 (SD, 2.9). There were no surgical complications or reoperations reported in this cohort, although there were 3 patients with recurrent instability at their last follow-up, resulting in a failure rate of 7%.

CONCLUSION

The current study is the first to report the medium-term outcomes of an all-inside endoscopic classic Bröstrom-Gould procedure. Overall, 93% of the patients had good functional outcomes, but approximately 25% of patients had decreased ankle activity levels at a mean of 5 years postoperatively, albeit with good satisfaction rates.

Ankle-GO score is associated with the probability of becoming coper after lateral ankle sprain: a 1-year prospective cohort study

OBJECTIVE

To analyse the association between Ankle-GO score during the return to sport process and the probability of becoming a coper 1 year after lateral ankle sprain (LAS). Copers were defined as patients returning to their preinjury sport without loss of function and reporting no episodes of reinjury or giving-way.

METHODS

Two months after a LAS, patients performed the Ankle-GO assessment which includes a cluster of four functional tests and two self-reported questionnaires for a maximum score of 25 points. One year after injury, participants were classified as copers or non-copers. Eight potential predictive variables associated with coper status were compared between the groups. Receiver operating characteristic curves (area under the curve (AUC)) and multivariable logistic regression models with OR and 95% CIs were used to determine the association of potential factors, including the Ankle-GO score, with copers.

RESULTS

64 patients (56% females; age 33.7±13.2 years) completed the Ankle-GO-GO at 2 months postinjury. At 1 year postinjury, 10 patients (15%) were lost to follow-up, and only 17 of 54 patients (31%) became copers. Two-month Ankle-GO score was higher among copers (9.9±4.9 points vs 6.9±3.7, p=0.015) and was associated with future coper status at 1 year (AUC=0.70). Patients with an Ankle-GO score above 11 points and male patients were more likely to become copers (OR=12.1; 95% CI 2.5 to 59, p=0.002 and OR=5.2; 95% CI 1.2 to 22.4, p=0.026, respectively).

CONCLUSION

The Ankle-GO may help identify patients more likely to become copers within a year of injury. Those with low Ankle-GO scores and female patients should receive additional rehabilitation to increase the odds of becoming a coper.

Arthroscopic Anatomic Lateral Ankle Reconstruction Using Allograft: A Simplified Approach

Ankle instability is a common medical condition that frequently necessitates surgical intervention to achieve ankle joint stability and enhance functional outcomes after failure of conservative treatment. Many surgical techniques have been described in the literature to restore joint stability, including repair or reconstruction of the anterior talofibular ligament and the calcaneofibular ligament. In this article, we describe a simplified arthroscopic technique for anatomic lateral ankle ligament reconstruction using an extensor hallucis longus allograft and involving percutaneous creation of the calcaneal tunnel after identification of the calcaneofibular ligament distal footprint insertion relative to the lateral malleolus.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.