Arthroscopic suture anchor repair of the lateral ligament ankle complex: a cadaveric study

Accuracy of Cutaneous Landmarks Compared to Ultrasound to Locate the Calcaneal Footprint of the CFL

The purpose was to determine the accuracy of the techniques of Lopes et al. and Michels et al., compared to ultrasound, to locate the center of the calcaneal footprint of the CFL in healthy volunteers. The authors recruited 17 healthy adult volunteers at 1 center with no current ankle pathologies and no previous surgical antecedents on either ankle. The authors recorded the age, sex, height, BMI, and ankle side for each volunteer. Measurements were made on both ankles of the 17 volunteers to increase the sample size and ensure less dispersion of data, independently by 2 surgeons: 1 senior surgeon with 15 years' experience and 1 junior with 3 years' experience. The location of the center of the calcaneal footprint of the CFL was determined by each surgeon using 3 methods: (1) the cutaneous technique of Lopes et al., (2) the cutaneous technique of Michels et al., and (3) ultrasound imaging. The 17 volunteers (34 feet) had a mean age of 26.3 ± 8.7 and a BMI of 21.7 ± 2.9. The Michels point was significantly closer (4.6 ± 3.7 mm) than the Lopes point (11.1 ± 5.4 mm) to the true center of the calcaneal footprint of the CFL determined by ultrasound, notably in the vertical direction. The Michels point was located significantly closer to the true center of the calcaneal footprint of the CFL and demonstrated less dispersion than the Lopes point, indicated by significantly lower absolute mean deviation from the true center of the calcaneal footprint of the CFL, and that ultrasound is therefore preferred to locate the footprint the CFL.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Clinical outcomes of arthroscopic lateral ligament repair using a knotless anchor for chronic lateral ankle instability

Background/objective

Arthroscopic lateral ligament repair (ALLR) for chronic lateral ankle instability (CLAI) has been improving with technical innovations. However, there is a lack of information regarding mid- and/or long-term clinical outcomes after the introduction of ALLR. This study aimed to report mid-term clinical outcomes of ALLR with a knotless anchor.

Methods

Thirty-two patients (11 men and 21 women; mean age, 28 ± 14 years) who underwent ALLR with a knotless anchor from December 2015 to October 2020 were included. The mean follow-up period was 31 ± 11 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were used for clinical evaluation preoperatively and at the 2-year follow-up. Surgical complications, particularly knot irritation, were also examined.

Results

The JSSF scale scores were significantly improved, from 71.3 ± 13.1 preoperatively to 96.6 ± 5.1 postoperatively (P < 0.05), and the SAFE-Q showed similar improvement in all subscales (P < 0.05). One case had a complication of persistent pain around the lateral portal (3.1%).

Conclusion

ALLR using a knotless anchor provided satisfactory clinical outcomes over 2 years, and no major complications, such as knot irritation, were observed.

Case series

Level of Evidence, 4.

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.

Comparison of arthroscopic and open Brostrom-Gould surgery for chronic ankle instability: a systematic review and meta-analysis

BACKGROUND

Approximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI) requiring surgical intervention. There has been growing interest among surgeons regarding whether arthroscopic techniques can replace open Brostrom-Gould surgery in treating CLAI. The purpose of this study was to pool the results of multiple studies comparing the treatment effects of these two fixation approaches.

METHODS

Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on CLAI that were repaired using the arthroscopic or open Broström-Gould technique. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, complications, and time efficiency.

RESULT

A total of 686 patients from 11 studies were included in the analysis. Among them, 351 patients underwent open repair, and 335 underwent arthroscopic Brostrom-Gould surgery. The present study revealed that arthroscopic and open Brostrom-Gould techniques demonstrated no significant differences in talar tilt, talar anterior translation, complication rate, and time to return to previous level of activity. Furthermore, no significant differences were observed in AOFAS, K-P, VAS, and Tegner scores at the 2-year follow-up. However, significant differences were noted between the two surgical approaches in terms of early weight-bearing (WMD = - 1.33 weeks, 95% CI = [- 1.91, - 0.76], P = 0.17, I2 = 40%), as well as AOFAS scores (WMD = 1.00, 95% CI = [0.05, 1.95], P = 0.73, I2 = 0%), K-P scores (WMD = 1.57, 95% CI = [0.49, 2.64], P = 0.15, I2 = 47%), and VAS scores (WMD = - 0.15, 95% CI = [- 0.60, 0.29], P < 0.08, I2 = 61%) within the first postoperative year.

CONCLUSIONS

Our findings support that arthroscopic repair yields comparable outcomes to open surgery. Consequently, we advocate for adopting arthroscopic repair as a preferred alternative to the conventional open Broström-Gould procedure for treating chronic lateral ankle instability.

The lowest point of fibula (LPF) could be used as a reliable bony landmark for arthroscopic anchor placement of lateral ankle ligaments ----compared with open Broström procedure

BACKGROUND

Arthroscopic technique procedures was wide accepted for the treatment of chronic ankle instability (CAI). But little acknowledge was involved to the bony landmarks and anatomic features of different bundles of lateral ligaments under arthroscopic view.

METHODS

Sixty patients with acute or chronic lateral ankle ligaments injury (LAI) were collected prospectively, and divided randomly into two groups. In arthroscopic group, the bone tunnels were made on the LPF arthroscopically. And in open group, the bone tunnels were made on the Fibular obscure tubercle (FOT) in open procedure. The inferior bundle of ATFL and Arcuate fibre was also identified reference to the LPF and labeled by a PDS II suture penetration. Following that, The distances of the bone tunnels to the different bony markers were measured and compare between two groups. The penetrating locations of PDS II on the inferior bundle of ATFL and Arcuate fibre were also confirmed intraoperatively. And the safe angle of anchor implantation on the axial view was measured on postoperative CT scan.

RESULTS

The distances of bone tunnel to the fibular tip, the fibular insertion of anterior-inferior tibiofibular ligament (AITFL), and the FOT in arthroscopic and open locating groups were 4.9 ± 2.2 and 6.3 ± 2.2 mm, 13.5 ± 2.7 and 12.4 ± 1.1 mm, 5.8 ± 2.2 and 5.6 ± 1.0 mm, respectively. The distances of bone tunnels to the FOT and fibular tip on 3d-CT view was 4.4 ± 1.5 and 4.6 ± 0.9 mm, 14.4 ± 3.2 and 13.2 ± 1.8 mm in arthroscopic and open group, and there were no significant differences between two groups. The safe angle of arthroscopic anchor placement on the axial plan was ranged from 24.9 ± 6.3o to 58.1 ± 8.0o. The PDS II sutures penetrating on the inferior bundles of ATFL and the arciform fibres were also comfirmed successfully by open visualizaion.The average distance of penetration point to the horizontal line cross the fibular tip was 2.3 ± 2.7 mm (ranged from - 3.1 to 6.0 mm), and to the vertical line cross the FOT was 2.7 ± 2.7 mm (ranged from - 2.5 to 7.5 mm).

CONCLUSION

Take the lowest point of fibula under arthroscopy (LPF) as a bony reference, we could identify the iATFL under arthroscopic visualization. By this way, we could place the suture anchors properly to the fibular footprint and suture the iATFL fibres successfully.

The Superficial Peroneal Nerve Is at Risk during the "All Inside" Arthroscopic Broström Procedure: A Cadaveric Study

Background: The arthroscopic Broström procedure is a promising treatment for chronic ankle instability. However, little is known regarding the location of the intermediate superficial peroneal nerve at the level of the inferior extensor retinaculum; knowledge about this location is important for procedural safety. The purpose of this cadaveric study was to clarify the anatomical relationship between the intermediate superficial peroneal nerve and the sural nerve at the level of the inferior extensor retinaculum. Methods: Eleven dissections of cadaveric lower extremities were performed. The origin of the experimental three-dimensional axis was defined as the location of the anterolateral portal during ankle arthroscopy. The distances from the standard anterolateral portal to the inferior extensor retinaculum, sural nerve, and intermediate superficial peroneal nerve were measured using an electronic digital caliper. The location of inferior extensor retinaculum, the tract of sural nerve, and intermediate superficial peroneal nerve were checked using average and standard deviations. For the statistical analyses, data are presented as average ± standard deviation, and then they are reported as means and standard deviations. Fisher's exact test was used to identify statistically significant differences. Results: At the level of the inferior extensor retinaculum, the mean distances from the anterolateral portal to the proximal and distal intermediate superficial peroneal nerve were 15.9 ± 4.1 (range, 11.3-23.0) mm and 30.1 ± 5.5 (range, 20.8-37.9) mm, respectively. The mean distances from the anterolateral portal to the proximal and distal sural nerve were 47.6 ± 5.7 (range, 37.4-57.2) mm and 47.2 ± 4.1 (range, 41.0-51.8) mm), respectively. Conclusions: During the arthroscopic Broström procedure, the intermediate superficial peroneal nerve may be damaged by the anterolateral portal; the proximal and distal parts of the intermediate superficial peroneal nerve were located within 15.9 and 30.1 mm, respectively, at the level of the inferior extensor retinaculum in cadavers. These areas should be considered danger zones during the arthroscopic Broström procedure.

Lateral ankle instability - repair/ reconstruct what's new

Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.

Determining the Feasibility of Arthroscopic Anterior Talofibular Ligament Repair Utilizing a Novel Classification System

The purposes of this study were to classify anterior talofibular ligament injuries (ATFL), to find out the feasibility of arthroscopic ATFL repair according to injury type and to investigate the diagnostic validity of magnetic resonance imaging (MRI) of ATFL injuries by comparing MRI and arthroscopic findings. The 197 ankles (93 right, 104 left, and 12 bilateral) of 185 patients (90 men and 107 women; mean age, 33.5 years, range: 15-68 years) were treated by arthroscopic modified Broström procedure after a diagnosis of chronic lateral ankle instability. ATFL injuries were classified according to their grade and location (type P: partial rupture, type C1: fibular detachment, type C2: talar detachment, type C3: midsubstance rupture, type C4: absence of ATFL, type C5: os subfibulare). Among the 197 injured ankles, according to ankle arthroscopy, 67 were type P (34%), 28 were type C1 (14%), 13 were type C2 (7%), 29 were type C3 (15%), 26 were type C4 (13%), and 34 were type C5 (17%). The kappa value for the agreement between the arthroscopic findings and MRI findings was also high (0.85; 95% confidence interval, 0.79-0.91). Our results also supported the use of MRI for diagnosing ATFL injuries and showed that it is an informative tool during the preoperative period.

Arthroscopic Broström-Gould repair has comparable radiological and clinical outcomes compared to traditional open Broström-Gould repair in high-demand patients

PURPOSE

This study sought to confirm whether traditional open Broström-Gould repair and arthroscopic Broström-Gould repair for chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients.

METHODS

This retrospective case-cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström-Gould repair and were followed up for ≥ 2 years. Patients were divided into the arthroscopic Broström-Gould repair group (AS Group) and the open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically.

RESULTS

A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K-P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.).

CONCLUSIONS

Traditional open and arthroscopic Broström-Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair in high-demand patients.

LEVEL OF EVIDENCE

Level III.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

Arthroscopic modified Broström operation versus open reconstruction with local periosteal flap in chronic ankle instability

INTRODUCTION

The modified Broström operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure. Comparative studies on the surgical therapy of CAI are limited and generally refer to similar surgical procedures. Aim of this study was to compare the arthroscopic MBO and the RPF.

MATERIALS AND METHODS

We retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. We compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

RESULTS

Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively. Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out. Also in terms of complications and follow-up operations, no significant difference was found between the two procedures.

CONCLUSIONS

Both surgical procedures give very good results one year postoperatively in terms of pain, instability, function and complication rate. With significantly better results regarding pain and instability three months postoperatively, the MBO allows a faster recovery in patients operated with this technique.

Crochet Hook Technique for Arthroscopic Anterior Talofibular Ligament Repair: Technique Note

Ankle sprains can lead to chronic lateral ankle instability caused by an injured anterior talofibular ligament (ATFL), and surgery is often required when conservative treatments fail. BROSTROM surgery is considered the gold standard and has a definite curative effect. Advancements in arthroscopic surgery and improvements in implanted anchors have led to an increase in ATFL repairs using arthroscopic surgery. Arthroscopic AFTL repair is less invasive, and patients could experience faster recovery compared to open AFTL repair. To simplify the complicated suture-passing processes in arthroscopic AFTL repair, we developed a crochet hook and loop wire technique, which is described in this paper.

Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture

Background

Anatomic repair of anterior talofibular ligament (ATFL) is used to manage chronic lateral ankle instability (CLAI). However, the optimal suture configuration used to repair the ATFL is not yet determined. It remains unclear whether suture configuration affects clinical outcomes in such patients.

Purpose

To compare the functional outcomes of all-inside arthroscopic ATFL repair using either a loop suture and or a free-edge suture configuration in CLAI patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

This retrospective cohort study included 71 patients with CLAI who had undergone an all-inside arthroscopic ATFL repair procedure with either loop suture (n = 36) or free-edge suture (n = 35) from February 2016 to July 2018. Comparable pre-operatively, the Visual analogy score (VAS), American Orthopedic Foot and Ankle Society scoring system (AOFAS), Karlsson Ankle Functional Score (KAFS) scoring system, Anterior Talar Translation (ATT) and Active Joint Position Sense (AJPS) were used to evaluate postoperative ankle function.

Results

There were no postoperative wound complications, implant reactions, or neurological or vascular injuries. Postoperative hospitalization, VAS, AOFAS, KAFS, AJPS and the time of return to sport were similar between the loop suture group and free-edge suture group. Requiring a longer procedure time, patients with loop suture configuration achieved better ATT.

Conclusion

All-inside arthroscopic ATFL repair procedure for CLAI treatment provides better ATT and comparable functional outcomes when a loop suture configuration is used instead of a free-edge suture configuration. A statistical difference in ATT was observed. Given the relatively short follow-up, it is questionable whether this will have any clinical relevance.

Functional results of modified Mason-Allen suture versus horizontal mattress suture in the arthroscopic Broström-Gould procedure for chronic ankle instability

Background

The arthroscopic Broström–Gould procedure (ABG) gained particular attention among clinicians and researchers due to its high rate of satisfactory results. There is a lack of evidence regarding the differences in clinical outcomes for the various suture techniques. The purpose of this study was to compare the differences in clinical effect in patients treated with one-anchor modified Mason–Allen suture or two-anchor horizontal mattress suture for chronic ankle instability (CAI).

Methods

This retrospective cohort study examined CAI patients who underwent either one-anchor modified Mason–Allen suture or two-anchor horizontal mattress suture ABG between January 2018 and January 2020. Patients were divided into two groups based on the suture knot type used and the associated number of anchors. The operative time, surgical cost, Visual Analog Scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) Score, Karlsson Ankle Functional Score (KAFS), the rate of return to sports, complications, and measured biomechanical strength using standardized equipment were compared between groups.

Results

Sixty-four CAI patients were included (one-anchor modified Mason–Allen suture group n = 30, two-anchor horizontal mattress suture group n = 34). Compared to the two-anchor horizontal mattress suture group, the one-anchor modified Mason–Allen suture group had significantly shorter operative time (p < .001) and lower surgical cost (p < .001). There were no postoperative complications in the two groups, and no significant differences in the VAS, AOFAS, KAFS, and rate of return to sports in postoperative follow-up between the two groups at 1 and 2 years after surgery. There was no statistically significant difference in biomechanical strength anterior drawer test displacement (p > .05) between the one-anchor modified Mason–Allen suture and two-anchor horizontal mattress suture at 2 years after surgery.

Conclusion

ABG using a one-anchor modified Mason–Allen suture showed comparable clinical results to a two-anchor horizontal mattress suture in the treatment of CAI at intermediate-term follow-up time. However, one-anchor modified Mason–Allen suture may be a faster, simpler, cost-effective substitute technology.

Level of evidence

Level III, comparative study.

Biomechanical Study of Arthroscopic All-Inside Anterior Talofibular Ligament Suture Augmentation Repair, Plus Suture Augmentation Repair and Anterior Tibiofibular Ligament's Distal Fascicle Transfer Augmentation Repair

Objective: To explore the biomechanical efficacy of arthroscopic all-inside anterior talofibular ligament (ATFL) suture augmentation repair, plus suture augmentation repair and anterior tibiofibular ligament-distal fascicle (ATiFL-DF) transfer augmentation repair, so as to provide a basis for the accurate selection of ATFL repair in clinical practice. Methods: Twenty-four (12 pairs) fresh frozen human cadaver ankle specimens were used. Six of the ankle specimens were set as the normal group, and the other 18 ankle specimens were used to establish ATFL injury models. The ATFL was then repaired using arthroscopic all-inside ATFL suture augmentation repair (suture augmentation group), plus suture augmentation repair (plus suture augmentation group) and ATiFL-DF transfer augmentation repair (biological augmentation group), respectively. After the repaired ATFL was separated, the ankle specimens were fixed on an electronic universal testing machine with a customized fixture for the tensile test, and the ultimate failure load (N) and stiffness (N/mm) of the ankle specimens were compared. Results: The ultimate failure load of the plus suture augmentation group (229.3 ± 66.7 N) was significantly higher than that in the normal group (148.2 ± 39.4 N, p = 0.045) and the biological augmentation group (131.3 ± 38.8 N, p = 0.013). There was no statistical difference in ultimate failure load between the suture augmentation group (167.2 ± 47.2 N), the normal group and the biological augmentation group. The stiffness of the plus suture augmentation group (26.2 ± 8.2 N/mm) was significantly higher than that in the normal group (12.1 ± 3.8 N/mm, p = 0.005) and the biological augmentation group (12.7 ± 5.2 N/mm, p = 0.007). The stiffness of the suture augmentation group (23.6 ± 7.0 N/mm) was significantly higher than that in the normal group (p = 0.024) and the biological augmentation group (p = 0.033). There was no statistical difference in stiffness between the plus suture augmentation group and the suture augmentation group, and no statistical difference in stiffness between the normal group and the biological augmentation group. Conclusions: The tensile strength and rigidity of plus suture augmentation repair were significantly better than those of normal ATFL, suture augmentation repair and ATiFL-DF transfer augmentation repair. Suture augmentation repair can obtain tensile strength similar to normal ATFL and ATiFL-DF transfer augmentation repair, and suture augmentation repair can obtain rigidity significantly better than normal ATFL and ATiFL-DF transfer augmentation repair. ATiFL-DF transfer augmentation repair can obtain tensile strength and rigidity similar to normal ATFL.

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

Background

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

Purpose

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

Study Design

Case series; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Ultrasound-Guided Anterior Talofibular Ligament Repair With Augmentation Can Restore Ankle Kinematics: A Cadaveric Biomechanical Study

Background:

Anterior talofibular ligament (ATFL) repair of the ankle is a common surgical procedure. Ultrasound (US)-guided anchor placement for ATFL repair can be performed anatomically and accurately. However, to our knowledge, no study has investigated ankle kinematics after US-guided ATFL repair.

Hypothesis:

US-guided ATFL repair with and without inferior extensor retinaculum (IER) augmentation will restore ankle kinematics.

Study Design:

Controlled laboratory study; Level of evidence, 4.

Methods:

A 6 degrees of freedom robotic testing system was used to apply multidirectional loads to fresh-frozen cadaveric ankles (N = 9). The following ankle states were evaluated: ATFL intact, ATFL deficient, combined ATFL repair and IER augmentation, and isolated US-guided ATFL repair. Three loading conditions (internal-external rotation torque, anterior-posterior load, and inversion-eversion torque) were applied at 4 ankle positions: 30° of plantarflexion, 15° of plantarflexion, 0° of plantarflexion, and 15° of dorsiflexion. The resulting kinematics were recorded and compared using a 1-way repeated-measures analysis of variance with the Benjamini-Hochberg test.

Results:

Anterior translation in response to an internal rotation torque significantly increased in the ATFL-deficient state compared with the ATFL-intact state at 30° and 15° of plantarflexion (P = .022 and .03, respectively). After the combined US-guided ATFL repair and augmentation, anterior translation was reduced significantly compared with the ATFL-deficient state at 30° and 15° of plantarflexion (P = .0012 and .005, respectively). Anterior translation was not significantly different for the isolated ATFL-repair state compared with the ATFL-deficient or ATFL-intact states at 30° and 15° of plantarflexion.

Conclusion:

Combined US-guided ATFL repair with augmentation of the IER reduced lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair did not reduce laxity due to ATFL deficiency, nor did it increase instability compared with the intact ankle.

Clinical Relevance:

US-guided ATFL repair with IER augmentation is a minimally-invasive technique to reduce lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair may be a viable option if accompanied by a period of immobilization.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

Percutaneous Inferior Extensor Retinaculum Augmentation Technique for Chronic Ankle Instability

OBJECTIVE

To specify indications and contraindications of the modified percutaneous inferior extensor retinaculum augmentation (PIERA) technique for chronic ankle instability cases, and to introduce technique details and report surgical outcomes and complications.

METHODS

The PIERA technique was performed on seven patients with chronic ankle instability (four females and three males, 36.4 ± 15.1 years of age, and course of symptoms of 33.7 ± 8.8 months) from June to October 2018 in this retrospective study of case series. All patients demonstrated attenuated ligamentous tissue quality, which was confirmed using preoperative ankle MRI. IER were drew up to the distal fibula using suture anchors with the ankle in neutral position for all cases, to engage the entire IER in reconstructing the stability of the ankle. Patients were assessed using American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS) score and Cumberland Ankle Instability Tool (CAIT) scores pre- and postoperatively at the last follow-up examination. Preoperative and postoperative outcome scores of patients were compared using paired t-test. A p value of less than 0.05 was regarded statistically significant.

RESULTS

Mean follow-up duration was 16.7 ± 1.6 months. The mean AOFAS score significantly improved from 66.9 ± 11.2 preoperatively to 93.7 ± 8.5 postoperatively (P = 0.001). Mean CAIT score significantly improved from 13.1 ± 4.7 preoperatively to 26.3 ± 1.8 postoperatively (P = 0.001). Patients did not report any wound healing problem, numbness, swelling, or instability at the last follow-up examination, except for one patient who reported pain and minimal stiffness, and presented an AOFAS score of less than 80 and a CAIT score below 24. All patients returned to at least recreational sport activity level.

CONCLUSION

The PIERA technique can improve the functional outcomes of patients with chronic ankle instability with few complications.

Fully Intra-articular Lasso-Loop Stitch Technique for Arthroscopic Anterior Talofibular Ligament Repair

BACKGROUND

Arthroscopic techniques have gradually become popular for anterior talofibular ligament (ATFL) repair. However, the reliability of the repair and the risk of nerve injuries are of concern. The aim of this study was to evaluate the fully intra-articular lasso-loop stitch technique for arthroscopic ATFL repair.

METHODS

From October 2018 to December 2019, 43 cases with chronic lateral ankle instability were treated with this fully intra-articular lasso-loop stitch technique using the Arthro-Pierce instrument. The Karlsson-Peterson score, Cumberland Ankle Instability Tool (CAIT) score, visual analog scale (VAS) score, anterior drawer and talar tilt stress fluoroscopy were evaluated at the preoperative and final follow-up appointments, respectively. All surgical complications were also recorded.

RESULTS

A total of 39 cases were followed up for a mean of 28.23 ± 3.64 months (range, 23-34 months). At the final follow-up, the averages of the Karlsson-Peterson, CAIT and VAS scores were 90.26 ± 6.58, 88.56 ± 7.21 and 0.79 ± 1.06, respectively. During surgery, 2 cases were modified with augmentation of the inferior extensor retinaculum. No nerve injuries were encountered. Only 1 female complained about mild knot irritation. A 25-year-old solider required revision surgery due to an accidental injury.

CONCLUSION

We found the fully intra-articular lasso-loop stitch technique for ATFL repair using the Arthro-Pierce instrument to be reliable and safe with a sufficient and good-quality ligament remnant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Bone fixation techniques for managing joint disorders and injuries: A review study

The majority of surgical procedures treating joint disorders require a technique to realize a firm implant-to-tissue and/or a tissue-to-tissue fixation. Fixation methods have direct effects on survival, performance and integration of orthopedic implants This review paper gives an overview of novel fixation techniques that have been evaluated and optimized for orthopaedic joint implants and could be alternatives for traditional implant fixation techniques or inspirations for future design of joint implantation procedures.

METHOD

The articles were selected using the Scopus search engine. Key words referring to traditional fixation methods have been excluded to find potential innovative fixation techniques. In order to review the recent anchorage systems, only articles that been published during the period of 2010-2020 have been included.

RESULTS

A total of 57 studies were analyzed. The result revealed that three main fixation principles are being employed: using mechanical interlockings, employing adhesives, and performing tissue-bonding strategies.

CONCLUSION

The development of fixation techniques demonstrates a transformation from the general anchoring tools like K-wires toward application-specific designs. Several new methods have been designed and evaluated, which highlight encouraging results as described in this review. It seems that mechanical fixations provide the strongest anchorage. Employing (bio)-adhesives as fixation tool could revolutionize the field of orthopedic surgery. However, the adhesives must be improved and optimized to meet the requirements of an anchorage system. Long-term fixation might be formed by tissue ingrowth approaches which showed promising results. In most cases further clinical studies are required to explore their outputs in clinical applications.

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.

Is arthroscopic surgery as successful as open approach in the treatment of lateral ankle instability?

PURPOSE

To evaluate the clinical results of arthroscopic repair and open Ahlgren-Larsson method in patients with chronic lateral ankle instability.

METHODS

We retrospectively evaluated 60 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS, and VAS scores.

RESULTS

Sixty patients with chronic lateral ankle instability were evaluated. 28 patients were treated with Ahlgren-Larsson method, and 32 patients were treated with arthroscopic repair. Follow-up duration was 35 ± 12 months for the open surgery group and 19 ± 2 months for the arthroscopic surgery group. The mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, BMI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in VAS in terms of pain and patient satisfaction in favor of arthroscopy group.

CONCLUSIONS

Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid.

LEVEL OF EVIDENCE

II.

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Outcomes of Open Versus Arthroscopic Broström Surgery for Chronic Lateral Ankle Instability: A Systematic Review and Meta-analysis of Comparative Studies

Background:

Nearly 20% of acute ankle sprains progress to chronic lateral ankle instability that requires surgical intervention. In recent years, there has been a growing interest in arthroscopic Broström techniques as an alternative to open surgery.

Purpose:

To review the most up-to-date evidence comparing the outcomes of open and arthroscopic Broström procedures for chronic lateral ankle instability.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

This review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant comparative studies in English up to May 2020 were identified. The primary outcomes were (1) functional scores (Karlsson Ankle Function Score and American Orthopaedic Foot & Ankle Society [AOFAS] score) and (2) the 10-point visual analog scale (VAS) score for pain. The secondary outcomes were differences in (1) postoperative anterior drawer and talar tilt, (2) surgical time and complication rate, and (3) time to return to sports and weightbearing.

Results:

A total of 408 patients in 8 studies met the inclusion criteria. Of these, 193 (47.3%) patients underwent open surgery, while 215 (52.7%) patients underwent arthroscopic surgery. There were significant differences between the open and arthroscopic repair groups in mean 6-month AOFAS scores (82.4 vs 92.25, respectively; mean difference [MD], 11.36; 95% CI, 0.14-2.56; I² = 90%; P = .03), 1-year AOFAS scores (80.05 vs 88.6; MD, –11.96; 95% CI, –21.26 to –2.76; I² = 82%; P = .01), 6-month VAS scores (1.7 vs 1.4; MD, –0.38; 95% CI, –0.54 to –0.21; I² = 78%; P < .001), and 1-year VAS scores (2.05 vs 1.45; MD, 0.31; 95% CI, 0.09-0.54; I² = 0%; P < .001). The mean time to weightbearing was 14.25 and 9.0 weeks in the open and arthroscopic repair groups, respectively (MD, 1.89; 95% CI, 1.24-2.54; I² = 99%; P < .001). There were no statistically significant differences in the remaining outcomes evaluated.

Conclusion:

While technically more demanding, arthroscopic Broström was superior to open Broström-Gould surgery in postoperative AOFAS scores, VAS pain scores, and time to return to weightbearing. The operative time, complication rate, talar tilt, and anterior drawer tests were excellent and statistically comparable. Long-term clinical trials are required before recommending arthroscopic Broström as the new gold standard.

Evaluation of BMI With an All Inside Arthroscopic Broström Procedure for Chronic Lateral Ankle Instability: An Analysis of 113 Patients

The all inside arthroscopic Broström surgical procedure for chronic lateral ankle instability is a minimally invasive procedure that is an option surgeons have when treating their patients. There have not been any studies analyzing the integrity of the repair to patients who have an elevated body mass index (BMI) to determine if the strength of the repair is adequate. We retrospectively evaluated a total of 113 consecutive patients who underwent this procedure. Fifty-nine patients had a BMI ≥30 kg/m²; 54 had a BMI <30 kg/m². Unpaired t tests were performed to determine if a difference in American Orthopedic Foot and Ankle Society, visual analog scale, and Foot Function Index were encountered. Our findings indicate that there is no significant difference between patients with a BMI ≥30 kg/m² compared to a BMI <30 kg/m² who undergo an all-inside arthroscopic Broström procedure for chronic lateral ankle instability. This information may help surgeons decide what procedure options are available when treating chronic lateral ankle instability.

Arthroscopic ankle lateral ligament repair alone versus arthroscopic ankle lateral ligament repair with reinforcement by inferior extensor retinaculum

PURPOSE

This study aimed to compare the clinical outcomes and postoperative activities of arthroscopic ankle lateral ligament (ALL) repair alone with arthroscopic ALL repair and reinforcement by the inferior extensor retinaculum (IER) for chronic ankle instability (CAI).

MATERIALS AND METHODS

All patients who underwent arthroscopic repair for CAI between 2017 and 2019 were evaluated. The Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q), and duration between the surgery and walking without any support, jogging, and complete return to sports were evaluated and compared. The exclusion criteria were (1) follow-up period of < 1 year after surgery, (2) the presence of associated ankle lesions requiring treatment during the same operative procedure, including patients with subfibular ossicle bigger than 5 mm on radiographs, chondral or osteochondral defect, bony impingement, deltoid ligament tear, fibular tendon pathology, or posterior ankle impingement, and (3) patients who underwent revision surgery.

RESULTS

We identified 126 patients who underwent surgery for CAI and subsequently excluded 36 patients on account of a short follow-up period (< 1 year), additional surgery, and previous surgery. The remaining 90 eligible patients included arthroscopic ALL repair alone (group A, n = 44) and arthroscopic ALL repair with reinforcement by the inferior extensor retinaculum (group G, n = 46) groups. There was no significant difference in the postoperative activities nor in the preoperative or postoperative JSSF scale and SAFE-Q between the two groups. However, significant differences were seen in the mean surgical time (15.5 ± 8.1 vs 20.1 ± 7.6, P = 0.013).

CONCLUSION

This study showed no difference in clinical outcomes between the two groups. However, arthroscopic ALL repair with reinforcement by IER resulted in a longer surgical time than arthroscopic ALL repair alone.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

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

PURPOSE

To determine the effects of unilateral and bilateral ankle stabilization surgery with or without additional concurrent procedures for other pathologies on return to activity in patients who were allowed unrestricted weight bearing postoperatively.

METHODS

Ninety-three athletes underwent 120 ankle stabilization surgeries including 27 that underwent bilateral simultaneous surgery using the all-inside arthroscopy-modified lasso-loop technique and were divided into two groups: arthroscopic ligament repair alone without concurrent procedures (group A) and with simultaneous procedures for other pathologies (group B). Group A was further subdivided into unilateral (group A1) and simultaneous bilateral ankle surgery (group A2), and group B into ankle stabilization surgery with simultaneous procedures not requiring weight bearing postoperatively (Group B1) and with concurrent procedures allowing weight bearing (Group B2). Return to activity postoperatively was assessed by recording the time to walk without any support, jog, and return to full athletic activities. Clinical outcomes were assessed preoperatively and 12 months postoperatively using a subjective clinical score.

RESULTS

The average time between surgery and unsupported walk, jog, and return to full athletic activities was 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3 days in group A, 17.2 ± 19.6, 34.5 ± 20.8, and 60.9 ± 22.8 days in group B, 1.7 ± 2.9, 16.1 ± 2.4, and 41.6 ± 18.2 days in group A1, 1.3 ± 0.6, 18.9 ± 5.5, and 44.6 ± 22.5 days in group A2, 25.3 ± 20.2, 43.3 ± 21.1, and 70.7 ± 23.1 days in group B1, and 4.8 ± 11.7, 20.7 ± 11.7, and 45.0 ± 13.7 days in group B2, respectively. These results indicate that the patients in group B2 showed a statistically significant faster time to return to activity than did those restricted from weight bearing. Differences in ankle stabilization alone between patients in groups A1 and A2 as well as groups B2 and A were not statistically significant. Clinical outcomes were similar for patients in groups B2 and A1 versus group A2.

CONCLUSION

Time to return to activity and clinical outcomes after ankle stabilization surgery using the modified lasso-loop technique were negatively affected if simultaneous bilateral surgery or simultaneous concurrent procedures were added or if weight bearing was unrestricted. However, a delay in return to athletic activity was observed when ankle stabilization surgery was performed using the modified lasso-loop technique with concurrent procedures that require non-weight bearing postoperatively.

LEVEL OF EVIDENCE

Level III.

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary

BACKGROUND

Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear.

PURPOSE

To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI).

RESULTS

Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups (P < .001). However, there were no significant differences in the clinical results and radiologic findings between the groups.

CONCLUSION

The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes.

Arthroscopic Surgical Technique for Lateral Ankle Ligament Instability

In the past several years, arthroscopic repair of the lateral ankle ligaments has grown because it has shown comparable results with the traditional open Brostrom-Gould procedure. In addition, arthroscopic repair allows reduced swelling and cosmesis. This article discusses the authors' technique for lateral ankle instability, with published data supporting biomechanical equivalency to the standard open Brostrom-Gould procedure. An optional internal brace can provide further strength to the repair and lead to a quicker recovery. Arthroscopic repair both with and without the internal brace have shown positive clinical outcomes for patients as well as high satisfaction rates.

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.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic 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.

A Novel Technique of Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor

Background:

Although arthroscopic lateral ligament repair (ALLR) with suture anchors for chronic lateral ankle instability has become widely accepted, some complications have been reported as well. Establishment of a new technique is essential for better clinical outcomes after ALLR.

Purpose

To report a novel technique and good clinical results of ALLR using a knotless suture anchor.

Study Design:

Case series; Level of evidence, 4.

Methods:

We examined 30 patients (16 men and 14 women) who underwent ALLR. The mean age of the patients was 30.0 years, and the average period of postoperative monitoring was 21 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale was used for clinical evaluation postoperatively, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient-reported results. Surgical complications were also examined.

Results:

The JSSF ankle-hindfoot scale showed a significant improvement from preoperatively to follow-up (from 72.1 to 96.1; P < 0.001), and the SAFE-Q was significantly improved in all subscales (pain and pain-related, physical function and daily living, social function, shoe-related, and general health and well-being; P < 0.004 for all). Complications included residual joint pain due to remaining osteophytes in 1 case, scar pain of the accessory anterolateral portal in 2 cases, and positive Tinel sign indicative of superficial peroneal nerve irritation at the anterolateral portal in 1 case.

Conclusion:

The clinical results of the novel ALLR technique were overall satisfactory. Knot-related complications, one of the main reasons for postoperative complications, were reduced by using a knotless suture anchor.

Arthroscopic versus open repair of lateral ankle ligament for chronic lateral ankle instability: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to analyze the current comparative studies of arthroscopic and open techniques for lateral ankle ligament repair to treat chronic lateral ankle instability.

METHODS

A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed during February 2018. Included studies were evaluated with regard to level of evidence and quality of evidence using the Modified Coleman Methodology Score. Total number of patients, patient age, follow-up time, gender ratio, surgical technique, surgical complications, complication rate, recurrent instability or revision rate, clinical outcome measures and percentage of patients who returned to sport at previous level were also evaluated. Statistical analysis was performed using RevMan, and a p value of < 0.05 was considered to be statistically significant.

RESULTS

Four comparative studies for a total of 207 ankles were included. There was a significant difference in favor of arthroscopic repair with regard to AOFAS score, and there was no significant difference with regard to Karlsson score. There was a statistically significant difference in AOFAS score in favor of the arthroscopic repair (MD; 1.41, 95% CI 0.29-2.52, I² = 0%, p < 0.05). There was no statistically significant difference in Karlsson score (MD; 0.00, 95% CI - 3.51 to 3.51, I² = 0%, n.s.). There was no statistically significant difference in total, nerve, or wound complications.

CONCLUSIONS

The current meta-analysis found that short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. There was no significant difference between arthroscopic and open repair with regards to Karlsson functional outcome score, total complication rate, or the nerve and wound complication subsets with the included studies with at least 12 months of follow-up. However, the current evidence is still limited, and further prospective trials with longer follow-up are needed.

LEVEL OF EVIDENCE

III.

All-Inside Arthroscopic Anterior Talofibular Ligament Anatomic Reconstruction With a Gracilis Tendon Autograft for Chronic Ankle Instability in High-Demand Patients

The goal of this study was to evaluate the surgical technique and clinical outcome of all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon autograft for chronic ankle instability in high-demand patients. Fifteen consecutive patients (14 [93.3%] males and 1 [6.7%] female, mean age 31.9 ± 7.8 [range 21 to 48] years) with chronic ankle instability were enrolled in this study. Under direct arthroscopic visualization, bone tunnels were created in the fibula and talus by a 4.5-mm cannulated drill system. The gracilis tendon autograft was passed through the tunnels and secured by 5.0-mm interference screws. At the final follow-up, functional evaluation was carried out according to the Ankle-Hindfoot Score by the American Orthopaedic Foot and Ankle Society, Sefton grading system, and visual analog scale score. Complications were also recorded. Mean follow-up was 19.5 ± 1.8 (range 18 to 24) months. No complications of wound infection and nerve injury were noted. No patients experienced recurrent ankle instability. Radiologically, the mean varus tilting angle was 15.2° ± 1.5° before surgery and 4.3° ± 1.2° at the last follow-up (p ≤ .001). The anterior drawer distance was 13.2 ± 1.5 mm before surgery and 4.8 ± 1.1 mm at last follow-up (p ≤ .001). The mean American Orthopaedic Foot and Ankle Society and visual analog scale scores were 56.8 ± 10.5 and 5.7 ± 1.3 before surgery, which became 90.2 ± 6.2 and 0.5 ± 0.8 after surgery. Fourteen (93.3%) patients reported excellent/good functional results according to the Sefton grading system (6 [40.0%] excellent, 8 [53.3%] good, and 1 [6.7%] fair). From our clinical experience, all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon is an effective treatment for chronic ankle instability in high-demand patients.

Anatomic Knot Suture Anchor Versus Knotless Suture Anchor Technique for Anterior Talofibular Ligament Repair: A Biomechanical Comparison

Background:

To date, there are few biomechanical studies comparing the strength between knot repair and knotless repair procedures for anterior talofibular ligament (ATFL) injury.

Purpose:

To perform a biomechanical comparison of the strength of the arthroscopic ATFL repair technique with knot or knotless suture anchors in a cadaveric model with partial or complete ATFL injuries.

Study Design:

Controlled laboratory study.

Methods:

A total of 24 fresh-frozen cadaveric ankles were used. Arthroscopy was used to identify, section, and repair the ATFL on the fibular insertion site. The specimens were then randomly placed into 1 of 4 groups: group A received complete ATFL section and 1–suture anchor repair with knot, group B received complete ATFL section and 1-anchor knotless repair, group C received partial ATFL section and 1–suture anchor repair with knot, and group D received partial ATFL section and 1-anchor knotless repair. After repair, the ATFL tension was measured first with a digitalized tensiometer. Specimens were then mounted on a materials testing system to determine the ultimate load to failure and stiffness.

Results:

The mean ± SD ligament tension measured during the arthroscopic procedure was 8.6 ± 0.6 N for group A, 9.2 ± 0.5 N for group B, 9.4 ± 1.1 N for group C, and 9.6 ± 0.9 N for group D. No significant difference in tension was detected among groups. In load-to-failure testing, the mean ultimate failure load was 27.9 ± 4.1 N for group A, 26.2 ± 9.3 N for group B, 81.9 ± 26.5 N for group C, and 88.1 ± 41.6 N for group D. The mean ultimate failure loads of the partial repair groups were significantly higher than those of the complete repair groups (C vs A, P = .008; D vs B, P = .002), while there was no significant difference between groups A and B (P > .05) or between groups C and D (P > .05).

Conclusion:

The results of the present study showed that there was no significant difference in biomechanical properties between knot repair and knotless repair techniques.

Clinical Relevance:

Biomechanically, the results showed that knot suture anchor and knotless suture repair provide similar biomechanical strength for ATFL injury. Unfortunately, these methods in the complete ATFL section models provided less than half the strength and stiffness in the partial ATFL section models at time zero after surgery. As a result, 1–suture anchor repair is not suitable for complete ATFL injury regardless of the repair method.

The CFL fails before the ATFL immediately after combined ligament repair in a biomechanical cadaveric model

PURPOSE

To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model.

METHODS

Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three-dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL-only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF).

RESULTS

The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL-only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively.

CONCLUSIONS

There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL-only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair.

LEVEL OF EVIDENCE

III, case-control therapeutic study.

Peroneal tendon irritation after arthroscopic modified Broström procedure: A case report

RATIONALE

With the development of ankle arthroscope techniques and procedures, the number of arthroscopic modified Broström procedures (MBPs) is increasing. All-inside arthroscopic MBP was developed recently, with good to excellent results. However, several complications have been reported in patients after arthroscopic MBP. This case report describes a rare complication of arthroscopic MBP.

PATIENT CONCERNS

A 34-year-old woman presented with severe pain in her right ankle and underwent arthroscopic MBP for lateral ankle instability. About 6 months postoperatively, she presented with severe pain on the lateral aspect of the right ankle, especially while walking.

DIAGNOSIS

In physical examinations, there was marked swelling around the ankle and focal tenderness in the posterolateral malleolar area. Ankle ultrasonography showed a diffuse low-echoic mass-like lesion at the distal fibula between the fibular tip and peroneus tendon. T1-weighted sagittal magnetic resonance imaging images showed an irregularly shaped mass-like lesion with a heterogeneous signal near the distal fibula posteriorly where the anchor protruded.

INTERVENTIONS

The suture anchor in the posterior distal fibula area, which had irritated the peroneus tendon, was removed with debridement of the granulomatous lesion.

OUTCOMES

At the 3-month follow-up, the patient was almost asymptomatic and had a nearly full range of motion. No complications or recurrent symptoms were noted at the 1-year follow-up.

LESSONS

Three-dimensional computed tomography studies of the appropriate fibular depth and position of suture anchors are needed to standardize the procedure and reduce complications.

Clinical outcomes of a modified all-inside arthroscopic repair of anterior talofibular ligament for chronic ankle instability: A preliminary report

The present study was conducted to evaluate the clinical outcomes of a modified all-inside arthroscopic repair technique via anterolateral and accessory anterolateral port for anterior talofibular ligament (ATFL) repair. A consecutive series of 32 patients (34 ankles) with chronic ankle instability were included and treated with the modified all-inside arthroscopic repair. The function was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS), visual analog score (VAS) score system, the Sefton grading system, and the anterior drawer test and talar tilt test. A total of 29 cases (30 ankles) were followed up for a mean of 33.7 ± 4.5 (range 30-44) months. Based on the Sefton grading system, 12 patients were regarded as excellent, 13 were good, 2 were fair, and 2 were poor. Twenty-five cases (86.2%) achieved satisfactory functional results. Ankle mobility returned to normal in 93% of patients. The AOFAS scores increased from 55.1 ± 12.3 (range 25-69) preoperatively to 89.7 ± 5.9 (range 74-100) (P < .001) at the last follow-up, while the VAS score decreased significantly (P < .001). There was no wound infection or nerve injury in all cases. In conclusion, based on high satisfaction rate in terms of ankle mobility and low complication rate, the modified all-inside arthroscopic repair of ATFL via anterolateral and accessory anterolateral port appears to be an effective treatment method for chronic ankle instability. Further studies are needed.

Stabilizing lateral ankle instability by suture tape - a cadaver study

BACKGROUND

Suture tape is a recent development to augment a Brostrom repair at least during the healing phase of the native tissues used for stabilization of the lateral ankle ligaments. The purpose of this study was to evaluate whether suture tape is an effective mechanical stabilizer against anterior talar drawer in a cadaver experiment when tested with a validated arthrometer.

METHODS

Different stability conditions were created in 14 cadaveric foot and leg specimens. Following anterior talofibular ligament (ATFL) dissection, isolated suture tape ATFL reconstruction was compared to the unaltered specimens, to the condition with ATFL cut, to the ATFL plus calcaneofibular ligament (CFL) cut conditions, and to the ATFL, CFL, and posterior talofibular ligament transected specimens. Three-dimensional bone-to-bone movement between fibula and calcaneus were simultaneously recorded using bone pin markers. Anterior translation was analysed between 20 and 40 N anterior talar drawer load, applied by an ankle arthrometer. Test conditions were compared using non-parametric statistics.

RESULTS

Dissection of ATFL increased anterior talar drawer in arthrometer and bone pin marker analyses (p = 0.003 and 0.004, respectively). When the CFL was additionally cut, no further increase of the anterior instability could statistically be documented (p = 0.810 and 0.626, respectively). Following suture tape reconstruction of the ATFL, stability was not different from the unaltered ankle (p = 0.173).

CONCLUSIONS

Suture tape augmentation of the ATFL effectively protects the unstable anterolateral ankle in the sagittal plane. The CFL does not seem to stabilize against the anterior talar drawer load.

Knotless Modified Arthroscopic-Broström Technique for Ankle Instability

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors' modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot-related complications. Level of Evidence: Level V, expert opinion.

[Arthroscopic repair of chronic lateral ankle instability]

OBJECTIVE

Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies.

INDICATIONS

Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability.

CONTRAINDICATIONS

Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome.

SURGICAL TECHNIQUE

Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using a suture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing and short leg cast for 2 weeks, then 4 weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months.

RESULTS

Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to a significant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3 temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2 temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported a significantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.

Similar Outcomes at Early Term After Arthroscopic or Open Repair of Chronic Ankle Instability: A Systematic Review and Meta-Analysis

Although the open modified Broström technique remains widely accepted as the gold standard for operative treatment of ankle instability, use of the arthroscopic repair technique has been rapidly increasing. Our aim is to conduct a comparative systematic review and meta-analysis of the data to determine whether there is a significant difference in clinical outcomes between arthroscopic and open repair for lateral ankle instability. A systematic literature review was performed using PubMed, Web of Science, the Cochrane Library, and EMBASE from 1980 to March 2018 to identify all English-language studies (level of evidence 1 to 3) comparing functional outcomes of arthroscopic versus open repair of lateral ankle instability. Four studies (1 level 1, 3 level 3) involving 207 patients met inclusion criteria. Of those, 97 participants were treated with arthroscopic repair, and 110 were treated with open repair. All of the subjective outcomes were improved for both groups across the 4 studies, without a significant difference in improvement between groups, except in 1 study, in which time to return to daily activity was significantly shorter in arthroscopic group (p < .05). Overall, this review demonstrated no statistically significant difference in outcome measures between arthroscopic versus open repair, both of which reported favorable and satisfactory outcomes, and produced equivalent clinical results. Additional randomized controlled studies of larger numbers of patients with longer follow-up times, however, are required to confirm whether arthroscopic repair leads to earlier recovery.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal

BACKGROUND

Anatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström-Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability.

METHODS

We reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months.

RESULTS

The mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture.

CONCLUSIONS

Chronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

A comparison of the "All-Inside" arthroscopic Broström procedure with the traditional open modified Broström-Gould technique: A review of 62 patients

BACKGROUND

The open Broström-Gould lateral ankle stabilization procedure has been the gold standard for primary lateral ankle stabilization. A new minimally invasive all-inside arthroscopic technique has been described for the correction of lateral ankle instability.

METHODS

We performed a review of patients who underwent lateral ankle stabilization by either the traditional open Broström-Gould (BG) or the All-Inside Bröstrom (AIB) technique to compare and identify any discrepancies between functional and/or patient satisfaction outcomes. A total of 62 patients underwent a lateral ankle stabilization. Of those 62 patients, 32 received a traditional open Broström-Gould procedure and 30 patients underwent an All-Inside Bröstrom type procedure. The two groups were compared preoperatively with AOFAS ankle-hindfoot scoring system and Visual Analog Score (VAS) for pain. Postoperatively, AOFAS, Karlsson Peterson and VAS scores were compared.

RESULTS

The mean preoperative VAS pain score for the open Broström-Gould was 7.28, the All-Inside Broström was 8.18. The mean postoperative VAS pain score for the open Broström-Gould was 1.2, the All-Inside Broström was 1.5. The mean preoperative AOFAS score for the Broström-Gould was 35.44, the All-Inside Broström was 35.07. The mean postoperative AOFAS score for the open Broström-Gould was 93.53, the All-Inside Broström was 95.33. The mean postoperative Karlsson Peterson score for the open Broström-Gould was 93.41, the All-Inside Broström was 91.80. The mean time to weight bearing for the Broström-Gould was 22 days, the All-Inside Broström was 12 days.

CONCLUSION

There were no statistically significant differences identified in any of the functional or patient satisfaction outcome scores using either technique. This review suggests the minimally invasive arthroscopic technique using bone anchors for lateral ankle stabilization may be comparable to the traditional open Broström-Gould with the added advantage of earlier time to weight bearing.

Arthroscopic Treatment of Ankle Instability: Brostrom

Over the last 10 years, significant advances have been made and successful techniques have now been developed that effectively treat ankle instability via the arthroscope.Currently arthroscopic lateral ligament repair techniques can be grouped into "arthroscopic-assisted techniques," "all-arthroscopic techniques," and "all-inside techniques." Recent studies have proven these arthroscopic techniques to be a simple, safe, and biomechanically equivalent, stable alternative to open Brostrom Gould lateral ligament reconstruction.

Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability

BACKGROUND

The surgical treatment of chronic ankle instability (CAI) relies chiefly on anterior talo-fibular ligament (ATFL) repair (with or without augmentation) or anatomical reconstruction with a tendon graft. Arthroscopy enables not only a complete assessment and the same-stage treatment of concomitant articular lesions, but also an accurate assessment of ligament lesions. Pre-operative imaging studies (MRI, CT, US) may fail to provide sufficient detail about chronic ATFL lesions to guide the decision between repair and reconstruction. The aim of this study was to develop an arthroscopic classification of chronic ATFL lesions designed to assist in selecting the optimal surgical technique.

MATERIAL AND METHODS

Sixty-nine anterior ankle arthroscopy videos recorded before surgery for CAI were studied retrospectively. ATFL dissection was performed in all patients. Based on the video analysis, five ATFL grades were identified: 0, normal ATFL thickness and tension; 1, ATFL distension with normal thickness; 2, ATFL avulsion with normal thickness; 3, thin ATFL with no resistance during the hook test; and 4, no ATFL, with a bald malleolus. Intra- and interobserver reproducibility of the arthroscopic classification of chronic ATFL lesions was evaluated by computing the kappa coefficients (κ) after assessment by two independent observers.

RESULTS

All 69 ATFLs were classified as abnormal (none was grade 0). Each ATFL could be matched to a grade. Intra-observer agreement was good for both observers: κ was 0.67 with 75% of agreement for one observer and 0.68 with 76% of agreement for the other observer. Inter-observer agreement was fair to good, with κ values ranging from 0.59 to 0.88 and agreement from 70% to 91%.

DISCUSSION

Arthroscopic ATFL dissection is a simple procedure that provides a highly accurate assessment of ATFL lesions and mechanical resistance, focussing chiefly on the superior ATFL. Grade 1 and 2 lesions can be repaired using the Broström-Gould procedure, whereas grade 3 and 4 lesions require anatomic reconstruction with grafting.

CONCLUSION

This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI. It is helpful for determining the best surgical technique for stabilising the ankle. These results must be confirmed in a larger study.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients

BACKGROUND

Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques.

MATERIAL AND METHODS

Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports.

RESULTS

The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients.

DISCUSSION

Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery.

CONCLUSION

Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.