One in Three Patients With Chronic Lateral Ankle Instability Has a Cartilage Lesion

A comparative study of postoperative clinical outcomes of lateral ankle ligament repair for early-stage ankle osteoarthritis in middle-aged and elderly patients

Although lateral ankle ligament repair has demonstrated favorable postoperative outcomes, few studies have focused on elderly patients. The aim of this study was to compare the postoperative clinical outcomes of lateral ankle ligament repair in middle-aged and elderly patients with early-stage ankle osteoarthritis (OA). This study was a retrospective analysis of 99 patients aged 40 years or older with chronic lateral ankle instability (LAI) associated with ankle OA who were followed up for at least 12 months after surgery. The patients were divided into two groups: 60 patients in the middle-aged group (40-64 years) and 39 patients in the elderly group (≥65 years), all of whom underwent lateral ankle ligament repair. The recovery time to preoperative walking levels and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and postoperatively were investigated and compared between the two groups. Compared with the preoperative scores, SAFE-Q scores improved significantly across all items in both groups at 12 months post-surgery. There was no difference in pain or pain-related scores between the two groups up to 12 months post-surgery. Furthermore, all patients recovered to their preoperative walking levels or above. However, the elderly group took significantly longer to recover after surgery than the middle-aged group did. Lateral ankle ligament repair yields favorable clinical outcomes even in elderly patients. However, elderly patients took significantly longer to recover walking levels after surgery than middle-aged patients. Therefore, preoperative patient education and postoperative rehabilitation protocols may need to be adjusted accordingly.

Recurrent sprains of chronic ankle instability with chronic syndesmotic injury are primarily correlated with plantarflexion instability and multisensory deficits

OBJECTIVE

To investigate postural control deficits and their correlation with recurrent ankle sprains in patients with both chronic ankle instability (CAI) and chronic syndesmotic injury (CSI).

DESIGN

Cross-sectional design.

SETTING

Motion laboratory and Orthopedic department.

PARTICIPANTS

73 individuals with CAI and 15 healthy controls Main outcome measures: Patients with CAI were divided into a CAI group (isolated CAI) and a CSI group (CAI with CSI) based on arthroscopic findings. Postural control was evaluated using the Sensory Organization Test, Adaptability Test, and Romberg Test.

RESULTS

The CSI group had significantly lower somatosensory, visual, and vestibular scores and higher visual dependency compared to CAI group and controls (p < 0.05-0.001). CSI groups showed higher sway energy than the CAI in the plantarflexion sway (p < 0.05). Correlation analysis indicated strong associations between sprain incidence and plantarflexion sway energy (r = 0.68, p < 0.001), VAS scores (r = 0.54, p < 0.001), and somatosensory deficits (r = -0.43, p < 0.001). The AUC for the logistic regression model was 0.906, indicating excellent model performance (p < 0.001).

CONCLUSIONS

Our results found that plantarflexion instability of the CSI correlates most strongly with the risk of ankle sprains, despite coexisting multisensory deficits. Hence, rehabilitation should address these deficits, pain management and targeted training.

Association of Factors Related to the Size and Hepple Classification of Medial Osteochondral Lesions of the Talus

BACKGROUND

Few studies have analyzed the association of factors contributing to the morphologic changes of medial osteochondral lesions of the talus (OLTs).

METHODS

Two hundred eighty consecutive patients who underwent surgery for OLTs from January 2010 to December 2022 were enrolled. The potential association of factors were age, gender, side of injury, duration of symptoms, body mass index, history of ankle sprain, chronic lateral ankle instability (CLAI), and ankle varus. Multivariate logistic regression analysis was performed to evaluate the association between these factors and both the size and Hepple classification of OLTs.

RESULTS

Size of OLTs was associated with age 40-60 years (OR 2.14, 95% CI 1.08-4.25; P = .029), age >60 years (OR 3.78, 95% CI 1.61-8.89; P = .002), duration of symptom 1-3 years (OR 2.06, 95% CI 1.03-4.15; P = .042), and duration of symptoms ≥3 years (OR 2.27, 95% CI 1.09-4.71; P = .028). CLAI was negatively correlated with the size of OLTs (OR 0.30, 95% CI 0.17-0.54; P < .001). Age >60 years was associated with Hepple V classification (OR 3.65, 95% CI 1.50-8.89; P = .004).

CONCLUSION

In our cohort we found older age positively correlated with Hepple V classification. Increasing age and duration of symptom are positively associated with increasing size of medial OLTs, whereas CLAI was negatively correlated with the lesion size.

Patients With Chronic Lateral Ankle Instability and Small Osteochondral Lesions of the Talus Obtain Good Postoperative Results: A Minimum 10-Year Follow-up With Radiographic Evidence

BACKGROUND

Few studies reported the long-term clinical outcomes and joint degeneration of patients with chronic lateral ankle instability (CLAI) and small osteochondral lesions of the talus (OLTs) following simultaneous open modified Broström-Gould (MBG) surgery and arthroscopic bone marrow stimulation (BMS). The purpose of this study was to study the long-term results of patients after BMS and BMG surgery, and to further evaluate the potential effect of OLT size on postoperative results.

METHODS

In this retrospective study, 110 CLAI patients were divided into 57 patients with OLTs (including 24 patients having combined small osteochondral lesions of the tibial plafond) receiving simultaneous BMS and MBG surgeries (BMS+MBG group), and 53 patients without OLTs receiving isolated open MBG surgery (MBG group). The OLT size and pre- and postoperative Kellgren-Lawrence grade were assessed. The subjective scores (visual analog scale pain score, Tegner activity, and Karlsson-Peterson scores), surgical complications, and return to sports were also compared pre- and postoperatively.

RESULTS

Patients were followed up at a mean of 144.2 ± 14.9 and 145.6 ± 11.4 months for the BMS+MBG and MBG groups, respectively. Subjective scores were significantly improved (P < .001), and no difference was found in subjective scores or surgical complications between the 2 groups (P > .05). Both groups showed progression of osteoarthritis grade (P < .001), but with no significant difference of changes from the preoperative to the final follow-up (BMS+MBG group: 0.84 ± 0.75 to 1.32 ± 0.80; MBG group: 0.32 ± 0.48 to 0.86 ± 0.56, changes: 0.48 ± 0.59 vs 0.55 ± 0.51, P = .575). For sports function, both groups had similar results in Tegner scores (5.8 ± 1.3 vs 6.2 ± 1.3, P = .081). However, in a subgroup analysis, we found that in the BMS+MBG group, patients exceeding the mean size of OLTs (50 mm2) were associated with an average lower postoperative Karlsson-Peterson score (P = .025) and higher postoperative osteoarthritis grade (P = .037), with more changes (P = .017) than those with OLTs <50 mm2.

CONCLUSION

Patients with CLAI and small OLTs following simultaneous open MBG surgery and arthroscopic BMS showed good long-term outcomes and only mild progression of joint degeneration-overall similar to patients treated for CLAI with MBG surgery. Moreover, as OLT size increased, good outcomes were less predictable.

Clinical outcomes of all-inside arthroscopic lateral ankle ligament reconstruction for chronic lateral ankle instability: A prospective series with minimum 12 month outcomes

BACKGROUND

Chronic lateral ankle instability (CAI) is a common condition that can be effectively treated with lateral ankle ligament reconstruction to restore ankle stability and function. The aim was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analog Score (VAS) and Euroqol-5D-5L (EQ-5D) patient-reported outcome measures (PROMs).

METHODS

This prospective series included 36 consecutive patients who underwent isolated arthroscopic lateral ligament reconstruction for CAI between November 2020 and November 2022 with minimum 12-month follow up. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, and a minimum of 12 months postoperatively. The MOXFQ is a foot and ankle-specific PROM that assesses foot and ankle function, the VAS measures pain and the EQ5D evaluates general health-related quality of life.

RESULTS

Patients were followed up for 12-25 months. In all patients, there was significant improvement in all postoperative PROMs (p < 0.05). The MOXFQ index decreased from 59.1 ± 19.2-13.5 ± 18.1 (p < 0.01), EQ-5D index increased from 0.607 ± 0.224-0.854 ± 0.175 (p < 0.01) and VAS pain decreased from 36.6 ± 22.3-13.6 ± 18.4 (p < 0.01).A total of 6 patients(16.3 %) were lost to follow up and mean follow-up time was 1.63 ± 0.54 years.

CONCLUSION

Arthroscopic lateral ankle ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Concomitant Stabilization Is Recommended When Treating Osteochondral Lesions of the Talus in Patients With Chronic Lateral Ankle Instability

Osteochondral lesions of the talus are commonly encountered in, and can be caused by, chronic lateral ankle instability. From a clinical and biomechanical point of view, treating chronic lateral ankle instability simultaneously during treatment of osteochondral lesions of the talus is paramount in optimizing patient outcomes, protecting the (repaired) ankle cartilage, and stopping the cascade of ankle cartilage damage. Preventing recurrent (micro)instability minimizes (shear) forces and further degeneration of ankle cartilage.

[Injuries to the lateral ankle ligaments]

Acute sprains and ruptures of the lateral ankle ligaments are the most common injuries of the ankle joint. They are often related to sporting activity and predominantly affect individuals under 40 years old. Lateral ligament injuries occur due to supination trauma. The anterior talofibular ligament is most commonly affected often in combination with the calcaneofibular ligament. In contrast, ruptures of all three lateral ankle ligaments (luxatio pedis supinatoria) or complete ruptures of the medial and lateral ligaments (luxatio pedis cum talo) are extremely rare. The clinical diagnostics have a high sensitivity and specificity and X-ray images are used to exclude fractures and other accompanying injuries. In cases of acute injuries conservative treatment in an orthosis for 5-6 weeks to prevent supination is the method of choice. Surgical treatment is reserved for exceptional indications. For both operative and conservative forms of treatment the functional treatment with initial movement exercises in a semi-rigid orthosis and the following proprioceptive training are crucial for the success of treatment and show superior results compared to immobilization in a surgical cast.

Concomitant Chronic Lateral Ankle Instability Affects Postoperative Functional Outcomes in Patients With Osteochondral Lesions of the Talus but Does Not Affect Cartilage Repair After Restoration of Ankle Stability

PURPOSE

To investigate the effect of concomitant chronic lateral ankle instability (CLAI) on postoperative clinical outcomes in patients with osteochondral lesions of the talus (OLTs).

METHODS

Patients who underwent surgery for OLTs between January 2018 and May 2022 were retrospectively evaluated. OLT patients underwent debridement, microfracture, or bone grafting, whereas patients with concomitant CLAI underwent lateral ligament repair or reconstruction. Functional assessments included the visual analog scale score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), and Tegner score, with a minimum follow-up of 24 months. Cartilage repair was evaluated using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 1 and MOCART 2.0 scores based on postoperative magnetic resonance imaging. Additionally, multiple linear regression analysis was performed to explore the effects of potential factors, and Spearman correlation coefficients (rs) were calculated to assess the relationship between these factors and outcome scores.

RESULTS

A total of 85 patients were included, with 39 in the OLT group and 46 in the OLT-CLAI group. The mean follow-up times were 46.95 ± 17.00 months (range, 24-76 months) and 41.80 ± 15.10 months (range, 24-76 months), respectively (P = .347). Compared with the OLT group, the OLT-CLAI group showed lower postoperative AOFAS and FAOS scores, with a significantly smaller overall improvement in the AOFAS score (P < .05). There was no significant difference in the number of patients achieving the minimal clinically important difference in functional scores between the groups. Multiple linear regression analysis showed that CLAI surgery negatively affected postoperative AOFAS (standardized β = -0.344, P = .001) and FAOS (standardized β = -0.332, P = .001) scores, with Spearman analysis indicating a moderate correlation (rs = -0.442 [P < .001] and rs = -0.339 [P = .002], respectively). No significant differences were observed between the groups in terms of MOCART 1 (61.52 ± 12.38 vs 65.89 ± 14.47) or MOCART 2.0 (68.70 ± 16.53 vs 73.75 ± 14.76) scores (P > .05), and multiple linear regression as well as Spearman analysis did not yield positive results.

CONCLUSIONS

OLT patients with concomitant CLAI had lower postoperative functional outcomes than those without CLAI. However, after surgical treatment of CLAI, cartilage repair in OLT patients was not affected.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Concomitant osteochondral lesion of the talus affects in vivo ankle kinetics in patients with chronic ankle instability

Aims

This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation.

Methods

A total of 16 subjects with CAI (eight without OLT and eight with OLT) and eight healthy subjects underwent gait analysis in a stair descent setting. Inverse dynamic analysis was applied to ground reaction forces and marker trajectories using the AnyBody Modeling System. One-dimensional statistical parametric mapping was performed to compare ankle joint reaction force and joint moment curve among groups.

Results

The patients with OLT showed significantly increased dorsiflexion moment in the ankle joint compared with healthy subjects during 38.2% to 40.9% of the gait cycle, and increased eversion moment in the ankle joint compared with patients without OLT during 25.5% to 27.6% of the gait cycle. Compared with healthy subjects, the patients with OLT showed increased anterior force during 42% to 43% of the gait cycle, and maximal medial force (p = 0.005, ηp2 = 0.399).

Conclusion

The patients with concomitant CAI and OLT exhibit increased dorsiflexion and eversion moment, as well as increased anterior and medial ankle joint reaction force during stair descent, compared with patients with CAI but without OLT and healthy subjects, respectively. Thus, a rehabilitative regimen targeting excessive ankle dorsiflexion and eversion moment may help to reduce ankle joint loading.

No difference between 5 and 6 weeks of non-weight bearing after osteochondral grafts for medial osteochondral defects of the talus with medial malleolar osteotomy

PURPOSE

The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT).

METHODS

A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed.

RESULTS

Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations.

CONCLUSION

No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT.

LEVEL OF EVIDENCE

Level III, Therapeutic.

Ten-Year Survival Rate of 82% in 262 Cases of Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus

BACKGROUND

The long-term sustainability of arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT) remains a matter of debate. The primary aim of the present study was to assess the 10-year survival free from revision in ankles that had undergone arthroscopic BMS for an OLT. The secondary aim was to evaluate the influence of baseline patient and lesion characteristics on survival.

METHODS

Patients who underwent arthroscopic BMS for a symptomatic OLT and had a minimum follow-up of 10 years were included to assess procedure survival. The primary outcome, the 10-year cumulative survival rate, was analyzed by the Kaplan-Meier survival method. Secondary outcomes were the median time to revision and the effects of baseline factors (lesion size, primary or non-primary lesion type, preoperative cysts, and obesity as defined by a body mass index [BMI] of ≥30 kg/m 2 ) on survival, analyzed with a Cox regression model and reported using hazard ratios (HRs).

RESULTS

The 262 included patients had a mean follow-up of 15.3 ± 4.8 years. The 10-year cumulative survival rate of the arthroscopic BMS procedures was 82% (95% confidence interval [CI]: 77% to 87%). At 15 years of follow-up, the cumulative survival rate was 82% (95% CI: 76% to 86%). The median time to revision was 2.4 years (interquartile range: 1.3 to 5.1 years). Of the baseline factors, obesity (HR: 3.0 [95% CI: 1.44 to 6.43], p < 0.01) was associated with decreased survival. Lesion size (HR: 0.9 [95% CI: 0.5 to 1.8], p = 0.8), non-primary lesion type (HR: 1.8 [95% CI: 0.9 to 3.4], p = 0.1), and the presence of preoperative cysts (HR: 1.0 [95% CI: 0.6 to 1.9], p = 0.9) were not significantly associated with survival.

CONCLUSIONS

At a minimum follow-up of 10 years, the survival rate of arthroscopic BMS for OLT was 82%. At 15 and 20 years of follow-up, survival appeared to remain stable. Obesity (BMI ≥ 30 kg/m 2 ) was associated with a higher likelihood of revision surgery. This risk factor should be incorporated into the treatment algorithm for OLT when counseling patients regarding surgery.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability

PURPOSE

Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique.

METHODS

All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared.

RESULTS

A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference.

CONCLUSION

Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients.

LEVEL OF EVIDENCE

Level III.

A matching and localization study of iliac bone graft for repair of talar cartilage injury secondary to lateral ankle instability

Background: To investigate the search for an Iliac-Talar Grafts on the iliac bone that is morphologically matched to a multiplanar injury lesion of the talus; while utilizing a bone-harvesting guide to ensure precise positioning of the Iliac-Talar Grafts. Methods: A total of twenty-two cases with both talar CT data and iliac CT data were collected from January 2019 to June 2023. One case each of talar deformity injury and bone disease were excluded, resulting in a selection of 20 cases. The medial and lateral target repair areas of the talus were formulated, and virtual surgery was performed by using digital orthopedic technology to locate an iliac-talar restoration on the iliac bone that matched the morphology of the multiplanar injury lesion of the talus. 3D chromatographic deviation analysis was used to assess the accuracy of Iliac-Talar Grafts in terms of morphometric matching and positioning, while personalized iliac bone extraction guides were designed to ensure accurate positioning of the Iliac-Talar Grafts. Results: The best fitting point for repairing the medial talar lesion is determined to be medial to the anterior iliac crest, specifically 2.935 ± 0.365 cm posterior to the anterior superior iliac spine, and 2.550 ± 0.559 cm anterior to the valgus-iliac crest point (VICP). Similarly, for the repair of the lateral talar lesion, the ideal position is found to be lateral to the posterior iliac crest, approximately 2.695 ± 0.640 cm posterior to the valgus-iliac crest point (VICP). Utilizing bone extraction guides enables precise positioning for iliac bone extraction. Conclusion: This study utilizes virtual surgery, 3D chromatographic deviation analysis, and guide plate techniques in digital orthopedics to precisely locate the Iliac-Talar Graft on the iliac bone, matching the morphology of the talar lesion; it provides a new solution for cutting the iliac bone implant that matches the the multifaceted talar lesion to be repaired.

Screening of Undiagnosed Increased Lateral Ankle Laxity Using Stress Ultrasonography

Background

Some patients with lateral ankle sprain (LAS) will experience chronic lateral ankle instability (CLAI). However, not all of those with residual increased lateral ankle laxity (ILAL) become symptomatic. There is a lack of evidence regarding the prevalence of undiagnosed ILAL in the general population.

Purpose

To evaluate the prevalence of undiagnosed ILAL with the use of stress ultrasonography (US) and to investigate the percentage of ankle sprain copers (ASCs) with ILAL.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The anterior talofibular ligament (ATFL) lengths in college students without diagnosis of CLAI were measured consecutively in stress and nonstress positions. The ATFL ratio was calculated as an indicator of lateral ankle laxity according to a previously reported method. The manual anterior drawer test was also performed. The Cumberland Ankle Instability Tool (CAIT) and Ankle Instability Instrument (AII) were used to assess subjective impairments related to CLAI. The correlation between the ATFL ratio and CAIT score was evaluated.

Results

A total of 207 ankles from 106 participants (mean age, 23.9 ± 2.2 years; male/female, 64/42) were included. Overall, 38 participants (35.8%; 50 ankles [24.2%]) were classified as having undiagnosed ILAL. Of the ankles with no history of LAS, 8% showed ILAL. Overall, 53 participants (50%) had a history of LAS and were all classified as ASCs. Of the 82 ankles from these ASCs, 40 (48.8%) were regarded as having undiagnosed ILAL. There was no correlation between the ATFL ratio and CAIT scores (r = -0.09, P = .414).

Conclusion

The prevalence of undiagnosed ILAL by stress US screening was approximately one-third in young adults. In this study, 48.8% of the ankles from ASCs showed ILAL.

Open lift-drill-fill-fix for medial osteochondral lesions of the talus: surgical technique

OBJECTIVE

Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy.

INDICATIONS

Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment.

CONTRAINDICATIONS

Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered.

SURGICAL TECHNIQUE

The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws.

POSTOPERATIVE MANAGEMENT

Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of a physical therapist.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review

BACKGROUND

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT.

DESIGN

A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated.

RESULTS

Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported.

CONCLUSIONS

This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Evaluation of Open Versus Arthroscopic Anterior Talofibular Ligament Reconstruction for Chronic Lateral Ankle Instability With Talar and Subtalar Cartilage MRI T2 Mapping: A 3-Year Prospective Study

BACKGROUND

Previous studies have examined patients with chronic lateral ankle instability (CLAI) undergoing open and arthroscopic anterior talofibular ligament (ATFL) reconstruction, reporting equivalent clinical results between the 2 procedures. However, data on the magnetic resonance imaging (MRI) outcomes on cartilage health after the 2 procedures are limited.

PURPOSE

To compare the cartilage MRI T2 values of the talar and subtalar joints between patients with CLAI undergoing open and arthroscopic ATFL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective study was conducted on patients who underwent open or arthroscopic ATFL reconstruction between January 2018 and December 2019, with a mean follow-up duration of 3 years. MRI scans and American Orthopaedic Foot & Ankle Society (AOFAS) and Tegner score estimations were completed by patients ≤1 week before surgery, as a baseline measurement, and at a 3-year follow-up. A total of 21 healthy volunteers were included who underwent MRI at baseline. Cartilage health was evaluated using MRI T2 mapping. The talar and subtalar cartilage regions were segmented into 14 subregions.

RESULTS

At baseline, patients with CLAI had substantially higher T2 values in the medial anterior, medial center, medial posterior, and lateral center regions on the talus compared with the healthy controls (P = .009, .003, .001, and .025, respectively). Remarkable increases in T2 values in the lateral posterior region on the talus were observed from baseline to follow-up in the open group (P = .007). Furthermore, T2 values were considerably higher in the medial center, medial posterior, lateral posterior, and lateral posterior calcaneal facets of the posterior subtalar joint at follow-up in the arthroscopic group compared with the baseline values (P = .025, .002, .006, and .044, respectively). No obvious differences in ΔT2 values were noted between the 2 groups at follow-up. The AOFAS and Tegner scores remarkably improved from baseline to follow-up for the 2 groups (open: 3.25 ± 0.58 vs 5.13 ± 0.81, P < .001; arthroscopic: 3.11 ± 0.90 vs 5.11 ± 1.08, P < .001), with no considerable difference between them.

CONCLUSION

The elevated T2 values of cartilage could not be fully recovered after open or arthroscopic ATFL reconstruction. Both arthroscopic and open ATFL reconstruction displayed similar effects on cartilage health concerning ΔT2, but the arthroscopic group demonstrated more degenerative cartilage subregions than the open group.

Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Uniformity of reporting is a requisite to be able to compare results of clinical studies on the treatment of osteochondral lesions of the talus (OLT). The primary aim of this study was to evaluate the frequency and quality of reporting of size, morphology, and location of OLTs.

DESIGN

A literature search was performed from 1996 to 2023 to identify clinical studies on surgical treatment of OLTs. Screening was performed by 2 reviewers, who subsequently graded the quality using the methodological index for non-randomized studies (MINORS). The primary outcome was the frequency and qualitative assessment of reporting of size, morphology, and location.

RESULTS

Of 3,074 articles, 262 articles were included. This comprised a total of 11,785 patients. Size was reported in 248 (95%) of the articles and was described with a measure for surface area in 83%, however, in 56%, definition of measurement is unknown. Intraclass coefficient (ICC) value for the reliability of size measurement was 0.94 for computed tomography (CT) scan and 0.87 for MRI scan. Morphology was reported in 172 (66%) of the articles and using a classification system in 23% of the studies. Location was reported in 220 (84%) of the studies.

CONCLUSION

No consensus was found on the reporting of morphology, with non-validated classification systems and different terminologies used. For location, reporting in 9 zones is underreported. Size was well reported and measurements are more reliable for CT compared with MRI. As these prognostic factors guide clinical decision-making, we advocate the development of a standardized and validated OLT classification to reach uniform reporting in literature.

LEVEL OF EVIDENCE

Level III, systematic review.

Anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation for chronic lateral ankle instability with poor remnant quality: results and complications

PURPOSE

Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients.

METHODS

One hundred and eight patients with CLAI, who were treated surgically using anatomic reconstruction with allograft tendon and suspensory fixation between April 2016 and January 2018 at our hospital, were retrospectively analysed. None of the patients had sufficient ligament remnants for the modified Broström procedure during the intraoperative evaluation. Eighteen patients were excluded. Seventeen patients were lost to follow-up and 73 patients completed the study. The mean duration of instability symptoms was 39.1 months (range, 6-480 months). The mean follow-up time was 57.5 months (range, 48-69 months). Clinical results were evaluated using the Karlsson scoring scale, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score, visual analogue scale (VAS), patients' subjective satisfaction, and incidence of complications. Mechanical stability was evaluated using the varus talar tilt angle (TTA) and anterior talar displacement (ATD).

RESULTS

The AOFAS-AH scores significantly improved from 67.7 ± 8.5 points to 89.8 ± 9.5 (p < 0.001). The Karlsson scoring scales evolved from 58.8 ± 16.5 to 88.4 ± 11.2 (p < 0.001). VAS scores significantly decreased from 2.9 ± 1.3 to 1.1 ± 1.0 (p < 0.001). On stress radiographs, TTA decreased from 15.1 ± 2.5 degrees to 5.8 ± 2.1 degrees (p < 0.001), whereas ATD reduced from 13.4 ± 2.9 mm to 5.7 ± 1.5 mm (p < 0.001). Patients' subjective satisfaction indicated 46 excellent, 20 good, 5 fair, and 2 bad results. Postoperatively, 15 cases (20.5%) did not achieve complete relief of discomfort or swelling, 9 cases (12.3%) experienced joint stiffness or decreased range of motion, and 6 cases (8.2%) had soft tissue irritation. Residual instability and reoperation are rare. Allograft rejection or wound infection was not observed.

CONCLUSION

For the CLAI patients with poor remnant quality, anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation is an effective procedure, while the top three complications in incidence were residual discomfort, joint stiffness, and soft tissue irritation.

LEVELS OF EVIDENCE

Level IV, retrospective case series.

Concomitant osteochondral lesions of the talus affect the stair descent biomechanics of patients with chronic ankle instability: A pilot study

BACKGROUND

Previous studies on the kinematics of patients with chronic ankle instability (CAI) that did not incorporate MRI and arthroscopic assessment could not differentiate between patients with CAI without osteochondral lesion of the talus (OLT) and patients with CAI and OLT and have thus presented contradictory results.

RESEARCH QUESTION

This study aimed to investigate the kinematic and electromyographic differences between patients with and without OLT.

METHODS

Sixteen subjects with CAI (eight without OLT and eight with OLT confirmed through MRI and arthroscopic assessment) and eight healthy subjects underwent gait analysis in a stair descent setting. The three groups' patient-reported outcomes; ankle joint range of motion in flexion, inversion and rotation; and muscle activation of the peroneus, tibialis anterior, and gastrocnemius during a gait cycle were analyzed and compared. A curve analysis, namely, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalized time series.

RESULTS

The patients with and without OLT had no difference in patient-reported outcomes. The maximal ankle plantarflexion of the patients without OLT and the healthy subjects was significantly larger than that of patients with OLT (p = 0.005). The maximal ankle internal rotation of patients without OLT was significantly larger than that of patients with OLT (p = 0.048). The peroneal activation during 0-6% of the gait cycle of patients with OLT was reduced compared with the healthy subjects.

SIGNIFICANCE

Patients with CAI and OLT and patients with CAI without OLT have no difference in patient-reported outcomes, but patients with OLT can be differentiated using the post-initial-contact peroneal activation deficit and the restriction of ankle plantarflexion and internal rotation during stair descent. These variables can be utilized to monitor the function of patients with CAI and their possibility of developing OLT.