Morphological Characteristics of Os Subfibulare Related to Failure of Conservative Treatment of Chronic Lateral Ankle Instability

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level Ⅲ, retrospective study.

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery

BACKGROUND

Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments.

METHODS

A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention.

RESULTS

Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months.

CONCLUSION

The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Male elite soccer players have a higher incidence of accessory ossicles in the foot and ankle

PURPOSE

Accessory ossicles are caused by the failure of the fusion of secondary ossification centres and are more likely to occur due to heavy loading during the growth period or improper treatment after injury. This study aimed to investigate the incidence of foot and ankle accessory ossicles in male professional soccer players.

METHODS

This study included male professional soccer players who underwent medical checkups at our hospital between 2017 and 2023 as the soccer group. Medical checkups included radiographs of bilateral anteroposterior and oblique foot, as well as bilateral anteroposterior and lateral ankle. Male patients age-matched with the soccer group who visited our hospital undergoing anteroposterior and oblique foot or anteroposterior and lateral ankle radiography were included in the control group. The incidence of accessory ossicles was investigated and compared between the soccer and control groups.

RESULTS

In this study, 276 ankles and 276 feet, as well as 121 ankles and 79 feet, were included in the soccer and control groups, respectively. The incidence of accessory ossicles in the soccer and control groups was as follows: accessory navicular 35.9%, 24% (P = .049), os peroneum 8.0%, 2.5% (P = .09); os supranaviculare 7.6%, 1.3% (P = .039); os infranaviculare 1.4%, 1.3% (P = .090); os calcaneus secundarius 4.3%, 0% (P = .059); os vesalianum 0%, 0%; os subfiblare 12.7%, 2.5% (P < .001); os subtibiale 18.1%, 2.5% (P = .001); and os trigonum 89%, 24% (P < .001).

CONCLUSIONS

Male professional soccer players had a higher incidence of accessory navicular, os supranaviculare, os subfiblare, os subtibiale, and os trigonum.

Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability

OBJECTIVE

To introduce the surgical technique and clinical outcomes of arthroscopic anterior talofibular ligament (ATFL) repair using the Internal Brace and lasso-loop technique for chronic ankle lateral instability.

METHODS

A retrospective study was performed on 29 patients who underwent all-arthroscopic ATFL repair with the Internal Brace and lasso-loop technique from January to August 2020. The patients included 24 males and five females, with a mean age of 30.17 years. Through the accessory anterolateral (AAL) portal, we drilled the bone tunnels and fixed the tape with 4.75 mm and 3.5 mm "SwiveLock" anchors and reattached the torn ligament by the lasso-loop technique.

RESULTS

All 29 patients underwent all-arthroscopic procedures smoothly without serious complications, such as infection and important nerve or vessel injuries. There were eight cases of lateral malleolar avulsion fractures and ten cases of talus cartilage injury. The visual analog scale (VAS), Karlsson-Peterson, Tegner, and American Orthopedic Foot and Ankle Society (AOFAS) scores were used to evaluate the clinical consequences. All the patients were followed up for 18.66 ± 4.85 months on average. The average pre-operative VAS score was 4.69 ± 1.04, which was significantly higher than the average post-operative VAS score of 1.14 ± 1.56. At the final follow-up appointments, the averages of Karlsson-Peterson, AOFAS, and Tenger scores were 75.83 ± 9.44, 88.31 ± 6.81, and 6.93 ± 1.79, respectively, which was significantly higher than that before the operation.

CONCLUSION

This arthroscopic anterior talofibular ligament repair with the Internal Brace and lasso-loop technique achieves satisfactory clinical outcomes with the benefits of high safety and reliability for chronic ankle lateral instability.

Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis

PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.

Comparison of symptomatic unstable ankle with and without os subfibulare

BACKGROUND

This study aimed to compare the patients background, clinical scores, condition of the lateral ligament, mechanical instabilities, and chondral lesions in ankles with symptomatic os subfibulare compared to those in ankles with chronic lateral instability without os subfibulare.

METHODS

Of the 212 ankles with a chronic lateral instability that were surgically treated, 72 ankles had an os subfibulare. All ankles were examined by arthroscopy during surgery. Age, sex, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores, remnant condition of the lateral ligaments, and chondral lesions were compared between ankles with symptomatic os subfibulare and ankles with chronic lateral instability without os subfibulare.

RESULTS

There were no statistically significant differences between the groups in terms of the sex ratio (males: females, 35:37 vs. 53:87, n.s.) and the AOFAS Ankle-Hindfoot Scale scores (median; 75 vs. 77, n.s.). There were statistically significant differences in patient age (median: 20 vs. 24.5 years, p < 0.01), talar tilt angle (median: 9.0° vs 12.0°, p < 0.01), anterior drawer distance (6.2 vs. 7.0 mm, p < 0.01), chondral lesions (G0:G1:G2:G3, 35:21:66:5 vs. 40:44:27:29, p < 0.01), condition of the anterior talofibular ligament (intact: repairable remnant: poor remnant, 0:70:2 vs. 1:112:27, p < 0.01), and condition of the calcaneofibular ligament (intact: repairable remnant: poor remnant, 44:26:2 vs. 77:35:28, p < 0.01) between the groups.

CONCLUSION

This study suggests that the condition of the lateral ligaments including mechanical instability and cartilage of the ankle were less severe in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The patients' age was lower in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The clinical scores and gender ratio were not statistically different between the group.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Three-Portal Approach of Arthroscopy for Anterior Ankle Impingement Syndrome: A Propensity Score-Matched Analysis

Objective

To introduce a 3‐portal approach of arthroscopic for anterior ankle impingement syndrome and to compare this method with 2‐portal arthroscopy.

Methods

From July 2011 to April 2019, a total of 52 patients (30 females, 22 males) with anterior ankle impingement syndrome underwent surgery with 2‐portal approach (anterior medial and anterior lateral approach; N = 26) and modified 3‐portal approach (anterior medial, anterior lateral, and an accessory anterior median approach; N = 26) of arthroscopic were recruited retrospectively after we performed a propensity score‐matched analysis (PSMA). The mean age at operation time was 44.1 years (range from 22 years to 74 years) and the mean follow‐up duration was more than two years (range from 2 years to 9 years). Clinical outcomes of all patients were evaluated according to the range of motion (ROM, dorsal flex angle), the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), the visual analogue scale (VAS), and the operation time before and after the surgery.

Results

During the follow‐up period, both two groups indicated significant improvement in these function scores. Clinical assessment showed that for the 2‐portal approach of arthroscopic the total average of AOFAS scores were significantly increased from preoperative 59.91 ± 5.281 points to postoperative 76.18 ± 1.471 points (P = 0.02), the VAS scores were significantly decreased from preoperative 7.64 ± 0.924 points to postoperative 4.18 ± 0.982 points (P = 0.04), and the dorsal flex angle was significantly increased from preoperative 12.27° ± 6.467° to postoperative 21.36° ± 3.931° at the last follow‐up (P = 0.035). However, for the 3‐portal approach of arthroscopic the total average of AOFAS scores were significantly increased from preoperative 48.64 ± 9.646 points to postoperative 79.18 ± 6.555 points (P = 0.015), the VAS scores were significantly decreased from preoperative 7.82 ± 0.751 points to postoperative 2.64 ± 1.629 points (P = 0.01), and the dorsal flex angle was significantly increased from preoperative 13.64° ± 7.775° to postoperative 20.45° ± 6.502° at the last follow‐up (P = 0.045). There were no significant differences among the dorsal flex angle, the AOFAS scores, and the VAS scores between the two groups at the last follow‐up (P > 0.05). Although the operation time of the 3‐portal approach of arthroscopic (74.82 ± 18.395 min) was longer than that of the 2‐portal approach of arthroscopic (92.55 ± 27.153 min), the difference was not significant (P > 0.05).

Conclusion

Both the 2‐portal and the 3‐portal approach of arthroscopic provides almost the same satisfactory clinical outcomes for anterior ankle impingement syndrome, but we strongly suggest the 3‐portal approach of arthroscopic which can supply greater joint contact area to treat advanced impingement syndrome for a good result.

Talus Secundarius: Case Series

BACKGROUND

Talus secundarius is a very rare accessory bone at the lateral border of the foot. It is attached via a synchondrosis or small synostosis to the lateral aspect of the talar body and has additional facets to the tip of the lateral malleolus and the superior aspect of the calcaneus.

METHODS

Over a period of 8 years, we have seen 5 patients with 6 cases of talus secundarius with an average age of 17 years at first presentation to the senior author. One ossicle was an incidental finding and completely asymptomatic. In the other 5 cases, the average duration of symptoms was 21 months at that time. In 3 cases, additional accessory bones were seen around the talus.

RESULTS

The average size of the ossicles was 18 × 12 × 8 mm. Complete removal resulted in considerable pain reduction without further functional restriction in 4 cases. Two cases (1 asymptomatic, 1 with mild intermittent symptoms) were treated nonoperatively. The average Foot Function Index improved from 22.6 to 4.8 in all patients and from 31.0 to 4.5 in the patients treated with excision for symptomatic talus secundarius (P < .01).

CONCLUSION

The knowledge of accessory bones at the foot is important, as missed diagnosis may lead to prolonged course of pain and unnecessary protection in the affected patients. Resection of symptomatic ossicles substantially reduces pain, but patients have to be counseled that some symptoms may prevail in a congenital deformity.

LEVEL OF EVIDENCE

Level IV, prospective case series.