Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure

Augmentation of the medial collateral ligament using suture tape reduces the recurrence after corrective surgery for severe hallux valgus

BACKGROUND

The severity of hallux valgus (HV) deformity is associated with recurrence after corrective surgery because of the degenerative change of the medial capsule including the medial collateral ligament (MCL) at the metatarsophalangeal joint. This study aimed to assess the effectiveness of the MCL augmentation using a suture tape anchor of the recurrence of HV and to evaluate the histological changes of the medial joint capsule in HV patients.

METHODS

Thirty-four feet with severe hallux valgus were included and divided into 2 groups. Seventeen feet had the MCL reconstruction using suture tape anchor with a combination of the corrective osteotomy as the suture tape group (mean age, 64.0 years), and other seventeen feet had the corrective osteotomy without MCL reconstruction as the control group (mean age, 62.0 years). HV angle (HVA) and intermetatarsal angle (IMA) on the weight-bearing radiograms and the Japanese Society for Surgery of the Foot (JSSF) score in both groups were compared at the final follow-up. The medial capsule was harvested from other 20 feet with HV and the relationship between the severity of HV and the histological findings was analyzed.

RESULTS

HVA, IMA, and JSSF scores in both groups were significantly improved from preoperatively to the final follow-up (P < 0.01). At the final follow-up, HVA in the suture tape group (9.2°) was significantly smaller than that in the control (15.4°) (P < 0.01). There were no significant differences in the IMA and the JSSF score at the final follow-up between both groups. Histological scores in HV with ≥40° HVA was significantly worse than those in <40°.

CONCLUSION

The medial joint capsule in severe HV deformity showed the degenerative change and the MCL reconstruction using suture tape combined with osteotomy provides a strong medial constraint to prevent the recurrence of the deformity in severe hallux valgus.

LEVEL OF CLINICAL EVIDENCE

3.

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.

Evaluation of Spin in the Clinical Literature of Suture Tape Augmentation for Ankle Instability

Background

Spin is defined as the use of specific reporting strategies to highlight the beneficial effect of a treatment despite nonsignificant results. The presence of spin in peer-reviewed literature can negatively impact clinical and research practices. The purpose of this study was to identify the quantity and types of spin present in primary studies and systematic reviews using suture tape augmentation for ankle instability as a model.

Methods

This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each abstract was assessed for the presence of the 15 most common types of spin. Extracted data included study title, authors, publication year, journal, level of evidence, study design, funding, reported adherence to PRISMA guidelines, and PROSPERO registration. Full texts of systematic reviews were used in the assessment of study quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

Results

Nineteen studies were included in the final sample. At least 1 type of spin was identified in each study except one (18 of 19, 94.7%). The most common type of spin observed was type 3 ("selective reporting or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention") (6 of 19, 31.6%), The second most reported category of spin was type 4 ("the conclusion claims safety based on non-statistically significant results with a wide confidence interval") (4 of 19, 21.1%). Among systematic reviews, we identified type 5 ("the conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") in 4 out of 6 (66.7%) of the articles that were included. No significant associations were found between study characteristics and type of spin.

Conclusion

In this exploration of the introduction of a new technology, we identified spin to be highly present in the abstracts of primary studies and systematic reviews concerning suture tape augmentation for ankle instability. Steps should be taken by scientific journals to ensure that spin is minimized in the abstract to accurately reflect the quality of the intervention.

Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review

BACKGROUND

"Failure" is a term that is frequently used to describe an unfavorable outcome for patients who undergo surgical treatment for lateral ankle instability (LAI). A standard definition of failure for the surgical treatment of ankle instability has not been established by clinicians and researchers.

PURPOSE

To identify the definitions of ankle instability treatment failure that are currently in the literature and to work toward the standardization of the definition.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of MEDLINE, SPORTDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for LAI and included information about surgical failure. Studies with level of evidence 1 to 4 were included in this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinions were excluded. The included studies were then reviewed for definitions of failure of any surgical procedure that was performed to correct LAI.

RESULTS

Of the 1200 studies found, 3.5% (42/1200) published between 1984 and 2021 met the inclusion criteria and were analyzed. After reviewing the data, we found numerous definitions were reported in the literature for LAI surgical failure. The most common was recurrent instability (40% [17/42]), followed by rerupture (19% [8/42]). For the original surgical procedure, the anatomic Broström-Gould technique was used most frequently (57% [24/42]). The failure rate of the Broström-Gould technique ranged from 1.1% to 45.2% depending on the definition of failure.

CONCLUSION

There were multiple definitions of failure for the surgical treatment of LAI, which is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. This definition should include specific, objective physical examination findings that eliminate the ambiguity surrounding failure.

Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue

PURPOSE

Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants.

METHODS

64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test.

RESULT

Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found.

CONCLUSION

Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

Revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedure

PURPOSE

The Brostrom-Gould procedure has been considered as a gold standard operative technique for chronic lateral ankle instability. Despite the popularity and excellent outcomes of the modified Brostrom procedure, some patients still experience recurrence of ankle instability. Few studies reported outcomes of revision reconstruction for patients with a failed modified Brostrom procedure. This study aimed to evaluate the outcomes of a percutaneous anatomic revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedure.

METHODS

From March 2017 to April 2020, 21 patients with persistent ankle instability after a modified Brostrom procedure underwent revision lateral ankle ligament reconstruction. The operation was performed through minimally invasive incisions. Functional assessment was performed using the Karlsson-Peterson ankle scoring system (KP) and the Visual Analogue Scale (VAS). The questionnaires of KP and VAS were completed before surgery and at the last follow-up. Patients' subjective satisfaction level was graded as excellent, good, fair, and poor. Preoperative and postoperative anterior talar displacement and varus talus tilt angle in stress radiographs were recorded.

RESULTS

The average age at the revision surgery time was 39.6years. The mean follow-up was 39.2months. The VAS score improved from 4.1 ± 1.5 preoperatively to 1.3 ± 1.3 at the final follow-up (p < .05). The KP score improved from 59.0 ± 20.2 preoperatively to 88.2 ± 9.6 at the last follow-up (p < .05). The mean varus talar tilt angle was 14.1 ± 3.9 mm preoperatively versus 4.9 ± 4.7 mm at the final follow-up (p < .05). The mean anterior talar displacement was 12.8 ± 2.2 mm versus 5.6 ± 3.7 mm at the last follow-up (p < .05).

CONCLUSIONS

The revision anatomic reconstruction of the lateral ligaments of the ankle is effective for patients with recurrent instability after a failed modified Broström procedure.

The Influence of Suture-Tape Augmentation on Biological Healing of the Anterior Talofibular Ligament in Chronic Ankle Instability: A Quantitative Analysis Using MRI

While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL.

Ankle Instability

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review

Background:

There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle.

Purpose:

To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed.

Results:

There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I² = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, –3.73 to 6.21]; I² = 66%; P = .63), talar tilt angle improvement (MD, –0.07 [95% CI, –0.68 to 0.54]; I² = 0%; P = .42), or anterior talar translation improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I² = 0%; P = .77).

Conclusion:

Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

A quantitative evaluation of the individual components contributing to the functional ankle instability in patients with modified Broström procedure

Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. A total of 46 patients (46 ankles) underwent the MBP for chronic ankle instability were eligible for this study and were followed for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a 6-meter hop test, and a cross 3-meter hop test. The error in joint-position sense significantly improved from a mean 4.3º to 2.8º (p < .001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm (p = .024). Balance retention time significantly improved from a mean 4.7 seconds to 6.4 seconds (p < .001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively (p = .031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense (p < .001), 86.9% in peroneal strength (p = .012), and 74.4% in postural control (p < .001) with significant side-to-side differences. Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively.

Anatomical study of the inferior extensor retinaculum and the oblique superolateral band: implications for the Brostrom-Gould procedure

Purpose

The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability.

Methods

Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP.

Results

Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP.

Conclusion

The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

Clinical outcomes of Tightrope system in the treatment of purely ligamentous Lisfranc injuries

Background

Purely ligamentous Lisfranc injuries are mainly caused by low energy damage and often require surgical treatment. There are several operative techniques for rigid fixation to solve this problem clinically. This study evaluated the effect of using the Tightrope system to reconstruct the Lisfranc ligament for elastic fixation.

Methods

We retrospectively analyzed 11 cases with purely ligamentous Lisfranc injuries treated with the Tightrope system from 2016 to 2019, including 8 male and 3 female. X-ray was performed regularly after operation to measure the distance between the first and second metatarsal joint and the visual analogue scale (VAS) score was used to evaluate pain relief. American orthopedic foot & ankle society (AOFAS) and Maryland foot score were recorded at the last follow-up.

Results

The average follow-up time was 20.5 months (range, 17–24). There was statistically significant difference in the distance between the first and second metatarsal joint and VAS score at 3 months, 6 months, and the last follow-up when compared with preoperative values (P < 0.05).Mean of postoperative AOFAS mid-foot scale and Maryland foot score were 92.4 ± 4.3, 94.1 ± 3.5, respectively. The Tightrope system was not removed and the foot obtained better biomechanical stability. No complications occurred during the operation.

Conclusion

Tightrope system in the treatment of purely ligamentous Lisfranc injuries can stabilize the tarsometatarsal joint and achieve satisfactory effect.

The changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure for chronic ankle instability

Purpose: Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. Methods: A total of 46 patients (46 ankles) who underwent the MBP for chronic ankle instability were eligible for this study and were followed up for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a six-meter hop test, and a cross three-meter hop test. Results: The error in joint-position sense significantly improved from a mean 4.3° to 2.8° (p < 0.001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm (p = 0.024). Balance retention time significantly improved from a mean 4.7 s to 6.4 s (p < 0.001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively (p = 0.031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense (p < 0.001), 86.9% in peroneal strength (p = 0.012), and 74.4% in postural control (p < 0.001), with significant side-to-side differences. Conclusion: Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively. Level of Evidence: Level IV (prospective case series).

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.

Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review

One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for "kinetic outcomes," "kinematic outcomes," "Broström procedure," and "lateral ligament repair." Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.

Revision Lateral Ankle Reconstruction 40 Years After Chrisman-Snook Procedure: A Case Report

CASE

A 70-year-old active woman presented with lateral ankle instability 40 years after a lateral ankle reconstruction procedure. Examination demonstrated gross instability, and advanced imaging revealed attenuation of her previous graft. She underwent anatomic reconstruction through a modified Brostrom-Gould technique and was able to return to hiking without pain.

CONCLUSION

Recurrent lateral ankle instability after reconstruction represents a unique challenge for orthopaedic surgeons. Utilization of a modified Brostrom-Gould procedure with suture tape augmentation is a promising alternative to allograft or autograft reconstruction for patients with active lifestyle goals in the context of recurrent instability.

Clinical and Functional Results of Broström-Gould Procedure With Suture Tape Augmentation: An Evaluation Using Three Scales

The mechanical superiority of suture tape augmentation associated with the Broström-Gould procedure for treating lateral ankle instability has been reported. This study aimed to describe functional results using the visual analog scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) scale, and Short Form of Quality of Life Survey (SF-36) in patients with ankle lateral instability who underwent the modified Broström-Gould repair and suture tape augmentation and to determine the recurrence of injury and the impact on the perception of its stability. This retrospective cohort study included patients with lateral ankle instability treated using the modified Broström-Gould procedure and suture tape augmentation from December 2015 to July 2018 with a 6- to 36-month follow-up. Clinical and functional results were evaluated using the 3 aforementioned scales. p ≤ 0.05 was considered statistically significant. Twenty-eight patients were included, 18 (64%) males and 10 (36%) females (mean ± standard deviation age of 33.25 ± 12.73). The mean pre- and postoperative VAS scores were 6 ± 1.18 and 0.53 ± 0.92, respectively. The average pre- and postoperative AOFAS scores were 65.89 ± 15.08 and 94.60 ± 6.88, respectively; results were excellent (91 to 100) in 18 (64%) patients and good (81 to 90) in 10 (36%). Three patients experienced recurrence of injury treated with physical therapy, and their progress was satisfactory; stability perception was maintained. Excellent clinical and functional results were demonstrated in our study using suture tape augmentation in the modified Broström-Gould procedure, which probably protects against the recurrence of lateral ankle instability.

Is generalized ligamentous laxity a contraindication for a modified Broström operation to treat chronic lateral ankle instability? A systematic review

BACKGROUND

To investigate whether generalized ligamentous laxity (GLL) really is a contraindication for use of the modified Broström operation to treat chronic lateral ankle instability (CLAI).

METHODS

Case series and cohort studies of the clinical outcomes of the use of the modified Broström operation to treat patients with CLAI and GLL were systematically reviewed and a meta-analysis conducted.

RESULTS

A total of 447 patients (458 ankles) from 2 case series and 3 cohort studies were systematically analyzed, with mean follow-up times that ranged from 12 to 108 months. Postoperative foot and ankle values analyzed included foot and ankle outcome scores, foot and ankle ability measurements, Karlsson-Peterson ankle scores, American orthopedic foot and ankle society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, anterior talar translations (ATT), talar tilt angles (TTA) and adverse events. Reliable postoperative ankle stability was achieved in CLAI patients with GLL in the 2 case series without major complications. Suture-tape augmentation combined with a modified Broström operation was employed in 1 case series, and the modified Broström operation was only performed in CLAI patients with GLL if the contralateral uninjured ankle showed normal TTA and ATT in another case series. In the 3 cohort studies, 2 reported poorer outcomes and a significantly greater failure rate in patients with GLL compared with those without GLL, and 1 reported equivalent clinical results. In the further pooled data analysis, there was a significant difference in the postoperative TTA value between the GLL and non-GLL groups (SMD: 0.885, 95% CI [0.599-1.171], P = 0.000; I² = 98%, P = 0.000). The incidence of postoperative recurrent instability was significantly higher in the GLL group (RR: 6.265, 95% CI [2.563-15.309], P = 0.000; I² = 0%, P = 0.985). Two studies reported the preoperative Beighton score in 7 ankles with postoperative recurrent instability, 6 of which had a preoperative Beighton score ≥7.

CONCLUSIONS

GLL may not be a contraindication to the modified Broström operation being used to treat CLAI. However, some augmentation operations may be combined with the classic modified Broström operation, especially for those patients with preoperative Beighton scores ≥7, or with abnormal ATT and TTA in the contralateral ankle. This assertion should be further confirmed by a prospective, large-sample cohort and control study focused on this special population who are at a higher risk of developing postoperative instability.

LEVEL OF CLINICAL EVIDENCE

Level 3.

Recognition of Failure Modes of Lateral Ankle Ligament Reconstruction: Revision and Salvage Options

Primary lateral ankle ligament reconstruction has a high success rate, but failures may lead to recurrent instability. In patients with recurrent lateral ankle instability, it is important to determine the mode of failure. Underlying cavovarus deformity and joint hypermobility must be identified and addressed at the time of revision surgical stabilization. The modified Brostrom-Gould procedure is typically performed for primary lateral ankle ligament reconstruction, but it may be used in revision stabilization procedures utilizing suture-tape augmentation. Revision lateral ankle stabilization surgery can also be addressed with anatomic allograft reconstruction of the ATFL and CFL, and is the authors'preferred technique.

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.

Extensor Retinaculum Flap and Fibular Periosteum Ligamentoplasty After Failed Surgery for Chronic Lateral Ankle Instability

BACKGROUND

The anterior talofibular ligament and the calcaneofibular ligament are 2 of the most frequently injured structures in sports, being damaged in 30% to 45% of all sports injuries. Most reconstructive procedures are successful but can deteriorate with time and can lead to low-grade radiographic degeneration.

METHODS

We operated on 26 consecutive patients from 2001 to 2008 who had failed previous surgical procedures for the lateral ligamentous complex of the ankle, with an average of 104 (range, 75-140) months.

RESULTS

The overall functional rating was excellent in 14 ankles, good in 10, fair in 1, and poor in 1. Twenty-four patients (92.3%) were satisfied with the procedure and 15 (57.7%) were able to return to their preinjury level of activity. Local complications were detected in 2 patients who presented with skin necrosis; 1 patient developed severe reflex sympathetic dystrophy.

CONCLUSION

Revision surgery for the management of failure after surgical treatment of chronic lateral ankle instability is under debate, and the literature is devoid of clinical studies with long-term follow-up. The technique described offers a high rate of long-term excellent and good results, with a low rate of complications and a good rate of return to preinjury level.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability

Background

Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.

Purpose

To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.

Results

A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.

Conclusion

No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair

PURPOSE

Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament's (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL's distal fascicle transfer for the treatment of chronic ankle instability.

METHODS

Five unpaired cadaver ankles underwent arthroscopic ATiFL's distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL's distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported.

RESULTS

All specimens revealed successful transfer of the tibial origin of the ATiFL's distal fascicle onto the talar insertion of anterior talofibular ligament's (ATFL) superior fascicle. The fibular origin of the ATiFL's distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8 mm. The median distance between the distal AL portal and SPN was 3.9 mm.

CONCLUSION

An all-arthroscopic approach to an ATiFL's distal fascicle transfer is a reliable method to reconstruct the ATFL's superior fascicle. Transfer of ATiFL's distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL's distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment.

METHODS

Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018.

RESULTS

One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies.

CONCLUSIONS

There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data.

LEVEL OF EVIDENCE

Level IV, review of level I, II, III and IV studies.

Flexible Fixation in Foot and Ankle Surgery

Flexible fixation has been described and utilized in various aspects of foot and ankle surgery over the past several decades. In regards to ankle surgery, flexible fixation devices have been used for stabilization of the ankle syndesmosis and augmentation of lateral collateral ankle ligament repair. In the foot, flexible fixation devices have been incorporated into hallux valgus or varus correction, Lisfranc injury repair, and more recently spring ligament repair augmentation. This article reviews the various applications for flexible fixation in foot and ankle surgery, as well as evidence-based literature on surgical applications and clinical outcomes.

Correlation Between Joint-Position Sense, Peroneal Strength, Postural Control, and Functional Performance Ability in Patients With Chronic Lateral Ankle Instability

BACKGROUND

The first aim of this study was to evaluate the side-to-side difference of joint-position sense, peroneal strength, postural control, and functional performance ability in patients with chronic lateral ankle instability. The second aim was to identify the correlation between various components contributing to the functional ankle instability (FAI).

METHODS

Thirty-five patients to be scheduled for the modified Broström procedure for chronic ankle instability were analyzed. Joint-position sense and peroneal strength were measured with an isokinetic dynamometer. Postural control ability was evaluated using the modified Romberg test. The functional performance test consisted of the 1-leg hop test, 6-meter hop test, and cross 3-m hop test. Spearman's correlation coefficient (r) was calculated to determine the linear association between the individual components of the FAI.

RESULTS

Except for the 6-m and cross 3-m hop tests, most examination tools for the FAI demonstrated significant side-to-side differences compared with the unaffected ankle. Spearman's correlation analysis revealed that individual components (joint-position sense, peroneal strength, postural control, and functional performance ability) of the FAI were significantly associated with one another, except between peroneal strength and postural control ability (r = 0.21, P = .195).

CONCLUSION

Joint-position sense, peroneal strength, postural control ability, and 1-leg hop test demonstrated significant side-to-side differences in patients with chronic lateral ankle instability. Individual components contributing to the FAI were significantly correlated with one another, except between peroneal strength and postural control ability. Postural control evaluation using the modified Romberg test could substitute for dynamometer testing, with convenience and economic advantage.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Effect of Lateral Ligament Augmentation Using Suture-Tape on Functional Ankle Instability

BACKGROUND:

Although lateral ligament augmentation using suture-tape has been effective for restoration of mechanical ankle stability, few data are available regarding changes of peroneal strength, proprioception, and postural control. The aim of this study was to determine effects of suture-tape augmentation on functional ankle instability (FAI).

METHODS:

Twenty-four patients who underwent suture-tape augmentation were eligible and were followed more than 2 years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test.

RESULTS:

CAIT and FAAM (average of daily and sports activity scores) significantly improved to average 27.2 points and 86.7 points, respectively, at final follow-up. Peak torque for eversion in 60 degrees/s angular velocity significantly improved to 10.6 Nm at final follow-up. Deficit ratio of peak torque for eversion significantly improved from mean 39.5% to 20.9%, and significant side-to-side difference was revealed ( P < .001). There were no significant differences in joint position sense. A significant improvement in balance retention time was revealed at final follow-up, and the relative deficit ratio compared to the unaffected side was 30.9%.

CONCLUSIONS:

Patient-reported functional outcomes significantly improved after lateral ligament augmentation using suture-tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were not significant at the intermediate-term follow-up. In addition, there was no positive effect on proprioception of the ankle.

LEVEL OF EVIDENCE:

Level IV, prospective case series.

Revision of Surgical Lateral Ankle Ligament Stabilization

Ankle sprains continue to be among the most common musculoskeletal injuries, most of which never require surgical treatment. Surgical treatment has traditionally been successful for those patients whose symptoms do not improve with nonoperative care. However, recurrent instability, although rare, can occur early or late after a stabilization procedure, as the result of an acute traumatic event or chronic repetitive minor injury. A complete workup of patients with recurrent ankle instability should be completed before revision surgery and should include evaluation for generalized joint hypermobility as well as anatomic variations, such as hindfoot varus, first ray plantarflexion, and midfoot cavus.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Foot and Ankle Surgery: Common Problems and Solutions

Participation in sports activity has increased significantly during the last several decades. This phenomenon has exposed orthopedic sports medicine surgeons to new challenges regarding the diagnosis and management of common sport-related injuries. Arthroscopy is becoming more commonly used in many of the surgical procedures for these injuries and carries the risk of complications. Wound and nerve complications make up the bulk of complications in most procedures. This article describes these complications associated with the common surgical procedures related to foot and ankle sport-related injuries and how to address and prevent them.