Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle

Treatment of Chronic Ankle Instability in the Military Population: A Systematic Review

BACKGROUND

The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare and evaluate chronic ankle instability treatment strategies in the military population.

METHODS

Electronic databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews guidelines for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports.

RESULTS

Eight studies met the inclusion criteria, representing 695 military service members-625 males (89.9%) and 70 females (10.1%)-and 4 treatment strategies: Broström-related procedures, modified Watson-Jones procedure, Colville's technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of satisfactory outcomes was 100% for Colville's technique, and ranged from 73.2% to 94.7% for Broström-related procedures and 72% to 80% for the modified Watson-Jones procedure. Mean American Orthopaedic Foot and Ankle Society scores, anterior drawer displacement, talar tilt, and visual analogue scale scores were also reported.

CONCLUSION

This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville's technique is another promising option for this patient population but would require additional studies to support this claim.

LEVELS OF EVIDENCE

Level IV.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years

BACKGROUND

An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation.

METHODS

Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used.

RESULTS

Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability.

CONCLUSION

At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone.

LEVEL OF EVIDENCE

Level II, retrospective cohort study.

Acute and Chronic Subtalar Joint Instability: Does It Really Exist?

Acute and chronic subtalar instability and commonly coexistent with other hindfoot pathology but can be difficult to diagnose. A high degree of clinical suspicion is required as most imaging modalities and clinical maneuvers are poor at detecting isolated subtalar instability. The initial treatment is similar to ankle instability, and a wide variety of operative interventions have been presented in the literature for persistent instability. Outcomes are variable and limited.

Chronic Lateral Ankle Instability: Can We Get Even Better with Surgical Treatment?

Lateral ligament attenuation may occur after repetitive ankle sprains, creating instability. Management of chronic ankle instability requires a comprehensive approach to mechanical and functional instability. Surgical treatment, however, is indicated when conservative treatment is not effective. Ankle ligament reconstruction is the most common surgical procedure to resolve mechanical instability. Anatomic open Broström-Gould reconstruction is the gold standard for repairing affected lateral ligaments and returning athletes to sports. Arthroscopy may also be beneficial for identifying associated injuries. In severe and long-standing instability, reconstruction with tendon augmentation could be necessary.

Particularities on Anatomy and Normal Postsurgical Appearances of the Ankle and Foot

The anatomy of the ankle and foot is complex, allowing for a wide range of functionality. The movements of the joints represent a complex dynamic interaction. A solid understanding of the characteristics and actions of the anatomic elements helps explain the mechanisms and patterns of injury. This article reviews the anatomy, with special focus on concepts that are the object of recent study and the features that favor the development of symptoms. Good understanding of the surgical procedures helps in providing information to guarantee a favorable outcome. We review the commonly expected postsurgical appearances and the most common postsurgical complications.

Characteristics of Synovial Fistula of the Ankle Joint: A Case Series

(1) Background: Little is known about the etiology, clinical features, diagnosis methods, treatments, and the prognosis of synovial fistula of the ankle joint. The purpose of this study is to investigate the clinical features of synovial fistula of the ankle joint. (2) Methods: Between March 2003 and December 2018, 40 cysts associated with synovial fistula of the ankle joint were treated consecutively by two surgeons. Case histories, clinical manifestations, intraoperative findings, surgical treatment methods, and treatment outcomes were evaluated to characterize fistula-associated cysts. The clinical results were assessed using the visual analog scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot functional scores, preoperatively and at the last follow-up. (3) Results: The main complaints were ankle instability and pain (15 patients), pain only (15 patients), instability (seven patients), and cosmetic problems (three patients). Eleven patients had a cyst with an open skin wound, and eight of these patients had undergone surgery under a misdiagnosis of bursitis. Cysts were located anterior to the lateral malleolus in 22 cases, next to the lateral malleolus in 13 cases, posterior to the lateral malleolus in three cases, and across the entire lateral malleolus in two cases. Mean VAS and AOFAS scores improved from 5.2 (range, from 1 to 7) and 72.3 (range, from 65 to 87) preoperatively to 1.1 (range, from 0 to 3) and 93.6 (range, from 85 to 100), respectively, at final follow-up visits. (4) Conclusions: Cyst occurrence due to a synovial fistula should be considered when treating a cyst around the lateral malleolus. Fistula repair and reinforcement with fibular periosteum provides a good treatment option for cysts attributed to synovial fistula of the ankle that fail to respond to conservative treatment.

Comparison Between the Simultaneous Reconstructions of the Anterior Talofibular Ligament and Calcaneofibular Ligament and the Single Reconstruction of the Anterior Talofibular Ligament for the Treatment of Chronic Lateral Ankle Instability

This study aimed to evaluate the procedures of reconstruction surgery for chronic lateral ankle instability. We compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. From 2015 to 2019, 14 consecutive patients diagnosed with chronic lateral ankle instability underwent arthroscopic anterior talofibular ligament reconstruction with or without calcaneofibular ligament reconstruction after conservative treatment. Seven patients underwent single anterior talofibular ligament reconstruction (group AT), and 7 patients underwent simultaneous reconstructions of the anterior talofibular ligament and calcaneofibular ligament (group AC). The Japanese Society for Surgery of the Foot scale scores and Karlsson scores significantly improved in all patients 1 year postoperatively. The radiographic measurement of the talar tilt angle and the talar anterior drawer distance at 1 year after surgery were also significantly improved compared to preoperative values. The postoperative talar tilt angle was significantly greater in group AT (median 6°, range 3°-7°) than that in group AC (median 3°, range 2°-5°; p = .038). The postoperative talar anterior drawer distance, Japanese Society for Surgery of the Foot scale score, and Karlsson score were not significantly different between the 2 groups. We found that although the clinical outcomes after the anterior talofibular ligament reconstruction with or without the calcaneofibular ligament reconstruction for chronic lateral ankle instability were good, instability of the talar tilt angle at 1 year postoperatively in patients who underwent single anterior talofibular ligament reconstruction was greater than that in patients who underwent simultaneous anterior talofibular and calcaneofibular ligament reconstructions.

Single Knotless Suture Anchor Repair of Anterior Talofibular Ligament Following Distal Fibula Nonunion Excision

Anterior talofibular ligament (ATFL) tear is the most common ankle ligament injury. This can lead to recurrent ankle instability, which is detrimental to ankle function and the patient's quality of life. Currently, several techniques have shown successful outcomes for ATFL repair. In this technical note, we describe an open ATFL repair using a single knotless suture anchor at the distal fibula location. This approach is rapid, equipment-efficient, and reproducible, while promising excellent results and high patient satisfaction by restoring ATFL anatomy.

Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature

INTRODUCTION

The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported.

AIMS AND OBJECTIVES

The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery.

MATERIALS AND METHODS

We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included.

MAIN RESULTS

After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play.

CONCLUSION

Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00532-0.

Lateral Ligament Reconstruction With Hamstring Graft for Ankle Instability: Outcomes for Primary and Revision Cases

BACKGROUND

Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device.

RESULTS

A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (-4.94° vs -7.03°; P = .415).

CONCLUSION

Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

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.

Investigation of Factors Affecting the Clinical Results of Arthroscopic Anterior Talofibular Ligament Repair for Chronic Lateral Ankle Instability

This study aimed to examine the factors affecting the clinical outcomes of anterior talofibular ligament (ATFL) repair surgery with arthroscopy for chronic lateral ankle instability (CLAI). From 2015 to 2018, 18 consecutive patients diagnosed with CLAI after conservative treatment for ≥3 months underwent arthroscopic ATFL repair surgery using the Broström-Gould technique. Clinical scores at 1 year postoperatively on the Karlsson scoring scale (median, 85 points) and the Japanese Society for Surgery of the Foot scale (median, 90 points) were significantly improved compared with preoperative scores (median, 50 and 66 points; p < .001 and <.001, respectively). The median period to start jogging was 2 and 6 months for patients without (n = 11) and with (n = 7) cartilage damage, respectively, showing a significant difference (p = .006). Four patients with cartilage damage could not return to preinjury sports within 1 year after surgery. In the stress radiographs, the talar tilt angle (TTA) significantly improved from a median of 6° preoperatively to a median of 3.5° postoperatively (p = .002). Talar anterior drawer distance (TAD) significantly improved from a median of 6.5 mm preoperatively to a median of 4.1 mm postoperatively (p < .001). There was no significant difference in TTA or TAD between patients without and with cartilage damage. The period to start jogging postoperatively was significantly correlated with postoperative TTA and TAD. It is suggested that the postoperative period to start activities was delayed because of the larger postoperative TTA and TAD. According to our results, the postoperative period to start activities may depend on cartilage damage and instability remaining postoperatively.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

Chronic Lateral Ankle Instability: Surgical Management

Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Open anatomic reconstruction is an effective method of stabilization. Ankle arthroscopy is a recommended to address intra-articular disorder before stabilization. An anatomic approach provides full range of motion, stability, and return to sport and activity. Allograft or suture tape augmentation can be useful for patients with generalized ligamentous laxity, patients with high body mass index, and elite athletes. Allograft reconstruction may be especially useful in revision procedures. Arthroscopic approach to lateral ankle ligament stabilization may provide good outcomes, with long-term data still limited.

Periosteal flap augmentation of the Modified Broström-Gould procedure for chronic lateral ankle instability

INTRODUCTION

Chronic lateral ankle instability occurs in up to 20% of ankle injuries. Most can be treated conservatively, but surgical reconstruction is required if conservative treatment fails. Modified Broström-Gould procedure is an effective surgical treatment and the augmentation of this procedure with a periosteal flap may confer additional stability. We report on the outcome of a technique combining a modified Broström-Gould procedure augmented with a periosteal flap in patients with chronic lateral ankle instability.

METHOD

Twenty-four males aged 18-42 (mean, 24) with chronic lateral ankle instability affecting 24 ankles underwent the modified Broström-Gould procedure augmented with a periosteal flap, and these surgeries were performed by a single surgeon. The mean follow-up period was 28.7 months. Patients were assessed pre- and post-operatively with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hind foot score.

RESULTS

Preoperatively, the mean AOFAS ankle and hind foot score was 67.38. Post-operatively, significant improvement was seen, with a score of 88.71 ( p < 0.05). None of the patients reported surgical or wound complications.

CONCLUSION

The technique of modified Broström-Gould procedure with periosteal flap augmentation appears to be a simple and safe operation for chronic lateral ankle instability. Patients with poor quality local ligamentous tissue, obese patients or high demand athletes generally benefit from this procedure. It allows effective augmentation of the reconstruction without causing any harm to local tendons or using additional costly implants.

Anatomic reconstruction of anterior talofibular ligament with tibial tuberosity-patellar tendon autograft for chronic lateral ankle instability

INTRODUCTION

Anatomic repair of the anterior talofibular ligament (ATFL) is challenging when the local ligamentous tissue is severely attenuated. Anatomic reconstruction of the ATFL with tibial tuberosity-patellar tendon (TT-PT) autograft is a feasible choice that can avoid the complicated tendon-bone healing and restore ankle stability.

MATERIALS AND METHODS

From 2009 to 2015, 31 chronic lateral ankle instability (CLAI) patients (31 ankles), who had a serious injury on the ATFL only, were treated with anatomic reconstruction of ATFL with TT-PT. American orthopedic foot and ankle society ankle-hindfoot score (AHS), visual analog scale for pain score (VAS), Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion were used to evaluate the clinical outcomes before and after operation. Radiographically, talar tilt angles and anterior drawer were assessed in pre- and postoperative ankle stress views.

RESULTS

Among the 31 ankles, 17 ankles with single-bundle ATFL and 14 ankles with double-bundle ATFL were found at operation. At a mean follow-up of 42 months (24-82 months), all patients were satisfied with the procedure. Mean AHS significantly increased from 60.5 ± 8.2 to 93.5 ± 4.8. Mean Karlsson-Peterson score significantly increased from 55.2 ± 11.0 preoperatively to 91.2 ± 6.9 at final follow-up. Average VAS significantly decreased from 5.9 ± 1.6 preoperatively to 1.4 ± 1.0 at the latest follow-up. Mean Tegner activity level was 3.7 ± 0.9 before operation, compared with 7.0 ± 0.8 after operation. On stress radiographs, mean talar tilt angle was 17.0 ± 3.4° before operation and 3.8 ± 2.1° at the latest follow-up. In addition, mean anterior tibiotalar translation was 7.5 ± 2.2 mm before operation and 1.8 ± 1.1 mm at the latest follow-up.

CONCLUSION

Anatomic reconstruction of the ATFL using a TT-PT autograft allows bone-bone healing in talus and tendon-tendon/periosteum healing in fibula rather than requiring tendon-bone healing, which is an alternative choice for treating CLAI caused by single ATFL insufficiency.

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

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

Clinical Outcomes of the Modified Broström Technique in the Management of Chronic Ankle Instability After Early, Intermediate, and Delayed Presentation

The modified Broström technique (MBT) is considered the reference standard for surgical management of ankle instability, with good short-term outcomes. However, limited evidence is available regarding outcomes for delayed presentations of instability. We report our outcomes for patients who underwent ligament repair using the MBT, from a single-surgeon retrospective study of consecutive patients. The minimum postoperative follow-up period was 6 months during a 5-year study period. The patients were retrospectively divided into 3 groups according to the delay in presentation: group 1, 6 months to 2 years; group 2, 2 to 4 years; and group 3, >4 years. We collected data on patient demographics, injury pattern, and intraoperative surgeon findings. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (AHS) was used to evaluate patient outcomes and satisfaction with surgery. Twenty-six patients were treated with MBT. The mean follow-up period was 36.9 (range 6-42) months. Twenty-five (96.2%) patients had unilateral injuries, and 1 (3.85%) had bilateral repairs. Of the 26 patients, 21 (80.8%) completed the AOFAS-AHS, with a mean score of 87.4 (range 12 to 100). The mean interval from injury to surgery was 47.9 months. The results were excellent in 15 (71.4%), good in 3 (14.3%), fair in 1 (4.8%), and poor in 2 (9.5%) using the AOFAS-AHS. We found no significant difference in the overall AOFAS-AHS score or postoperative satisfaction among the groups (p > .05). All patients had a stable ankle joint at their final follow-up visit. In conclusion, patients with persistent or chronic ankle instability have good clinical outcomes and satisfaction after the MBT, irrespective of the time from injury to presentation.

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.

Surgical Treatment of Chronic Lateral Ankle Instability Using an Inferior Extensor Retinaculum Flap: A Retrospective Study

Chronic lateral ankle instability causes significant problems with physical activity. The purpose of the present study was to evaluate the results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap. A consecutive series of 38 patients were included with a minimum follow-up duration of 2 years. The functional results were assessed using the Karlsson and American Orthopaedic Foot and Ankle Society scale scores. The pre- and postoperative radiologic assessment was performed using stress radiographs to measure varus tilt and anterior drawer tests. All 38 patients were followed up for 2.5 to 7.2 years, and 35 patients were satisfied. The American Orthopaedic Foot and Ankle Society scale score had improved significantly from 57 (range 20 to 70) points preoperatively to 95 (range 80 to 100) points postoperatively (p < .0001), and 35 patients believed their ankle was more stable after surgery. The patients had returned to their previous sports activities an average of 4.7 (range 2 to 12) months after surgery. On the stress radiographs, the mean talar tilt angle had improved significantly from 15.2° (range 6° to 26°) preoperatively to 3.8° (range 1° to 8°) at the final follow-up visit (p < .001), and the mean anterior talar had improved significantly from 13.2 (range 8 to 18) mm preoperatively to 4 (range 4 to 7) mm at the final follow-up visit (p < .002). Regarding the prognostic factors, a link was found between the functional result and residual radiologic laxity measured on the stress radiographs. Reconstruction of the lateral ligaments for chronic ankle instability combining capsuloligamentous retensioning and reinforcement with an extensor retinaculum flap resulted in successful outcomes, excellent ankle stability, and preservation of ankle joint mobility. This technique addressed both lateral ankle and subtalar instability by developing an extraarticular interosseous ligament.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up

INTRODUCTION

A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ.

HYPOTHESIS

The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair.

MATERIALS AND METHODS

A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected.

RESULTS

Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair.

CONCLUSION

Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair.

STUDY DESIGN

Review of the literature; level of proof IV.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review

BACKGROUND

Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Broström-Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies.

METHODS

A systematic literature review using PubMed/Medline databases was performed (July 1972-July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed.

RESULTS

The total ankles treated with an open Broström ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months-27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60-100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months-14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44-100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases.

CONCLUSIONS

The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.

A new minimally invasive method for anatomic reconstruction of the lateral ankle ligaments with a Tightrope system

BACKGROUND

Several minimally invasive anatomic reconstruction techniques of the lateral ligaments have been introduced for the treatment of chronic lateral ankle instability. However, these strategies may not always follow accurate ligament anatomic attachments, especially in the construction of the fibular bone tunnels.

OBJECTIVES

This study reported a new percutaneous technique for reconstruction of the ligaments of lateral ankle anatomically with a Tightrope system.

METHODS

From April 2016 to August 2016, 25 ankles of 24 patients with chronic ankle instability underwent our new percutaneous anatomic reconstruction of the lateral ligaments with a Tightrope system. The operation was performed through several small incisions. The fibular tunnel was made obliquely from the anteromedial side of lateral malleolus tip towards retro-malleolar cortex. The graft was fixed in the tunnel with the help of a Tightrope system. The calcaneal tunnel and talar tunnel were made as our previous method. The mean final follow-up was 12.2 months (range 10-14). Visual Analogue Scale for pain, American Orthopaedic Foot and Ankle Society score, and patients' subjective satisfaction were used to measure clinical outcomes. Preoperative and postoperative stress tests were performed and radiographic parameters were measured.

RESULTS

The Visual Analogue Scale decreased from 3.0 ± 1.4 to 1.3 ± 0.8 at the last follow-up (p < 0.01). The American Orthopaedic Foot and Ankle Society score was improved from 70.2 ± 5.4 preoperatively to 92.4 ± 5.3 at the final follow-up (p < 0.01). Radiologically, the mean anterior talar displacement was 13.1 ± 2.7 mm preoperatively versus 5.6 ± 1.3 mm at last follow-up (p < 0.01),and the mean varus talar tilt angle was 15.0° ± 2.4° preoperatively versus 5.6° ± 1.9° at the last follow-up (p < 0.01). Patients were satisfied ('excellent' or 'good') in 23 ankles (92%). Two patients reported residual instability but less apprehension than the preoperative condition.

CONCLUSIONS

Percutaneous anatomic reconstruction of the lateral ligaments of the ankle with a Tightrope system is an anatomic and effective procedure for the treatment of chronic lateral ankle instability.

[Anatomic stabilization of chronic lateral instability of the ankle : Gold technique]

OBJECTIVES

Anatomical reconstruction of the lateral ligament complex in the ankle.

INDICATIONS

Chronic lateral ankle instability.

CONTRAINDICATIONS

Severe osteoarthritis, obesity, hindfoot varus, general contraindications (infection, circulatory disorders, diabetic foot syndrome).

SURGICAL TECHNIQUE

Anatomical V‑shaped reconstruction of the lateral ligament complex with half of the peroneus brevis tendon and additional retinaculum stabilization.

POSTOPERATIVE MANAGEMENT

Lower leg orthesis (e. g. protect.CAT Walker, medi GmbH, Bayreuth, Germany) for 6 weeks. Week 1-2, no weight bearing, no active pro- and supination. Starting in week 3-4, begin with partial weight bearing, pain adapted. Starting in week 7, free range of motion, begin with progressive training.

RESULTS

Between March 2014 and June 2016, 16 patients (6 female, 10 male) were treated with the above-named technique. Average age was 32.8 years (range 17.9-57.1 years). Ten patients completed the 6‑ and 12-month follow-ups. None of these 10 patients reported a feeling of instability. In the clinical examination, the lateral ligament complex was stable. Patients showed a free range of motion at the 12-month follow-up.

Recent Developments in the Treatment of Ankle and Subtalar Instability

It was nearly a centenary ago that severe ankle sprain was recognized as an injury of the ankle ligament(s). With the recent technological advances and tools in imaging and surgical procedures, the management of ankle sprains - including subtalar injuries - has drastically improved. The repair or reconstruction of ankle ligaments is getting more anatomical and less invasive than previously. More specifically, ligamentous reconstruction with tendon graft has been the gold standard in the management of severely damaged ligament, however, it does not reproduce the original ultrastructure of the ankle ligaments. The anatomical ligament structure of a ligament comprises a ligament with enthesis at both ends and the structure should also exhibit proprioceptive function. To date, it remains impossible to reconstruct a functionally intact and anatomical ligament. Cooperation of the regenerative medicine and surgical technology in expected to improve reconstructions of the ankle ligament, however, we need more time to develop a technology in reproducing the ideal ligament complex.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft

BACKGROUND

The anterior half of the peroneus longus tendon (AHPLT) has been reported to be an effective autograft for ligament reconstruction with respect to strength and safety. However, there is little information regarding donor site morbidity after harvesting the AHPLT. Furthermore, to the best of our knowledge, there has not been a study on the isokinetic evaluation of ankle plantar flexion and eversion after AHPLT harvesting.

PURPOSE

To evaluate the clinical and radiographic results after lateral ankle ligament reconstruction using the AHPLT. We further investigated whether harvesting the AHPLT for lateral ankle ligament reconstruction decreases the strength of ankle plantar flexion and eversion.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty consecutive patients (31 cases) were treated by anatomic lateral ligament reconstruction using the AHPLT. For the clinical assessment, visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson-Peterson scores were evaluated preoperatively and at the last follow-up. For the radiographic assessment, talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up. The peak isokinetic torques for ankle plantar flexion at angular velocities of 30 and 120 deg/s and eversion at angular velocities of 30 and 60 deg/s were measured at a minimum of 1 year after surgery.

RESULTS

The mean VAS score improved significantly from 6.4 ± 1.7 preoperatively to 1.6 ± 1.5 at the last follow-up ( P < .001). The mean respective AOFAS and Karlsson-Peterson scores improved significantly from 57.2 ± 12.8 and 66.9 ± 13.6 preoperatively to 89.0 ± 10.0 and 93.3 ± 5.7 at the last follow-up ( P < .001). The mean talar tilt angle improved significantly from 15.3° ± 6.2° preoperatively to 3.4° ± 3.0° at the last follow-up ( P < .001), and the mean anterior talar displacement improved significantly from 10.2 ± 3.3 mm preoperatively to 6.3 ± 1.9 mm at the last follow-up ( P < .001). No significant differences were observed between the uninvolved and involved legs in the mean peak torque for plantar flexion at angular speeds of 30 deg/s ( P = .517) and 120 deg/s ( P = .347) or for eversion at angular speeds of 30 deg/s ( P = .913) and 60 deg/s ( P = .983).

CONCLUSION

Anatomic lateral ligament reconstruction using the AHPLT showed good clinical and radiographic results without a significant decrease in the peroneus longus strength. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability.

Lateral ligament reconstruction procedures for the ankle

Capsule/ligament lesions of the lateral compartment of the ankle lead to lateral laxity, which is a prime contributor to chronic ankle instability. Lateral ligament reconstruction stabilizes the joint. Exhaustive preoperative clinical and paraclinical work-up is essential. The present article classifies, presents and criticizes the main techniques in terms of long-term stabilization and reduction of osteoarthritis risk. Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligament reconstruction are the two recommended options. Non-anatomic reconstructions using the peroneus brevis should be abandoned. Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available. Postoperative neuromuscular reprogramming is fundamental to optimal recovery. Finally, the concept of complex ankle instability is discussed from the diagnostic and therapeutic points of view. The various forms of ligament reconstruction failure and corresponding treatments are reported.

Ankle Arthroscopic Reconstruction of Lateral Ligaments (Ankle Anti-ROLL)

Ankle instability is a condition that often requires surgery to stabilize the ankle joint that will improve pain and function if nonoperative treatments fail. Ankle stabilization surgery may be performed as a repair in which the native existing anterior talofibular ligament or calcaneofibular ligament (or both) is imbricated or reattached. Alternatively, when native ankle ligaments are insufficient for repair, a reconstruction of the ligaments may be performed in which an autologous or allograft tendon is used to reconstruct the anterior talofibular ligament or calcaneofibular ligament (or both). Currently, ankle stabilization surgery is most commonly performed through an open incision, but arthroscopic ankle stabilization using repair techniques has been described and is being used more often. We present our technique for anatomic ankle arthroscopic reconstruction of the lateral ligaments (anti-ROLL) performed in an all-inside-out manner that is likely safe for patients and minimally invasive.

Arthroscopic Approach to Osteochondral Defects, Impingement, and Instability

Osteochondral defects, impingement, and instability of the ankle are common injuries in athletes. In this article, we review these diagnoses and their treatment options, with a focus on arthroscopic approaches. The treatment options continue to evolve, supported by innovation and outcome studies. In this article, we describe the advantages and disadvantages of both open and arthroscopic treatments using published evidence.

Efficacy and Safety of Split Peroneal Tendon Lateral Ankle Stabilization

Chronic lateral ankle instability is a common condition. Split peroneal tendon lateral ankle stabilization, a modification of the Chrisman-Snook procedure, is biomechanically stable and often used for severe and/or recurrent chronic lateral ankle instability. The purpose of the present study was to evaluate the efficacy and safety of this technique. Specifically, the midterm recurrence of instability and postoperative complications, such as stiffness, neurologic pain, and wound healing complications, were evaluated. We evaluated 30 consecutive procedures with a minimal follow-up period of 1 year. The mean follow-up period was 25 ± 13 (median 19, range 13 to 62) months. Five patients (17%) developed recurrent ankle instability, of whom 4 underwent revision surgery. One superficial infection and two wound disruptions developed. Two patients experienced stiffness and eight (27%) surgically induced neurologic complaints, such as sural neuritis. Finally, 2 patients developed complex regional pain syndrome.

Outcome of subtalar instability reconstruction using the semitendinosus allograft tendon and biotenodesis screws

PURPOSE

Subtalar instability (STI) has often been obscured by lateral ankle instability. Moreover, although there have been several reports of techniques for reconstructing STI, no clinical outcome results are known to have been published. The authors report the clinical and radiographic outcomes of the ligament reconstruction of STI with a recently reported novel technique utilising a semitendinosus tendon allograft and interference screws.

METHODS

This study is based on 20 ankles that underwent ligament reconstruction for STI between 2009 and 2013. The average follow-up period was 15.0 ± 5 months, and the average age at surgery was 28.1 ± 10.8 years old. Visual analogue (VAS) pain scores, American Orthopedic Foot and Ankle Society (AOFAS) and Karlsson-Peterson ankle scores as well as patient satisfaction were evaluated. Radiographic evaluation of medial translations of calcaneus and subtalar tilt angles was preformed with ankle and Broden's stress radiographs.

RESULTS

The VAS pain score decreased from 6.1 ± 1.1 preoperatively to 1.8 ± 1.2 post-operatively (p < 0.05). The AOFAS score improved from 66.0 ± 12.2 preoperatively to 89.6 ± 6.7 post-operatively, and the Karlsson-Peterson score improved from 57.0 ± 13.5 to 91.1 ± 6.8 (p < 0.05). There were no complications such as recurred STI or subtalar joint stiffness. All of the patients were satisfied with the surgery. Subtalar tilt angle decreased from 11.5° preoperatively to 3.0° post-operatively, and the calcaneal medial translations decreased from 7.4 to 3.9 mm.

CONCLUSION

This is the first report on the comprehensive clinical and radiographic outcomes of STI reconstruction using a semitendinosus tendon allograft and interference screws. The novel technique of STI reconstruction was found to show encouraging clinical outcomes with high patient satisfaction.

LEVELS OF EVIDENCE

IV.

Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon

PURPOSE

The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Broström procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed.

METHODS

Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at surgery was 24 years (range 19-46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12-51 months) follow-up.

RESULTS

The Karlsson-Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52%) were very satisfied with the results, nine patients (31%) were satisfied, four patients (14%) were fair, and one patient (3%) was dissatisfied with the results.

CONCLUSIONS

Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments.

LEVEL OF EVIDENCE

Case-series, Level IV.

Lateral Ankle Stabilization Using Acellular Human Dermal Allograft Augmentation

BACKGROUND

We describe a retrospective study that uses the Broström-type surgical procedure with modifications that augment deficient and torn ligaments with acellular human dermal grafts. At the onset of this study, the most prevalent dermal graft available to us was GraftJacket (Wright Medical Technology, Arlington, Tennessee). Greater than 50% of the study participants were grafted with this product, but more recently other equally effective human dermal grafts have been used with no apparent difference.

METHODS

Thirty-five lateral ankle stabilization procedures were performed in the past 6 years on 33 patients. Eight patients were considered athletes (mean age, 23 years). The balance of the study group consisted of sedentary patients (mean age, 41 years). The mean patient body mass index (calculated as the weight in kilograms divided by the square of the height in meters) was 31.

RESULTS

All of the patients were satisfied with their results, with no recurrent instability. Two patients in this group went on to have contralateral ankle stabilization in a similar manner owing to their satisfaction. Complications included two soft-tissue infections.

CONCLUSIONS

Lateral ankle stabilization using acellular human dermal graft augmentation is a useful tool in the surgical treatment of ankle instability. This procedure offers distinct advantages over traditional methods of ankle repair and can be performed with relatively limited surgical exposure. Ease of operation, consistent results, and limited patient morbidity should allow surgeons to use this procedure independently or adjunctively to improve surgical outcomes.

Ankle lateral ligament reconstruction for chronic instability

PURPOSE

To report the outcome of a technique combining direct anatomic reconstruction of the anterior talofibular ligament (ATFL) with augmented reconstruction using the peroneus brevis tendon fixed by a bio-absorbable interference screw.

METHODS

13 men and 2 women aged 17 to 36 (mean, 24) years with recurrent inversion injuries of the right (n=5) and left (n=10) ankles underwent lateral ankle reconstruction by a single surgeon. All patients had a positive anterior drawer test and heel eversion stress test, and some degree of tenderness to palpation over the anterolateral joint capsule. All patients had complete or partial tear of the ATFL and the calcaneofibular ligament, except for one. The torn ligaments were repaired anatomically and reinforced with a split peroneus brevis tendon rerouted through the fibula and fixed with a bioabsorbable interference screw. The outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and the Foot and Ankle Outcome Score (FAOS) at 6 months.

RESULTS

The mean time from injury to surgery was 40.5 months. The mean follow-up duration was 13.6 (range, 6-26) months. No patient had surgical or wound complications. The mean AOFAS ankle and hindfoot score was 91.5 (median, 93; range, 79-100). The mean FAOS was 78.8 (median, 77; range, 61-100). 10 patients had no limitation in both daily and recreational activities; 3 had limitation in recreational activities, and 2 had limitation in both. 12 patients had normal and 3 had moderate limitation in hindfoot motion. One patient had hindfoot instability.

CONCLUSION

The combination of augmented and direct anatomic reconstructions enables early mobilisation despite limitation in hindfoot motion and is a viable option for chronic hindfoot instability.

Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique

Arthroscopy is becoming an essential tool for the treatment of chronic lateral ankle instability. It allows the surgeon to determine which ligaments are injured and choose the most appropriate surgical repair technique, and also to assess and treat any associated injuries. Several arthroscopic techniques for lateral ankle ligament repair have recently been developed. As a consequence, it may be possible to carry out complete lateral ligament reconstruction with an all-arthroscopic procedure. Such an arthroscopic lateral ankle ligament reconstruction technique is described in this article.

A ligament reattachment technique for high-demand athletes with chronic ankle instability

The present prospective study was conducted to evaluate the clinical outcomes of the new ligament reattachment procedure for chronic lateral ankle instability in high-demand athletes. A total of 24 athletes <30 years old were followed for >2 years after undergoing the modified Brostrom procedure using the suture bridge technique. The clinical evaluation included the Karlsson score, the Sefton grading system, and the period to return to exercise. As an evaluation of mechanical stability, the talar tilt angle and anterior talar translation were measured on stress radiographs. The Karlsson score had improved significantly from a preoperative average of 43.5 points to 92.2 points. Using the Sefton grading system, 22 (91.7%) patients achieved satisfactory results. The period to return to exercise was as follows: a mean of 8.4 weeks for jogging, 12.5 weeks for spurt running, 10.5 weeks for jumping, 9.2 weeks for 1 leg standing for >1 minute, 10.6 weeks for walking on uneven ground, and 11.2 weeks for going downstairs. The talar tilt angle and anterior talar translation had improved significantly from the preoperative average of 15.4° and 13.3 mm to 3.8° and 4.2 mm at 2 months postoperatively and 4.9° and 4.8 mm at the final follow-up visit, respectively. The modified Brostrom procedure using the suture bridge technique resulted in satisfactory clinical outcomes comparable to those with conventional ligament reattachment techniques. The suture bridge technique appears to be an effective treatment option for chronic ankle instability in high-demand athletes.

Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft

Lateral ankle sprains are common; if conservative treatment fails and chronic instability develops, stabilization surgery is indicated. Numerous surgical procedures have been described, but those that most closely reproduce normal ankle lateral ligament anatomy and kinematics have been shown to have the best outcomes. Arthroscopy is a common adjunct to open ligament surgery, but it is traditionally only used to improve the diagnosis and the management of any associated intra-articular lesions. The stabilization itself is performed open because standard anterior ankle arthroscopy provides only partial visualization of the anterior talofibular ligament from above and the calcaneofibular ligament attachments cannot be seen at all. However, lateral ankle endoscopy can provide a view of this area that is superior to open surgery. We have developed a technique of ankle endoscopy that enables anatomic positioning of the repair or fixation of the graft. In this article we describe a safe and reproducible arthroscopic anatomic reconstruction of the lateral ligaments of the ankle using a gracilis autograft. The aim of this procedure is to obtain a more physiological reconstruction while maintaining all the advantages of an arthroscopic approach.

The modified Broström-Gould procedure--early results using a newly described surgical technique

Ankle lateral ligament injuries are one of the most common sporting injuries, with the majority being successfully treated conservatively. However, reconstruction is required if this fails. We present the clinical results of a newly described surgical technique of triple-breasting the lateral ligament complex using suture anchors. Sixteen patients (18 ankles) were treated with this new technique. The mean duration of symptoms was 77 months. The mean follow-up was 25 months. All patients underwent an arthroscopy followed by lateral ligament reconstruction by this new technique. Additional pathology included osteoarthritis (2), ankle impingement due to anterior cheilus (2), osteochondral defects (3) and non-union of fracture of anterior process of calcaneus. Additional procedures above diagnostic arthroscopy, soft tissue debridement and modified Broström-Gould repair included debridement and microfracture (3), open excision of anterior calcaneal process (1) and arthroscopic anterior ankle cheilectomy (2). At final follow-up, all ankles were subjectively and objectively stable. Mean AOFAS score improved from 53 to 88. This was statistically significant (p<0.05). Eight patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity. The early results of our modification show it to be safe, successful and comparable with previously published series with all patients having objectively and subjectively stable ankles at final follow-up.

Qualitative and Quantitative Anatomic Investigation of the Lateral Ankle Ligaments for Surgical Reconstruction Procedures

BACKGROUND

Lateral ankle sprains are common sports injuries that may require surgery for chronic lateral ankle instability. Anatomic repair or reconstruction is desired, yet there is a scarcity of quantitative information regarding the origins and insertions of the lateral ligaments related to surgically pertinent osseous landmarks.

METHODS

Fourteen ankle specimens were dissected to isolate the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament. A three-dimensional coordinate measurement device was used to determine the origins, insertions, footprint areas, orientations, and distances from osseous landmarks.

RESULTS

A single-banded anterior talofibular ligament was identified in seven of the fourteen specimens, and a double-banded anterior talofibular ligament was identified in the remaining seven. The single-banded anterior talofibular ligament originated an average of 13.8 mm (95% confidence interval [CI], 12.3 to 15.3) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 17.8 mm (95% CI, 16.3 to 19.3) superior to the apex of the lateral talar process along the anterior border of the talar lateral articular facet. The calcaneofibular ligament originated an average of 5.3 mm (95% CI, 4.2 to 6.5) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 16.3 mm (95% CI, 14.5 to 18.1) from the posterior point of the peroneal tubercle. The posterior talofibular ligament was the largest ligament and originated an average of 4.8 mm (95% CI, 3.7 to 5.9) superior to the inferior tip of the lateral malleolus in the digital fossa to insert an average of 13.2 mm (95% CI, 11.5 to 14.9) from the talar posterolateral tubercle. The cervical ligament originated on the superior part of the calcaneus and inserted at a point that was approximately 50% of the talar neck anteroposterior distance.

CONCLUSIONS

Consistent distances from the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament footprint centers to osseous landmarks were identified.

CLINICAL RELEVANCE

Footprint center distances from surgically relevant osseous landmarks identified in this study can be used during reconstructive surgery of the lateral ankle ligaments and may result in more anatomically accurate placement of the reconstructed ligaments.

Lateral ankle instability in high-demand athletes: reconstruction with fibular periosteal flap

PURPOSE

Fibular periosteal flaps have been used to address chronic lateral ankle instability, but there are no studies in the literature reporting functional outcomes after this particular procedure in high-demand athletes. We postulated that for chronic instability, nonanatomical reconstruction of the lateral ankle ligament with a fibular periosteal flap will return high-demand athletes to their previous levels of activity.

METHODS

Forty patients who had grade III ankle sprain and experienced no success after a course of supervised conservative management lasting at least six months and who had a preinjury Tegner score of ≥ 6 underwent a lateral compartment reconstruction with a fibular periosteal flap. Each patient was given the Tegner and Karlsson questionnaire and was evaluated by the Zwipp method, Foot and Ankle Outcome Score (FAOS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score at the six-month, one, two and three-year time points. Range of motion (ROM) of the affected ankle was assessed, and stress X-rays were performed. Mean patient age was 24.5 (range17-30) years, and no patient was lost to follow-up.

RESULTS

Mean follow-up was 36 (minimum 18) months, mean Tegner scores at the one, two and three-year time points were 8.8, 8.9 and 8.9, respectively, and mean Karlsson scores were 93 ± 5.2, 95 ± 3.1 and 94.9, respectively. AOFAS and FAOS scores improved from a mean of 69.4 and 71.4, respectively, in the preoperative group to a mean of 97.2 and 94.4, respectively, at the last follow-up. The ROM was equal to the contralateral ankle in all but two patients at the two-year follow-up. No major complications were found.

CONCLUSION

Nonanatomical ligament reconstruction with a fibular periosteal flap for chronic lateral ankle instability was effective in returning high-demand athletes to their preinjury functional levels.

Comparison of bone tunnel and suture anchor techniques in the modified Broström procedure for chronic lateral ankle instability

BACKGROUND

The modified Broström procedure is frequently used to treat chronic lateral ankle instability. There are 2 common methods of the modified Broström procedure, which are the bone tunnel and suture anchor techniques.

PURPOSE

To compare the clinical outcomes of the modified Broström procedure using the bone tunnel and suture anchor techniques.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Eighty-one patients (81 ankles) treated with the modified Broström procedure for chronic lateral ankle instability constituted the study cohort. The 81 ankles were divided into 2 groups, namely, a bone tunnel technique (BT group; 40 ankles) and a suture anchor technique (SA group; 41 ankles). The Karlsson score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, anterior talar translation, and talar tilt angle were used to evaluate clinical and radiographic outcomes. The BT group consisted of 32 men and 8 women with a mean age of 34.8 years at surgery and a mean follow-up duration of 34.2 months. The SA group consisted of 33 men and 8 women with a mean age of 33.3 years at surgery and a mean follow-up duration of 32.8 months.

RESULTS

Mean Karlsson scores improved significantly from 57.0 points preoperatively to 94.9 points at final follow-up in the BT group and from 59.9 points preoperatively to 96.4 points at final follow-up in the SA group. Mean AOFAS scores also improved from 64.2 points preoperatively to 97.8 points at final follow-up in the BT group and from 70.3 points preoperatively to 97.4 points at final follow-up in the SA group. Mean anterior talar translations in the BT group and SA group improved from 9.0 mm and 9.2 mm preoperatively to 6.5 mm and 6.8 mm at final follow-up, respectively. Mean talar tilt angles were 12.0° in the BT group and 12.5° in the SA group preoperatively and 8.8° at final follow-up for both groups. No significant differences were found between the 2 groups in terms of the Karlsson score, AOFAS score, anterior talar translation, and talar tilt angle.

CONCLUSION

The bone tunnel and suture anchor techniques of the modified Broström procedure showed similar good functional and radiographic outcomes. Both techniques appear to be effective and reliable methods for the treatment of chronic lateral ankle instability.

Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft

BACKGROUND

Multiple techniques have been described for reconstruction of the lateral ligaments of the ankle. Most require extensive exposure and dissection, which may lead to potential problems with wound healing, higher risk of nerve injury, fibrosis, and stiffness. This study reports on the results of a minimally invasive method to reconstruct the ligaments using a semitendinosus tendon autograft and achieve a stable ankle while avoiding these problems.

MATERIALS AND METHODS

From September 2006 to May 2010, 25 patients (14 males, 11 females) with chronic ankle instability underwent lateral ligament reconstruction. The average age was 32.4 (range, 17 to 62) years old. A semitendinosus autograft was harvested through 2 small knee incisions. For the ankle reconstruction, 4 small incisions of 5 mm each were made at the medial and lateral side of the fibular tip, the talar neck, and the middle of the calcaneus. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) was then performed through these small incisions. The mean final follow-up was 32.3 (range, 12 to 56) months. AOFAS questionnaires were used to measure clinical outcomes and donor site morbidity and patient satisfaction are also reported. Preoperative and postoperative stress tests were performed and radiographic parameters were measured.

RESULTS

The mean AOFAS score increased on average from 71.1 to 95.1 (P < .001). Two patients reported residual instability on uneven ground. No patient reported weakness or disability from the donor site. The satisfaction level was excellent in 20 patients and good in 5 patients. Significant improvement in stress radiographic parameters was noted for the talar tilt angle, with reduction from a mean of 14.0 to 3.8 degrees (P < .001); anterior talar displacement reduced from a mean of 12.3 to 4.6 mm (P < .001).

CONCLUSION

Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach can achieve a stable ankle while avoiding extensive exposure and risk of nerve injury.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Evaluation of a modified Broström-Gould procedure for treatment of chronic lateral ankle instability: A retrospective study with critical analysis of outcome scoring

BACKGROUND

Chronic lateral ankle instability accounts for 20% of the ankle injuries. This study evaluates functional outcome of the modified Broström-Gould technique using suture anchors, with 4 different clinical scores.

METHODS

A consecutive series of 41 patients were included with a minimum follow-up of one year. The function was assessed using 4 clinical scores including: the AOFAS for hind foot; the FAAM; the CAIT and the CAIS.

RESULTS

Out of 41 patients; 27 patients were very satisfied, 11 satisfied and 3 were not satisfied. Ankle mobility returned to normal in 93% of patients. At follow-up the AOFAS was 89/100 (37-100), the FAAM 85/100% (35-100%), the CAIT 20/30 (5-30), and the CAIS 74/100% (27-100%).

CONCLUSION

Outcome of modified Broström-Gould procedure is good with high satisfaction rate in terms of ankle mobility. The disparity in outcome of scores, signals towards the need of a standard evaluation system.

Long-term follow-up of lateral reconstruction with extensor retinaculum flap for chronic ankle instability

BACKGROUND

Chronic instability is a common complication of lateral ankle sprains. Furthermore, patients often have unrecognized associated lesions affecting the ankle and subtalar joints. Many stabilizing surgical techniques have been described, each with variable results. This article reports the long-term results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap.

PATIENTS AND METHODS

This is a retrospective, multicenter study. One hundred fifty cases were reviewed at a mean follow-up of 11 years. Functional results were assessed using the Karlsson score. Pre- and postoperative radiological assessment employed stress x-rays to measure varus tilt and anterior drawer and the Van Dijk classification to grade osteoarthrosis. The Stata 10 program was used for statistical analysis.

RESULTS

A thorough preoperative workup identified ligamentous lesions of the subtalar joint in 30% of cases. At review, 93% of patients were satisfied. Residual instability was present in only 4.8%. Radiographic analysis of both ankles revealed a differential in varus tilt of only 0.12° and in anterior drawer of 0.17~mm. There was no deterioration of the articular surfaces after 11 years of follow-up.

CONCLUSION

To the authors' knowledge, this is the largest series reported with such a follow-up. This technique addressed both lateral ankle and subtalar instability without sacrificing the peroneal tendons. It protected against progression of posttraumatic arthrosis and provided superior results to other reported techniques in terms of patient satisfaction and residual instability.

Tenodesis reconstruction for chronic ankle instability: graft considerations and structures at risk with tunnel placement

Lateral ankle ligament surgical reconstruction can take many forms, including anatomic and nonanatomic reconstructions. The nonanatomic reconstructions require the use of autograft or allograft tendons to recreate the vectors of the injured anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The purpose of this study was to determine the minimum, maximum, and average graft length requirements for a modified Chrisman-Snook procedure. The structures at risk during drilling of the bone tunnels were documented to guide recommendations for tunnel placement. Modified Chrisman-Snook lateral ligament reconstructions were performed on 10 cadaveric below-the-knee specimens, with no known pathology. Transosseus tunnels were placed through and through the fibula, talus, and calcaneus at the origin and insertion sites of the ATFL and CFL. The minimum, maximum, and average graft length requirements were 91 mm, 170 mm, and 120.7 ± 23.84 mm, respectively. The overall average graft requirement was approximately 120 mm. The length of graft was correlated with the height of the patient. Medial structures that were directly encountered, in at least one specimen, with the transosseus tunnels included the tibial nerve, tibial artery and flexor hallucis longus tendon. The posterior tibial nerve was the structure at greatest risk. The length of the graft, when performing the modified Chrisman-Snook, should measure approximately 120 mm, but considerable variability exists depending on the size of the patient. To avoid injury to medial structures, the transosseus tunnels should be made using either a blind hole technique or guide wire to avoid perforating the medial cortex.

LEVELS OF EVIDENCE

Cadaveric, Level V.