Operative Treatment of Lateral Ankle Instability

Ligament Quality Predicts Recurrence and Functional Outcomes After Arthroscopic All-Inside ATFL Repair

PURPOSE

This study aimed to evaluate the clinical outcomes of arthroscopic all-inside anterior talofibular ligament (ATFL) repair based on the quality of the remnant ligament.

METHODS

We retrospectively analyzed consecutive patients with chronic ankle instability(CAI) who underwent arthroscopic ATFL repair with a minimum follow-up period of 24 months. Patients were categorized into two groups based on the arthroscopic ATFL grade: group G, characterized by good-to-moderate tissue quality with distension or ATFL discontinuity; and group P, characterized by poor tissue quality with a hypoplastic ATFL. Outcome measurements were obtained preoperatively and postoperatively. Patients-reported outcomes were assessed using the visual analog scale score, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score. Objective outcomes included posturographic analysis and radiological evaluations, such as stress radiographs and axial view magnetic resonance imaging (MRI).

RESULTS

Both groups exhibited postoperative improvements in the subjective and objective clinical outcomes (all p < 0.05). For the sports unit of FAOS, 75.3% of Group G exceeded the MCID threshold, compared with 57.8% of Group P, showing a statistically significant difference (p = 0.027). Group P demonstrated significantly lower FAOS scores in the sports unit (Group G: 86.9 ± 32.8, Group P: 61.9 ± 26.4, p = 0.016), an increased fall risk as determined using posturography at the final follow-up (group G: 28.6 ± 22.4, group P: 49.7 ± 23.3, p = 0.019), and a higher retear rate on axial-view MRI (group G: 2.6%, 2/77, group P: 10.9%, 7/64, p = 0.044).

CONCLUSION

Arthroscopic all-inside ATFL repair is an effective treatment for CAI, regardless of the quality of the remnant ligament. However, patients with poor ligament quality have inferior clinical outcomes, particularly in terms of sports-related activities, as reflected by both lower scores and fewer patients exceeding the MCID threshold. Additionally, the fall risk index and retear rates were higher in patients with poor ligament quality, highlighting the impact of ligament quality on postoperative stability and functional recovery.

LEVEL OF EVIDENCE

Prognostic, Level III, retrospective cohort study.

Anatomical analysis of the lateral ligament complex in the neutral position and during plantar flexion

AIM

The purpose of this study was to obtain anatomical information on the anterior talofibular ligament (ATFL), anterior tibiofibular ligament (ATiFL) and calcaneofibular ligament (CFL) in the neutral position and during plantar flexion.

METHODS

Seventy specimens with whole ankle ligaments were recorded for anatomy education. ATFLs with single, double, and triple bands corresponded to Types A, B, and C. In our study, different types of ATFLs with information on the length, width, ATFL/CFL angle, ATFL/ATiFL angle, and the distance of the fibular center of insertion (fCOI) of ATFL-CFL-ATiFL in the neutral position and 20° plantar flexion, was collected.

RESULTS

In Type B, the length, width, and ATFL/ATiFL angle of the superior and inferior bands varied (length, P < 0.001; width, P < 0.001; ATFL/ATiFL angle, P < 0.001). Among the types, the total widths of Types A/B and A/C were significantly different (P < 0.01; P < 0.001). In terms of postural changes, significant differences in the ATFL/ATiFL angle were observed for Type A (P < 0.001), Type B (P < 0.001), and Type C (P < 0.01).

CONCLUSIONS

In conclusion, attention should be given to the ATFL widths of different ATFL types during surgical treatment because of the significant differences among the three ATFL types. The relative independence of ATiFL and the cooperative relationship between ATFL and CFL are instructive for different ATFL surgical procedures. The ATFL, CFL, and ATiFL data can be used for anatomical reconstruction and secondary proofreading for ATFL injury or chronic ankle instability.

Augmentation with the inferior extensor retinaculum may facilitate earlier recovery in all-inside arthroscopic management of chronic lateral ankle instability

BACKGROUND

To compare the clinical outcomes of inferior extensor retinaculum (IER) augmentation following repair of the anterior talofibular ligament (ATFL) with isolated ATFL repair in patients with an arthroscopically confirmed grade 3 lesion of the ATFL.

METHODS

We conducted a retrospective study of consecutive chronic lateral ankle instability (CLAI) patients who underwent arthroscopic ATFL repair between March 2018 and August 2022. The average age of the patients was 31.5 ± 7.4 years (range, 16-50 years). All patients underwent all-inside arthroscopic repair, and were divided into two groups based on the ligament repair method: the Broström-Gould group (n = 64) and the Broström group (n = 67). At 3, 6, 12 and 24 months after surgery, ankle inversion stress tests and anterior drawer tests were employed to assess the stability of the ankle joint. The American Orthopedic Foot and Ankle Society ankle hindfoot scale(AOFAS-AH) and Karlsson ankle function score (KAFS) were employed to assess ankle function; the Tegner score was employed to assess the patient's level of exercise; the Foot and Ankle Outcome Score [FAOS, including score of symptoms-diseases, pain, function-daily living score, function in sports and recreational activities, and quality of life] was used to assess the patient's daily activity ability.

RESULTS

The Tegner score, FAOS-function-daily living score, and FAOS-function in sports and recreational activities in the Broström-Gould group consistently outperformed the Broström group at 3 months and 6 months post-surgery, with the differences being statistically significant (all P < 0.05). However, although the differences are statistically significant, the clinical relevance of this statistical significance remains uncertain. At 12 and 24 months, there were no statistically significant differences between the two groups.

CONCLUSIONS

For CLAI patients with arthroscopic grade 3 lesion of the ATFL, both the all-inside arthroscopic Broström-Gould procedure and the Broström procedure provide stability and enhance ankle joint function, resulting in similar functional outcomes at a 2-year follow-up. IER augmentation following ATFL repair may facilitate earlier recovery exercises compared to isolated all-inside ATFL repair.

Usefulness of Suture-Tape Augmentation Based on Intraoperative Ankle Stress Radiographs During Anatomical Ligament Repair for Chronic Lateral Ankle Instability

BACKGROUND

During the modified Broström procedure for chronic ankle instability, surgeons often experience cases with insufficiently restored mechanical stability even after anatomical ligament repair. In these cases, longer postoperative immobilization and delayed rehabilitation can be required, and a risk for recurrence of instability may persist. This study aimed to evaluate the clinical usefulness of suture-tape augmentation based on intraoperative stress radiographs during anatomical ligament repair for chronic ankle instability.

METHODS

Twenty-four patients who underwent additional suture-tape reinforcement because of residual mechanical instability on intraoperative stress radiographs were followed up ≥3 years. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Changes in mechanical stability were analyzed through periodic stress radiographs, and postural control ability was evaluated with the modified Romberg test.

RESULTS

FAOS and FAAM scores improved significantly from preoperative mean 55.1 and 52.4 points to 92.3 and 90.2 points at final follow-up, respectively (P < .001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 15.8 degrees and 13.6 mm to 2.9 degrees and 4.2 mm, respectively (P < .001). Balance retention time improved significantly from preoperative mean 3.6 to 6.4 seconds (P < .001). Although 9 patients experienced sprain injury after surgery, no patient showed recurrence of mechanical and subjective instability, and 21 patients (87.5%) were able to return to preinjury level of sports activity.

CONCLUSION

Evaluation of residual mechanical instability through intraoperative stress view and additional suture-tape augmentation showed satisfactory clinical outcomes at midterm follow-up. Suture-tape augmentation based on intraoperative stress radiographs seems to be a useful surgical option for patients with insufficiently restored mechanical stability even after anatomical ligament repair. This combined procedure can provide a reliable mechanical stability that can be performed after recognition of residual instability during the index surgery.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability

It is important to eliminate instability related to chronic lateral ankle instability (CLAI) to prevent osteoarthritis progression. We performed arthroscopic anterior talofibular ligament (ATFL) repair and performed calcaneofibular ligament (CFL) repair if instability remained. This study aimed to assess the clinical outcomes of our arthroscopic procedure compared to that of open surgery. Forty ankles underwent arthroscopic surgery and 23 ankles underwent open surgery to repair the lateral ankle ligaments for CLAI. In the arthroscopic surgery, varus stress was applied under fluoroscopy after ATFL repair, and CFL repair was performed if instability remained. Open surgery was performed using the Broström procedure with ATFL and CFL repair. To assess clinical outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) and Karlsson-Peterson (KP) scores were collected preoperatively and at the final follow-up. The talar tilt angle (TTA) was measured preoperatively and 1 year postoperatively. The arthroscopic group showed significantly higher AOFAS and KP scores at the final follow-up compared to the open surgery group. There was no significant difference in TTA at 1 year between the groups. In open surgery, 2 patients required revision surgery. There were no major complications, but scar-related pain in 2 cases of open surgery was reported. Arthroscopic ATFL repair with the CFL repair gave satisfactory clinical outcomes compared to open surgery in CLAI because of low invasive to soft tissue including the joint capsule. It is important to minimize soft tissue dissection in repairing the lateral ankle ligament in patients with CLAI.

Comparison of Knot-Tying Techniques During the Arthroscopic Broström-Gould Procedure: Semiconstrained Freehand Versus Knot Pusher Techniques

BACKGROUND

The arthroscopic Broström technique with or without Gould modification has been used to treat patients with anterior talofibular ligament injury who failed nonoperative management and progressed to chronic lateral ankle instability. However, some patients develop limited range of motion over the ankle joint postoperatively.

PURPOSE/HYPOTHESIS

To compare the clinical outcomes and midterm functional performance of knot-tying techniques between using a knot pusher and a semiconstrained freehand tie during arthroscopic Broström-Gould procedure with inferior extensor retinaculum (IER) augmentation. It was hypothesized that the semiconstrained freehand tie would provide better plantarflexion of the ankle joint compared with the knot pusher.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Included were 135 consecutive patients with mild-to-moderate lateral ankle instability (mean age, 42.7 years; range, 16-78 years) who underwent an arthroscopic Broström-Gould procedure from March 1, 2016, to April 30, 2022. The patients were divided into 2 groups according to the tying technique used in the Gould modification: surgical tie using a knot pusher (KP group; n = 30) or a semiconstrained freehand tie (FT group; n = 105). Radiographic parameters and ultrasound dynamic testing were examined during the preoperative assessment. Preoperative and 2-year postoperative assessments comprised American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale for pain, and 12-Item Short Form Survey (SF-12) scores.

RESULTS

The 2 groups had no differences in age, sex, or severity distribution in the preoperative assessment. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale pain, and SF-12 scores were significantly better at the postoperative evaluation (all P < .05) in both groups. No significant difference was noted between groups in outcome scores. In the KP group, however, 7 out of 30 patients (23.3%) developed ankle stiffness with tightness when performing plantarflexion movement. No patients in the FT group reported similar symptoms.

CONCLUSION

For mild-to-moderate chronic lateral ankle instability, we propose an arthroscopic Broström procedure with the addition of IER augmentation using a semiconstrained freehand tie to avoid overtightening the IER. This ensures favorable patient satisfaction and clinical outcomes without limitation of plantarflexion of the ankle joint and avoids the possible complication of stiffness with plantarflexion.

Advancement of Periosteal and Capsular Complexes With or Without Augmentation Using a Free Graft From Lower Extensor Retinaculum: A Comparative Study With Propensity Score Matching

Background

This study compared the outcome of the L-shaped (L-AD) advancement of the periosteal and capsular complexes with or without augmentation using a free graft of the lower extensor retinaculum (AUG) in patients with chronic lateral ankle instability.

Methods

A matched pair analysis was performed of retrospectively collected medical records of patients undergoing lateral ankle ligament repair who had completed at least 2 years of follow-up. Patients who underwent L-AD with AUG and patients undergoing L-AD alone were matched for age, sex, stress radiography findings, and body mass index. Patients with general joint laxity, osteoarthritic changes in the ankle, and subtalar symptoms and who underwent simultaneous surgical treatment for conditions other than that for lateral ankle ligament were excluded. A total of 46 patients were included in the study (23 patients in each group). Clinical outcome scores and postoperative mechanical instability were compared.

Results

The median American Orthopaedic Foot & Ankle Society (AOFAS) score improved significantly (P < .001) from 72 to 97 in the L-AD alone group and from 77 to 100 in the L-AD with AUG group. The mean (±SD) talar tilt angles improved significantly from 11.1 to 4.7 degrees postoperatively (P < .001) in the L-AD alone group vs 9.7 to 5.2 degrees (P < .001) in the L-AD with AUG group. The mean anterior drawer distances were improved significantly postoperatively from 6.4 to 4.7 mm (P < .001) in the L-AD alone group, and from 6.5 to 4.5 mm (P < .001) in the L-AD with AUG group.

Conclusion

The L-AD technique significantly improved AOFAS scores and mechanical instability of ankles with chronic lateral instability with a very low complication rate. Additional augmentation using a free graft showed no advantages in the ankle with a talar tilt of <20 degrees.

Level of Evidence

Level III, retrospective case-control series.

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.

Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury

Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.

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

Background:

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

Hypothesis:

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

Study Design:

Controlled laboratory study; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Clinical Relevance:

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

Comparison of symptomatic unstable ankle with and without os subfibulare

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Do We Need Extensor Retinacular Enhancement on Broström Lateral Ankle Repair? A Systematic Review and Meta-analysis

Aims This meta-analysis compared inferior extensor retinaculum (IER) enhancement in Broström-Gould procedure and anatomical Broström repair.  We aim to evaluate functional ankle score (American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson score), talar tilt, talar anterior translation, and complications between both groups. Methods A comprehensive systematic literature search was carried out using Wiley Library, Scopus, Pubmed, ScienceDirect, and EuropePMC databases from inception up until 19 December 2020. While the intervention was IER enhancement, the control was those without IER enhancement. The primary outcome was the functional ankle score (AOFAS and Karlsson score). The secondary outcomes were talar tilt, talar anterior translation, and other complications. Results There was a total of 298 patients from 7 studies included in this systematic review and meta-analysis. IER enhancement was associated with lower AOFAS (mean difference -1.115 [-2.197, -0.033], p=0.043; I2: 0%) during follow-up. Lower Karlsson score was observed in the IER enhancement group (mean difference -2.004 [-3.442, -0.567], p=0.006; I2: 3.71%) during follow-up. Talar tilt (mean difference -0.145 degree [-0.436, 0.146], p=0.329; I2: 0%) and anterior displacement (mean difference -0.109 mm [-0.096, 0.314], p=0.299; I2: 0%) in the two groups were similar on follow-up. The complications were similar in both groups (OR 0.87 [0.40, 1.89], p=0.719; I2: 0%). Meta-regression analysis indicates that the association between IER and AOFAS was not affected by age (p=0.927) and male gender (p=0.930). Conclusion This meta-analysis showed that ATFL repair with non-IER enhancement was non-inferior compared to those with IER enhancement.

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.

Arthroscopic All-Inside Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinacular Reinforcement: A Prospective Randomized Study

BACKGROUND

The utility of inferior extensor retinacular (IER) reinforcement for arthroscopic repair of a lateral ankle injury is debatable. We hypothesized that the outcomes would not differ significantly between arthroscopic all-inside anterior talofibular ligament (ATFL) repair with and without IER reinforcement.

METHODS

We prospectively randomized 73 patients who had arthroscopic all-inside ATFL repair into 2 groups: those who had IER reinforcement (37 patients) and those who had no IER reinforcement (36 patients). The primary outcome was the Karlsson Ankle Functional Score (KAFS). The secondary outcomes included the Foot and Ankle Outcome Score (FAOS), Tegner activity score (TAS), ankle range of motion, and radiographic parameters. The functional outcomes were evaluated preoperatively and at 6 and 12 months postoperatively. Stress radiographs were obtained preoperatively and at 12 months postoperatively.

RESULTS

The KAFS, all FAOS subscale scores, and TAS improved significantly at 1 year postoperatively in both groups, with no significant differences between the groups with respect to the preoperative and postoperative values. Significant differences were not observed between the ankle range of motion values recorded preoperatively and at 1 year postoperatively in both groups; the preoperative and postoperative range of motion values did not differ significantly between the groups. The mean talar tilt and talar anterior translation decreased significantly at 1 year postoperatively in both groups, with no significant differences between the groups preoperatively and postoperatively. One patient in each group had neuralgia of the superficial peroneal nerve; 2 patients in the IER reinforcement group had knot irritation causing mild discomfort.

CONCLUSIONS

Arthroscopic all-inside ATFL repair with and without IER reinforcement showed comparable functional and stress radiographic outcomes at 1 year. Performing IER reinforcement in addition to all-inside arthroscopic direct ATFL remnant repair is not necessary.

LEVEL OF EVIDENCE

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

Concomitant Lateral Ankle and Peroneal Tendon Instability Treated With Simultaneous Arthroscopic Broström and Tendoscopic Superior Peroneal Retinaculum Repair: A Case Report

Chronic lateral ankle instability is a prevalent condition, and it is commonly associated with other foot and ankle injuries. Among the associated injuries, peroneal tendon pathologies and anterolateral ankle impingement are frequently encountered. In this report, a case of concomitant chronic lateral ankle instability and dislocation of the peroneal tendons is described. While this combination of injuries is not uncommon, the method of treatment entailed arthroscopic repair of the anterior talofibular ligament and endoscopic repair of the superior peroneal retinaculum, procedures that eliminated the anterior drawer instability that had been present, and the patient remained symptom free after 24 months of follow-up.

A four-step approach improves long-term functional outcomes in patients suffering from chronic ankle instability: a retrospective study with a follow-up of 7-16 years

PURPOSE

The aim of the present study was to assess the long-term outcomes of the treatment of chronic ankle instability (CAI) with a four-step protocol.

METHODS

Fifty-four patients with isolated anterior talo-fibular ligament (ATFL) lesion suffering from CAI who underwent surgical treatment between 2000 and 2009 were assessed. All the patients underwent a four-step protocol including synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Median age at surgery was 31.6 years (18-48). Patients were examined preoperatively and at follow-up. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion (ROM) and manual laxity tests.

RESULTS

AOFAS (preoperative, 64.8; postoperative, 92.4; p < 0.001) and Karlsson-Peterson score (preoperative, 62.5; postoperative, 88.8; p < 0.001) significantly improved after a median 11 years follow-up (7-16 years). Similarly median Tegner activity level significantly increased at follow-up compared to pre-operatory status (6.0 and 4.0 respectively, p < 0.001). Objective examination documented a statistically significant improvement in terms of ankle stability compared to pre-operative manual laxity tests, with negative anterior drawer test observed in 48 (88.9%) patients (p < 0.001). Sagittal ROM was full in 50 patients (92%). Nine patients had subsequent ankle sprains (15.6%), two patients required further surgery, while seven were treated conservatively. No major complications were reported.

CONCLUSION

Satisfying subjective and objective clinical outcomes in selected patients with isolated ATFL lesion suffering from CAI were reported with a treatment protocol including arthroscopic synovectomy, debridement of ATFL remnants, capsular shrinkage, and immobilization. These findings are of clinical relevance because they provide a suitable minimally invasive method for the treatment of mild to moderate ankle instability.

LEVEL OF EVIDENCE

Level IV.

Clinical Outcomes of Open Versus Arthroscopic Broström Procedure for Lateral Ankle Instability: A Meta-analysis

Arthroscopic repair of the anterior talofibular ligament is becoming increasingly popular as a surgical option for lateral ankle instability. However, studies directly comparing outcomes of open and arthroscopic anterior talofibular ligament repair continue to present conflicting conclusions. This review aims to compare the clinical outcomes of arthroscopic and open Broström procedure. A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE from January 2010 to March 2020 to identify all clinical studies (level of evidence I-III) comparing outcomes of arthroscopic versus open Broström procedure for chronic lateral ankle instability. Six studies were included in this review. The arthroscopic technique, compared to the open technique, resulted in higher American Orthopaedic Foot and Ankle Society scores (weighted mean difference [WMD] = 1.20, 95% confidence interval [CI]: 0.05-2.34, p= .04), higher Karlsson scores (WMD = 1.86, 95% CI: 0.46-3.25, p= .009) and lower Visual Analog Scale pain scores (WMD = -0.31, 95% CI: -0.51 to -0.10, p= .003). There were no differences between the groups in terms of postoperative anterior drawer test (WMD = -0.10, 95% CI: -0.60 to 0.39, p= .68), talar tilt (WMD = 0.31, 95% CI: -0.10 to 0.72, p= .14) or overall complication rates (odds ratio [OR] = 0.78, 95% CI: 0.37-1.64, p= .51). The odds of wound-related complications in arthroscopic Broström procedures was significantly lower than that of open Broström procedures (OR = 0.25, 95% CI: 0.07-0.95, p= .04). Current evidence shows that arthroscopic repairs offer comparable clinical outcomes with a lower wound complication rate, compared to traditional open repairs.

The signal intensity of preoperative magnetic resonance imaging has predictive value for determining the arthroscopic reparability of the anterior talofibular ligament

PURPOSE

Arthroscopic all-inside anterior talofibular ligament (ATFL) repair is a common surgical technique for chronic ankle instability (CAI), and the condition of the ATFL remnants is associated with its reparability. ATFL reparability can affect the clinical course, but the relationship between magnetic resonance imaging (MRI) findings and the intraoperative ATFL reparability is still unclear. The purpose of this study was to investigate the relationship between ATFL signal intensities according to MRI and intraoperative ATFL reparability.

METHODS

This study included 55 cases of CAI (n = 37) and osteochondral lesion of the talus (n = 18) that underwent MRI followed by subsequent arthroscopy. MRI signal intensity was measured preoperatively to calculate the signal to noise ratio (SNR). During arthroscopy, the presence of an ATFL tear was checked and the ATFL tension was classified as taut, mild laxity, or laxity; ATFL quality was classified as excellent (normal), moderate (abnormal but reparable), or poor (irreparable). It was then analyzed whether there was a relationship between the intraoperative findings and the SNR.

RESULTS

The mean SNR was 23.4 ± 21.6. The SNR was significantly different according to the presence of an ATFL tear and ATFL tension and quality (all P = 0.001). The SNR was better correlated with ATFL quality (r = 0.708) than the presence of a tear (r = 0.545) or degree of tension (r = 0.653). The diagnostic SNR cutoff point to distinguish a normal ATFL from an abnormal but reparable ATFL was 11.2, and that to distinguish between an irreparable and reparable ATFL, was 32.3.

CONCLUSION

The SNR, representing MRI signal intensities, is highly correlated with the intraoperative measures of the ATFL. Therefore, the SNR had predictive value for determining the arthroscopic reparability of the ATFL.

LEVEL OF EVIDENCE

Level III.

Assessment of plantaris and peroneus tertius tendons as graft materials for ankle ligament reconstructions - A cadaveric biomechanical study

Both the plantaris tendon and the peroneus tertius tendon are used as auto- and allogenous graft materials to reconstruct the ankle ligament complex. However, it is unclear to what extent these graft materials resemble the load-deformation behavior of the ankle ligaments. A total of 34 human ankle ligaments and 35 tendons were assessed mechanically deploying a quasi-static tensile testing setup. Tendons were significantly stiffer (median elastic moduli: plantaris tendon = 465.7 MPa, peroneus tertius tendon = 338.5 MPa, medial ligament = 61.4 MPa, lateral ligament = 49.3 MPa; p ≤ 0.035), but more distensible (median strain at maximum force: plantaris tendon = 15.1%, peroneus tertius tendon = 15.3%, medial ligament = 9.3%, lateral ligament = 9.6%; p ≤ 0.008) and mechanically tougher (median ultimate tensile strength: plantaris tendon = 51.0 MPa, peroneus tertius tendon = 40.5 MPa, medial ligament = 4.1 MPa, lateral ligament = 3.5 MPa; p ≤ 0.033) when compared to medial and lateral ankle ligaments. The lateral ligaments of the right ankle were significantly tougher compared to the left side (p = 0.015). The elastic modulus of the medial ligament (r = 0.489, p = 0.045) and the peroneus tertius tendon (r = 0.517, p = 0.014) yielded an age-dependent increase. Both tendons seem biomechanically suitable graft materials to replace the medial and lateral ankle ligaments during physiological loading. The age-dependent increase in tissue elastic properties of the medial vs. lateral ankle ligaments, and differences in ultimate tensile strength between the lateral ligaments left vs. right, may reflect the complex asymmetric loading behavior of both ankle ligaments.

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

Background:

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

Purpose

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

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.

Does arthroscopic repair show superiority over open repair of lateral ankle ligament for chronic lateral ankle instability: a systematic review and meta-analysis

Background

There is still no definite consensus on whether arthroscopic repair shows superiority over open repair for chronic lateral ankle instability. We conducted a systematic review and meta-analysis of the current comparative studies to make a generalized analysis.

Methods

PubMed, Embase, and Web of Science databases were searched from inception to April 2020. Included studies were assessed by the level of evidence and quality of evidence (Cochrane Handbook or MINORS). The process of data extraction was conducted by two independent authors. The comparative results of clinical outcomes, stress radiographic outcomes, and complication rates between two groups were pooled. Statistical analysis was performed using STATA.

Results

Nine comparative studies for a total of 473 patients (250 arthroscopic repair, 223 open repair) were included. For the clinical outcomes, a significant difference was found in favor of arthroscopic repair with regard to AOFAS scores (MD 0.32, 95% CI 0.12 to 0.53, I² = 7.7%, P = .370) and VAS scores (MD − 0.30, 95% CI − 0.54 to − 0.05, I² = 48.3%, P = .102). No significant difference was found regarding to stress radiographic outcomes. Importantly, the total complication rate (RR 0.88, 95% CI 0.51 to 1.49, I² = 0%, P = .957) as well as nerve complication rate (RR 1.21, 95% CI 0.53 to 2.75, I² = 0%, P = .975) of arthroscopic repair group is not significantly different to that of open repair group.

Conclusions

Arthroscopic repair for lateral ankle instability shows excellent clinical results comparable to open repair. Especially, arthroscopic repair might alleviate more pain due to the minimally invasive procedure. Patients receiving arthroscopic repair do not result in a higher total complication rate and nerve injury rate.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BACKGROUND

The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.

METHODS

Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.

RESULTS

The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.

CONCLUSION

Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

A comparison between arthroscopic and open surgery for treatment outcomes of chronic lateral ankle instability accompanied by osteochondral lesions of the talus

BACKGROUND

This study aimed to examine the efficacy and safety of the arthroscopic treatment of osteochondral lesion of talus (OLT) and lateral ankle instability. It was hypothesized that the outcome of all-arthroscopic surgery was no worse than that of the combined open and arthroscopic surgery for treating chronic lateral ankle instability accompanied by OLT.

METHODS

The patients diagnosed of chronic lateral ankle instability accompanied by OLT, who were surgically treated between May 2015 and May2017, were targeted for inclusion. Specifically, patients who received the arthroscopic treatment of OLT and lateral ankle instability were enrolled in the all-arthroscopic group, while patients who received the arthroscopic treatment of OLT and open lateral ankle stabilization were enrolled in the combined open and arthroscopic group. All the patients were followed up in terms of the Karlsson Ankle Functional Score, visual analog scale (VAS) score, Tegner activity score, and American Orthopaedic Foot & Ankle Society (AOFAS) score. Meanwhile, the satisfaction and complication rates were evaluated and compared.

RESULTS

This retrospective study included a total of 67 patients, including 32 patients in the all-arthroscopic group and 35 patients in the combined group. At a minimum of 24-month follow-up, the functional outcomes were significantly improved in both groups in relation to the preoperative condition. However, the two groups did not differ significantly from each other in terms of the Karlsson score (83.1 ± 8.2 vs 81.7 ± 9.1; P = 0.89), the VAS score (1.8 ± 1.6 vs 2.1 ± 1.7; P = 0.73), the Tegner score (5.5 ± 2.3 vs 5.0 ± 2.1; P = 0.72), and the AOFAS score (87.7 ± 7.6 vs 86.9 ± 7.3; P = 0.77). In addition, the satisfaction and complication rates exhibited no significant differences between the two groups.

CONCLUSION

In comparison with the open lateral ankle stabilization and arthroscopic treatment of OLT, the all-arthroscopic procedure showed no difference in clinical outcomes at a minimum of 24-month follow-up. Despite the benefits of minimally invasive arthroscopic procedure combined with a relatively aggressive postoperative rehabilitation protocol, the clinical outcomes for patients with chronic lateral ankle instability accompanied by OLT did not yield significant improvement.

TRIAL REGISTRATION

The present study was carried out with the approval issued by the Institutional Review Board of Xiangya Hospital (no. 202002010).

Arthroscopic treatment of lateral ankle instability. Is there a safe zone? An anatomic study

BACKGROUND

The purpose of this study is to describe the relative location of superficial anatomic landmarks and likely location of structures at risk in order to predict the proximity of the later and avoid their injury during the arthroscopic treatment of lateral ankle instability.

METHODS

Fifteen cadaver ankles were dissected. Based on superficial anatomic landmarks, the location and distances to the structures at risk (extensor tendons, peroneus tertius, peroneal tendons, main branch or intermediate branch of the superficial peroneal nerve, and the sural nerve) were measured.

RESULTS

The distance from the lateral malleolus along the peroneus brevis to its intersection by the sural nerve was 38.5±10.5mm and from it to the superficial peroneal nerve was 32.0±7.4mm. Based on the minimum distances, a rectangular area of 25mm×22mm was obtained. The anterior talofibular ligament and the proximal border of the inferior extensor retinaculum were within this area.

CONCLUSIONS

Our study suggests that based on superficial anatomic landmarks, it is possible to define an anatomic area in order to avoid structures at risk. In addition to the usual precautions, these anatomical references may contribute to lower the complication rate associated to the arthroscopic treatment of lateral ankle instability.

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.

The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study

PURPOSE

The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints METHODS: An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position.

RESULTS

Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30 mm each. Footprint morphometrics were heterogenous amongst the different CFL variants.

CONCLUSION

The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

Absence of ATFL remnant does not affect the clinical outcomes of the modified broström operation for chronic ankle instability

PURPOSE

The modified Broström operation for chronic ankle instability has demonstrated good clinical results. Absence of ligamentous tissue is a risk factor for recurrence of ankle instability after surgery. This study evaluated the effect of quality of ligament tissue (anterior talofibular ligament, ATFL) on prognosis, in a cohort of patients with chronic ankle instability after the modified Broström operation.

METHODS

This was a retrospective case series. Overall, 60 patients underwent the modified Broström operation for chronic ankle instability (mean follow-up, 30.1 [range, 24-47] months). Presence of ATFL remnant was assessed on ultrasound, magnetic resonance imaging, and arthroscopy in all patients. Foot and ankle outcome score (FAOS) was used to evaluate functional outcomes. Clinical outcomes were compared by the condition of the ligament remnant. Association with other risk factors was evaluated using multiple linear regression analysis.

RESULTS

ATFL was visible in 51/60 cases on ultrasound. Thirty, 22, and eight patients had thin or absent; normal thickness; and thick ATFL on magnetic resonance imaging, respectively. ATFL was visible in 15 patients on arthroscopy and nonvisible or not clear in 45. No significant differences occurred in FAOS with the presence of ATFL remnant on ultrasound, arthroscopy, and the grade of ATFL thickness on magnetic resonance imaging. No correlation was found between FAOS and the thickness of ATFL.

CONCLUSION

The results suggest that the modified Broström operation for patients with chronic ankle instability was good, regardless of the presence or absence of ATFL remnant.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Open Broström-Gould Repair vs Arthroscopic Anatomical Repair of the Anterior Talofibular Ligament for Chronic Lateral Ankle Instability

BACKGROUND

The comparative studies on open vs arthroscopic anterior talofibular ligament (ATFL) repair are limited. This study aimed to compare the early therapeutic efficacy and cost between the traditional open Broström-Gould repair and all-arthroscopic anatomical repair of the ATFL for chronic lateral ankle instability.

METHODS

A total of 27 of patients with chronic lateral ankle instability undergoing repair of the ATFL between January 2013 and June 2015 were retrospectively included with a traditional open surgery (n = 10) group and arthroscopy (n = 17) group. The surgery duration, surgical cost, postoperative complications, and the preoperative/postoperative American Orthopaedic Foot & Ankle Society Score (AOFAS) and Karlsson-Peterson score were compared between groups.

RESULTS

Compared to the arthroscopy group, the open surgery group had significantly shorter surgery duration and lower surgical cost. However, there was no significant difference in hospitalization duration between groups. At 3 years after operation, the AOFAS and Karlsson scores were significantly improved in both groups. Nevertheless, there was no significant difference in the AOFAS and Karlsson scores between groups at both preoperative and postoperative assessment. No significant difference was found in the incidence of postoperative complications between the 2 groups.

CONCLUSION

These results suggest that open Broström-Gould repair and all-arthroscopic anatomical repair of the ATFL have comparable therapeutic efficacy for chronic lateral ankle instability. The arthroscopic surgery had a smaller incision, while the open Broström-Gould had a shorter surgery duration and lower cost.

LEVEL OF EVIDENCE

Level III, comparative study.

3D MRI evaluation of morphological characteristics of lateral ankle ligaments in injured patients and uninjured controls

BACKGROUND

With ultrasonography or 2D magnetic resonance imaging (MRI) of the lateral ankle ligament, it is particularly difficult to show the entire calcaneofibular ligament (CFL). The purpose of this study was to evaluate the morphological characteristics of the lateral ankle ligaments in injured patients and uninjured controls using 3D MRI.

METHODS

A total of 64 ankles of 59 healthy volunteers and lateral ligament injury patients (mean age of 32.4 years) were examined. The 64 ankles included a healthy group of 11 ankles, an acute injury group of 12 ankles that underwent MRI a month after injury, and a chronic injury group of 41 ankles that underwent MRI more than 3 months after injury. Using a 3.0-T MRI system, imaging was done with fast imaging employing steady-state acquisition cycled phases. Oblique sagittal images that most clearly depicted the entire anterior talofibular ligament (ATFL) and CFL were prepared manually and evaluated using a workstation.

RESULTS

In the healthy group, both the ATFL and CFL were clearly and entirely visualized. The mean width in the central portion was 4.0 ± 1.0 mm in the ATFL and 4.8 ± 0.6 mm in the CFL. 3D MRI in the acute injury group showed findings of diffuse swelling with hyperintensity in the ATFL of all patients. The CFL in 7 of 12 ankles showed findings of diffuse swelling with hyperintensity. In the chronic injury group, morphological abnormalities of the ATFL were seen in 19 of 41 ankles. The ligament signal disappeared in 2 ankles, thinned in 4 ankles, and showed swelling in 13 ankles. Morphological abnormalities of the CFL were seen in 17 of 41 ankles. The ligament signal disappeared in 1 ankle, thinned in 2 ankles, and showed swelling in 14 ankles.

CONCLUSION

3D MRI may be a useful modality to visualize both the ATFL and the CFL.

Revisiting the Prevalence of Associated Copathologies in Chronic Lateral Ankle Instability: Are There Any Predictors of Outcome?

BACKGROUND

Multiple ankle pathologies have been found to coexist with chronic lateral ankle ligament instability, but their prevalence varies widely in the literature. The purpose of this study is to reexamine the prevalence of these associated pathologies and to determine their impact on reoperation rate.

METHODS

We retrospectively reviewed 382 cases of lateral ankle ligament repair/reconstruction between June 2006 and November 2016. Patient charts and radiograph reports were examined for the presence of any associated foot and ankle pathologies as well as clinical course. The effect of copathologies on reoperation rate was examined using binary logistic regression and the χ2 test.

RESULTS

We included a total of 99 cases. Copathologies included peroneal pathology (75/99, 75.8%), ankle impingement (40/99, 40.4%), and osteochondral lesion of the talus (17/99, 17.2%); 36.4% (36/99) had a low-lying muscle belly of peroneus brevis. The total reoperation rate was 12/92 (13.1%). It was lower in cases with peroneal pathology (8.7% vs 27.5%, P = .032).

CONCLUSION

Peroneal pathology, ankle impingement, and osteochondral lesions were the most common associated copathologies in surgical patients with chronic lateral ankle ligament instability. The presence of peroneal pathology may lead to fewer reoperations, possibly as a result of a more comprehensive first-time surgical approach. Level of Evidence: Level III: Retrospective cohort.

Malalignment and Lateral Ankle Instability: Causes of Failure from the Varus Tibia to the Cavovarus Foot

A lower leg or hindfoot varus malalignment is a frequently encountered but underestimated cause of chronic ankle instability and ankle arthritis in the long term. When evaluating patients with ankle instability, a high index of clinical suspicion for tibia and hindfoot malalignment and subsequent biomechanics should be maintained. Management of lateral ankle instability in the presence of varus malalignment must comprise a generous indication for accurate hindfoot realignment. In young and active patients, realignment should be combined with formal lateral ligamentous repair.

Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review

PURPOSE

The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability.

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane Library databases was performed during August 2017. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated.

RESULTS

Eight studies for a total of 269 ankles were included; 87.5% of studies were LOE III or IV, and the QOE in all studies was of poor or fair quality. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores ranged from 41.2 to 69.9, and postoperative AOFAS scores ranged from 90.2 to 98. All studies using AOFAS score showed an increase in postoperative outcome score of 22.8 to 54.2 at a mean follow-up of 17.1 months. Five studies used Karlsson-Peterson scores with mean postoperative score of 88.5 (range, 76.2-93.6) at a mean follow-up of 21.2 months. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 11.6% in the included studies. The overall rate of return to sport was 100%.

CONCLUSIONS

The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. However, there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure, and there are no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate (11.5%) associated with the arthroscopic procedures, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, III, and IV studies.

Editorial Commentary: Repair of Lateral Ankle Ligament: Is Arthroscopic Technique the Next Station?

Arthroscopic lateral ankle ligament repair (ALALR) is safe and effective, yet a review of the current literature does not show the superiority of ALALR over the open technique. ALALR is a relatively new procedure, and, in the future, it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care.

Surgical Procedures for Chronic Lateral Ankle Instability

Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.