Rupture of the lateral ligaments of the ankle: operation or plaster cast? A propective study

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

PURPOSE

Despite being a significant public health problem, ankle sprains' prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

METHODS

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

RESULTS

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

CONCLUSION

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

LEVEL OF EVIDENCE

Level III.

A new classification of anterior talofibular ligament injuries based on ultrasonography findings

BACKGROUND

Ultrasonography (US) has become a useful tool in the evaluation of thickness and continuity of damaged ligaments owing to the rapid advances in its performance and availability. Furthermore, US examination is economical and can be undertaken in a more timely manner than MRI, as it can be performed during the first patient visit. It is also likely to be more accurate than the traditional method of palpating ligaments to diagnose possible injury. The anterior talofibular ligament (ATFL) is most frequently injured of the lateral ankle ligaments and easy to depict on US. This study aimed to assess the treatment outcomes of lateral ankle ligament injuries using a new classification for ATFL injuries based on US findings.

METHODS

A total of 140 acute lateral ankle ligament injuries in 132 patients (46 men, 86 women) treated non-operatively were evaluated retrospectively. The average age of the patients was 17.8 years (range, 7-57 years). Patients with a complaint of lateral ankle injury were examined using US, and the anterior talofibular ligament damage was classified into 5 types depending on the type of the injury. The treatment method was selected based on the ultrasonographic classification, and the clinical results were assessed by original evaluation and compared between treatment methods and classification types.

RESULTS

A Good or Excellent treatment result was obtained in 133 out of 140 injuries (95.0%). Significant differences were observed in the distribution of treatment methods by injury type (P < 0.001), and the distribution of outcomes was significantly different from the uniform distribution (P < 0.001). Our findings demonstrate that the ultrasonographic classification proposed in this study can be used to determine the appropriate treatment resulting in good outcomes for all types of anterior talofibular ligament damage.

CONCLUSION

Visualization of injured ligaments using US may introduce a novel approach of rating and treating ligament injuries.

Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis

BACKGROUND

Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.

OBJECTIVE

To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

DESIGN

Overview of intervention systematic reviews.

PARTICIPANTS

Individuals with acute ankle sprain/CAI.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were injury/reinjury incidence and function.

RESULTS

46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

CONCLUSIONS

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

Comparison of All-Inside Arthroscopic and Open Techniques for the Modified Broström Procedure for Ankle Instability

BACKGROUND

No reported study has compared clinical and radiologic outcomes between an all-inside arthroscopic modified Broström operation (MBO) and an open MBO. The purpose of this study was to compare clinical and radiologic outcomes of all-inside arthroscopic and open MBOs.

METHODS

From August 2012 to July 2014, 48 patients were included. They were divided into 2 groups: all-inside arthroscopic MBO (25 patients) and open MBO (23 patients). The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, and Karlsson score were used to evaluate clinical outcomes. Anterior talar translation and talar tilt were used to evaluate radiologic outcomes. All patients had lateral ankle instability. MBO was performed in 87 patients. Of these, 50 patients met the inclusion criteria. All patients had giving way, persistent pain, and an inability to resume their preinjury activity level for more than 6 months. Patients were randomized into 2 groups, all-inside arthroscopic MBO and open MBO, using a permuted block randomization method. Clinical outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum of 12 months postoperatively using the Karlsson score, the AOFAS ankle-hindfoot score, and pain VAS scores. Radiologic outcome evaluations were performed preoperatively and at 1 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle.

RESULTS

After randomization, 25 ankles were allocated to the all-inside arthroscopic MBO group and 25 to the open MBO group. Two ankles in the open MBO group were excluded from the analysis because they were lost to follow-up. Thus, evaluations were performed for 25 ankles in the all-inside arthroscopic MBO group and 23 in the open MBO group. There was no difference in age, gender, symptom duration, preoperative AOFAS, VAS, Karlsson scores, anterior talar translation, or talar tilt between the 2 groups (all P > .05). At the final follow-up, the AOFAS, VAS, and the Karlsson scores had improved significantly in both groups (P < .001). There was no difference in the Karlsson, AOFAS, or VAS scores, anterior talar translation, or talar tilt between the 2 groups at final follow-up (all P > .05).

CONCLUSIONS

There was no difference in the clinical or radiologic outcome between the all-inside arthroscopic MBO and open MBO for the treatment of lateral ankle instability at up to 1 year after surgery. An all-inside arthroscopic MBO should be considered carefully in patients who have lateral ankle instability.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Mechanical stability, muscle strength and proprioception in the functionally unstable ankle

Functional instability of the ankle is common following inversion sprain. Factors suggested as causes of this disability include mechanical instability of the talocrural joint, peroneal muscle weakness and motor incoordination due to impaired proprioception. This study documented physical examination characteristics of functionally unstable ankles relevant to these theories. Each ankle of 45 subjects with unilateral functional instability was examined. Mechanical stability was assessed by standard clinical instability tests. Evertor and inventor muscle strength was measured using the Cybex II dynamometer. The Uni-axial Balance Evaluator (UBE) was used to assess dynamic control of the ankle and was considered capable of detecting unilaterally impaired proprioception. Mechanical instability was frequently absent in the functionally unstable ankles tested. Evertor muscle strength was similar in the normal and functionally unstable ankles. UBE results were consistent with the theory of impaired proprioception contributing to functional instability, but the need for further research is emphasised.

Influence of activity level on the outcome of treatment of lateral ankle ligament rupture

BACKGROUND

Few studies of treatment of lateral ankle ligament rupture have given careful consideration to the activity levels of patients. In the present study, we investigated whether a patient's activity level influences the outcome of the treatment of lateral ankle ligament rupture and whether treatment should be determined according to activity level.

METHODS

A total of 115 consecutive patients with lateral ankle ligament rupture were treated with short-term cast immobilization followed by functional bracing. We divided preinjury activity levels and activity levels at follow-up into four classes according to the International Knee Documentation Committee standards. Follow-up examination 1 year after injury included clinical assessment (anterior drawer test, range of motion, maximum circumference of the calf, tenderness, swelling), reinjury assessment, and functional evaluation by means of the Karlsson scoring system.

RESULTS

We found significant differences in ankle stability and reinjuries between the four groups classified by their preinjury activity level. The number of patients with ankle instability and reinjury was significantly higher in the high-activity group than in the low-activity groups. We also found significant difference between groups classified by activity level at follow-up with regard to the Karlsson score.

CONCLUSIONS

The outcome of treatment of lateral ankle ligament rupture is significantly influenced by the patient activity level, and treatment may need to be determined according to this activity level.

Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability

PURPOSE

To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability.

METHODS

Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6-20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale.

RESULTS

Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85-100) and 4 (19%) attained good scores (70-84).

CONCLUSION

The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian population with a higher prevalence of generalised joint hyperlaxity.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults

BACKGROUND

Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and use of an external support (e.g. ankle brace), and surgical repair or reconstruction.

OBJECTIVES

We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings.

MAIN RESULTS

Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants. The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I(2) statistics showed the remaining trials to be more homogeneous. The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group.

AUTHORS' CONCLUSIONS

There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomised controlled trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Comparative results of conservative treatments for isolated anterior talofibular ligament (ATFL) injury and injury to both the ATFL and calcaneofibular ligament of the ankle as assessed by subtalar arthrography

BACKGROUND

There have been no reports describing the results of conservative treatment of acute lateral ligament injury of the ankle in detail in terms of the severity of the injury, and the results of conservative treatment for injury with severe instability are still controversial. The purpose of this study was to assess the results of nonoperative treatment of acute lateral ligament injury according to its severity.

METHODS

Fifty-five consecutive acute lateral ankle ligament injuries in 54 patients who were treated nonoperatively were followed up as a prospective study. Twenty-seven were male patients and 27 were female patients; the average age was 23.9 years (12-55 years). The patients were divided into two groups according to the extent of the ligament injury: patients with an isolated injury of the anterior talofibular ligament and those with combined injuries of the anterior talofibular ligament and the calcaneofibular ligament. In addition to the routine examinations for inversion ankle sprain, subtalar arthrography was mainly used to assess the condition of the calcaneofibular ligament. The arthrography was performed an average of 3.5 days after the injury (0-5 days).

RESULTS

Fifty-five ankles of patients who were treated nonoperatively according to the same protocol were included in this study, and were followed up for an average of 5.0 years (37-86 months). At the time of the final follow-up, 22 of 25 (88%) ankles with an isolated injury to the anterior talofibular ligament were asymptomatic; in contrast, only 9 of 30 (30%) ankles with combined injuries of the anterior talofibular and calcaneofibular ligament were asymptomatic. The average American Orthopaedic Foot and Ankle Society score of the isolated injuries was 97.8 points, in contrast to 92.4 points for the combined injuries.

CONCLUSIONS

The results of nonoperative treatment with 1 week immobilization followed by a functional brace were excellent in patients with an isolated injury of the anterior talofibular ligament, but were unsatisfactory in those with combined injuries of the anterior talofibular and calcaneofibular ligaments.

A prospective, randomized clinical investigation of the treatment of first-time ankle sprains

BACKGROUND

Acute ankle ligament sprains are treated with the use of controlled mobilization with protection provided by external support (eg, functional treatment); however, there is little information regarding the best type of external support to use.

HYPOTHESIS

There is no difference between elastic wrapping, bracing, bracing combined with elastic wrapping, and casting for treatment of acute, first-time ankle ligament sprains in terms of the time a patient requires to return to normal function.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Patients suffering their first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo functional treatment with different types of external supports. The patients completed daily logs until they returned to normal function and were followed up at 6 months.

RESULTS

Treatment of grade I sprains with the Air-Stirrup brace combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those treated with the Air-Stirrup brace alone and in half the time required for those treated with an elastic wrap alone. Treatment of grade II sprains with the Air-Stirrup brace combined with the elastic wrap allowed patients to return to normal walking and stair climbing in the shortest time interval. Treatment of grade III sprains with the Air-Stirrup brace or a walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for frequency of reinjury, ankle motion, and function.

CONCLUSION

Treatment of first-time grade I and II ankle ligament sprains with the Air-Stirrup brace combined with an elastic wrap provides earlier return to preinjury function compared to use of the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for 10 days.

Ankle sprain discharge instructions from the emergency department

OBJECTIVES

(1) To describe the incidence of inclusion of early mobilization components in emergency department (ED) discharge instructions; (2) to describe the prescribed follow-up appointments; and (3) to analyze the differences between the treatment of pediatric and adult patients.

METHODS

A 1-year retrospective chart review of ED records of a large urban hospital was performed. Medical records of 374 (95%) of the 397 adult and pediatric patients with ICD-9 code for ankle sprains were reviewed (213 males and 171 females, mean age 28.4 +/- 14.5; 291 adults, 93 pediatric).

RESULTS

Sixteen percent of records contained discharge instructions that included rest, ice, compression, elevation, and medications (RICEM). Twenty percent included RICE. Pediatricians (33.7%) were more likely than adult physicians (10.3%) to have given RICEM (P < 0.0001) and RICE (P = 0.05, pedi = 45.8%, adult = 13.1%). Follow-up referrals were recommended as needed 50% of the time. Follow-up referrals were made to community clinics (59%), orthopedic clinic (23%), the ED (14%), and others (4%). Pediatricians were more likely to recommend routine scheduled follow up (pedi = 62%, adult = 47%, P = 0.018), suggest follow-up in a community clinic or doctors office (pedi = 68.6%, adult = 51.2%, P < 0.0001), and to recommend earlier follow up (pedi = 1.6 weeks +/- 1.1, adult = 2.0 weeks +/- 1.1, P = 0.002) than adult physicians.

CONCLUSIONS

Programs that train physicians who work in the ED need to include education on the proper treatment, rehabilitation, and follow up of patients with acute ankle sprains. Providing easy-to-complete discharge instruction templates can help providers give patients discharge instructions that may help patients minimize the risk of long-term sequelae.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults

BACKGROUND

Inversion injuries, primarily sprains, of the ankle are one of the most commonly treated injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and the use of an external support (e.g. ankle brace or taping), and surgical repair or reconstruction.

OBJECTIVES

We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute injuries to the lateral ligament complex of the ankle in adults.

DATA COLLECTION AND ANALYSIS

At least two, usually three, reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled using fixed and random effects models and relative risks with 95% confidence intervals for dichotomous outcomes calculated. Heterogeneity between trials was tested using a standard chi-squared test. We undertook sensitivity analyses to explore the effects of inclusion of quasi-randomised trials and subgroup analyses by the two main methods of conservative treatment.

MAIN RESULTS

Seventeen studies, involving a total of 1950 mostly young active adult males, were included. All trials had methodological flaws. In particular, allocation was rated as effectively concealed in only one trial and there was no report of masking outcome assessors to the interventions in any trial. Outcome measures were variously defined and data for pooling for individual outcomes were only available for a maximum of 11 studies. While there were statistically significant differences for three primary outcomes (non-return to pre-injury level of sports; undefined pain or pain on activity; and subjective or functional instability) in favour of the surgical treatment group using the fixed effects model, these findings failed to demonstrate robustness in sensitivity analyses. Exclusion of the data from explicitly quasi-randomised trials or, given the highly statistically significant heterogeneity, analyses using the random effects model modified these findings to non-statistically significant differences. There was no statistically significant difference in ankle sprain recurrence, the other primary outcome measure. Though there was a statistically significantly higher incidence of objective instability in conservatively treated patients, the functional implications of this are uncertain. There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. Subgroup analyses by type of conservative treatment (plaster cast or functional treatment) revealed no statistically significant differences in effect for any of the six outcomes examined.

REVIEWER'S CONCLUSIONS

There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. Sufficiently powered, good quality and adequately reported randomised trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Complications of lateral ankle ligament reconstruction

Complications after ankle ligament reconstruction are infrequent, but present significant challenges to the treating orthopaedist. Local wound problems and nerve injuries may cause difficulty in the early postoperative period. Recurrent instability may be attributable to failure of the operation, poor rehabilitation, reinjury, or unrecognized predisposing factors. Postoperative stiffness of the subtalar and ankle joints frequently is reported after anatomic and nonanatomic tenodesis procedures and may cause significant morbidity. The current author reviews reported complications and treatment options in failed lateral ankle ligament surgery.

Treatment of ruptures of the lateral ankle ligaments: a meta-analysis

BACKGROUND

Ruptures of the lateral ankle ligaments are very common; however, treatment remains controversial. The aim of the current study was to perform a meta-analysis of randomized, controlled clinical trials of existing treatment strategies for acute ruptures of the lateral ankle ligaments.

METHODS

Randomized, controlled trials reported between 1966 and 1998 were included if they involved acute ruptures of the lateral ankle ligaments. Randomized, controlled trials are defined as comparative studies with an intervention group and a control group in which the assignment of participants to a group is determined by the formal procedure of randomization. Summary measures of effectiveness were expressed as relative risks with use of random effects modeling.

RESULTS

When analyzing the trials, we searched for comparable outcome measures in both short and long-term follow-up studies (studies with six months to 3.8 years of follow-up). This resulted in the analyses of three outcome measures: time lost from work, residual pain, and giving-way. This report summarizes the results of twenty-seven trials. With respect to giving-way, a significant difference was noted between operative treatment and functional treatment (relative risk, 0.23; 95 percent confidence interval, 0.17 to 0.31) in favor of operative treatment and a significant difference was also noted between functional treatment and treatment with a cast for six weeks (relative risk, 0.69; 95 percent confidence interval, 0.50 to 0.94) in favor of functional treatment. With respect to residual pain, no significant difference was found between operative and functional treatment and a significant difference was found between functional treatment and treatment with a cast for six weeks (relative risk, 0.67; 95 percent confidence interval, 0.50 to 0.90). We found minimal or no treatment to result in more residual pain (relative risk, 0.53; 95 percent confidence interval, 0.27 to 1.02) and giving-way (relative risk, 0.34; 95 percent confidence interval, 0.17 to 0.71) than did functional treatment.

CONCLUSIONS

We concluded that a no-treatment strategy for ruptures of the lateral ankle ligaments leads to more residual symptoms. Operative treatment leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks.

Emergency department evaluation and treatment of ankle and foot injuries

Ankle and foot injuries are among the most common sports injuries and extremity complaints presenting to the emergency department. Although generally benign, some of these injuries have prolonged morbidity. This article reviews the anatomy of the foot and ankle and examines the approach and therapy for common types of injuries.

Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment

Acute lateral ankle ligament sprains are common in young athletes (15 to 35 years of age). Diagnostic and treatment protocols vary. Therapies range from cast immobilisation or acute surgical repair to functional rehabilitation. The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments. Injuries typically occur during plantar flexion and inversion; the ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected. Commonly, an athlete with a lateral ankle ligament sprain reports having 'rolled over' the outside of their ankle. The entire ankle and foot must be examined to ensure there are no other injuries. Clinical stability tests for ligamentous disruption include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. Radiographs may rule out treatable fractures in severe injuries or when pain or tenderness are not associated with lateral ligaments. Stress radiographs do not affect treatment. Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management. A non-operative 'functional treatment' programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle. Treatment for grade III injuries is more controversial. A comprehensive literature evaluation and meta-analysis showed that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability. Functional treatment was complication-free, whereas surgery had serious, though infrequent, complications. Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so even competitive athletes can receive initial conservative treatment. Sequelae of lateral ligament injuries are common. After conservative or surgical treatment, 10 to 30% of patients have chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness and 'giving-way'. Well-designed physical therapy programmes usually reduce instability. For individuals with chronic instability refractory to conservative measures, surgery may be needed. Subtalar instability should be carefully evaluated when considering surgery.

Late results of surgical repair in recent ruptures of the lateral ligament of the ankle

Between 1979 and 1994, 75 patients underwent primary repair of a Grade III rupture of the lateral ligament of the ankle. The operation was indicated after the demonstration of ankle instability on stress X-rays by anterior displacement of the talus by more than 8 mm or/and a talar tilt of more than 10 degrees. The patients were either young or engaged in sports activities or physically demanding jobs. An end-to-end suture of the torn ligament was undertaken under general anaesthesia. A non-weight-bearing cast was used for the first 2 weeks, followed by a walking cast until 6 weeks postoperatively. Sixty-one patients were followed up for 1-15 years (mean 10.3 years). At follow-up all but one patient had returned to their pre-injury level of activity without complaint or restriction.

Long-term functional outcome after primary repair of the lateral ligaments of the ankle

We retrospectively reexamined a total of 100 patients 6 to 8 years after primary repair of ruptured lateral ligaments of the ankle. Fifty-nine percent of the injuries had occurred in sports; the other main causes of the injuries were accidents at work (12%), in traffic (10%), and at home (4%). Almost two-thirds of the sports injuries were sustained in volleyball. The most common type of injury was a combined rupture of the anterior talofibular and the calcaneofibular ligaments (66 patients). According to subjective assessment, 74 patients had excellent or good results. For the anterior drawer sign test, 75 patients showed no sign of instability in their injured ankles. The scores in our performance test protocol of ankle injuries were classified as excellent or good in 65 patients, fair in 27 patients, and poor in 8 patients. The overall long-term results were acceptable in the majority of the patients. Prospective, randomized studies are needed to clarify if nonoperative treatment (i.e., early controlled mobilization) would give similar long-term results.

Dynamic orthopaedic brace in the treatment of ankle sprains

Ankle sprains may lead to disabling sequelae such as joint instability and persistent pain. Immobilization with plaster cast may give rise to joint stiffness and muscle atrophy. Twenty patients with acute inversion sprains of the ankle were treated with a "dynamic" orthopaedic brace after a 10-day plaster immobilization. A control group, consisting of 10 subjects, received a weight-bearing short-leg plaster cast for 25 days. A clinical evaluation and an instrumental isokinetic investigation (Cybex) were performed as scheduled. The clinical findings suggest an earlier and more comprehensive functional recovery in the group receiving the "dynamic" brace compared to the casted group. The isokinetic test revealed a statistically significantly better performance for most parameters in the brace group especially regarding the ankle joint invertors.

Long-term follow-up of inversion trauma of the ankle

In our institution lateral ankle ligament injuries are classified into three grades according to the extent of instability found on physical examination and/or stress X-rays. Grade I and II lesions are taped, while treatment of grade III lesions consists of operative reconstruction of the ruptured ligaments. In 1989 we published the results of 1012 patients after 9 months' follow-up. About 30% had residual complaints. The nature and frequency of the complaints were equally divided among the three groups. To examine the long-term follow-up results, we conducted a retrospective study with the same group of patients after 6.5 years. Although ankle ligament injuries are still considered rather innocent lesions, we conclude that even after 6.5 years patients can still have residual complaints (pain, fear of giving-way, actual instability, swelling), which interfere with daily living and/or sport activities. The result deteriorated with time. This was especially prominent in the grade II group, where the percentage of poor and fair results doubled. The overall percentage of residual complaints was 39%. We conclude that there is no such thing as "a simple sprain".

[Therapy and results of fresh lateral instability of the upper ankle joint]

During a retrospective study we especially examined the late outcome in therapy of injuries of the lateral capsula ligament-lesions in 210 patients. In addition we scrutinized the literature on this subject within the last 60 years, concerning the results of different therapy methods were checked. 203 collective writings on this subject, 23,279 patients and our own results achieved in the BG Accident Hospital in Murnau (Germany) all added up to 23,389 patients. We did not only observe the subjective opinion regarding the outcome of the therapy but also the socio-economic factors, such as the duration of incapability to work and do sports. Emphasis was laid on the remaining complaints: reduction of movement, swelling, pain during stress and instability (in the sense of recurring injuries). The results of this thesis show the dependence of the therapy in respect to the age of the patient. So we have developed a different therapy-concept for those under age of 30 and for those over the age of 30 years.

Comparative study of therapies for fibular ligament rupture of the lateral ankle joint in competitive basketball players

This retrospective study compares the results of different therapies for fibular ligament rupture in a homogenous group of professional athletes. The endpoint "competitive sports" was an outcome consideration. Subjects were examined by means of a standardized questionnaire and a structured interview. One hundred and seventy-nine of the questionnaires were completed and returned for evaluation. All of the basketball players with severe ankle sprain (supination trauma with swelling, pain, and inability to bear stress) were included. Those players with fractures of the foot, pronation trauma, or additional distal fibula or tibia fractures were excluded from this study. Of the 179 basketball players 160 (89%) had suffered severe ankle sprain. The treatment was divided into three groups: primary surgery (N = 35), plaster cast (N = 39), and functional treatment (N = 89). While simple ligament injuries (Grade I and II) were mostly treated functionally, complex ligament injuries (Grade III) were usually operated on. A total of 119 (74%) of the players reported no further pain. For pain reduction surgical and functional treatments showed advantages over plaster treatment. In the surgical group 63% of the players judged their regained stability to be equivalent to that of their healthy leg. Only 50% of the players in the plaster and functional groups believed their ankle joints to have regained the same stability as before their injuries. Despite the achievement of good results through surgery, there were clear differences in the players' assessments of their performance in competitive sports. Most subjects (92%) did not have any problems in everyday life regardless of which kind of therapy had been chosen.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary orthotic treatment of ruptured ankle ligaments: a recommended procedure

The results of a study after 1 and 2 years of a prospective randomised trial of operative versus conservative treatment of ankle ligament rupture, demonstrate that purely functional orthotic therapy is the method of choice. This relates both to patient need and economical considerations. The trial demonstrated that without an operation it was possible to achieve a high degree of mechanical stability, a reduction of work disability time down to 3 weeks and full sports capability within 3 months. Consequently, and as a result of the trial, the only remaining surgical indications would seem to be dislocations of the foot and ankle, ankle ligament rupture with additional intra-articular pathology, and second-stage injuries or re-ruptures. The joint-stabilising function of the prototype splint developed in this study was improved on the basis of experimental investigations, using a Y-shaped leather band (designated CALIGAMED), which is available in 6 sizes for right and left ankle.

[Surgical or conservative therapy of rupture of the lateral ligament of the ankle joint?]

To determine whether operative treatment is superior to conservative therapy, 60 patients were randomized to surgical suture and cast immobilisation for six weeks (n = 30) or cast immobilisation alone for the same time (n = 30) for acute rupture of the ligaments of the ankle. Variables of well being (ability to work, to do sports, dysesthesia, pain during exercise, swelling, tendency for recurrent distorsion), stability (dislocation and tilting of the talus on X-ray examination) and the radiological evidence of arthrosis were chosen as endpoints. Complete follow-up was obtained one year after the accident. In both groups we did not find any evidence of arthrosis one year after the accident. No significant differences were found between the study groups neither for the parameters of well being nor for objective criteria of stability. No correlation was found between well being and stability of the ankle joint. These results suggest that for the chosen endpoints no treatment modality can be recommended after one year follow-up. Only long-term studies using incidence of arthrosis as the most important endpoint will be able to answer the question whether conservative or operative treatment of rupture of the ankle ligaments is superior.

Early mobilizing treatment for grade III ankle ligament injuries

Eighty patients with grade III lateral ligament ruptures were treated either with total immobilization in a walking plaster cast or early mobilization in a stabilizing orthosis. The criterion for entrance was a talar tilt of more than 9 degrees and an anterior translation of more than 10 mm at stress radiography, a previously stable ankle, and a contralateral ankle showing normal stress radiographic values. Ninety-one percent of the patients were evaluated at 7 weeks, 3 months, and 1 year postinjury. While functionally treated patients reached normal mobility and resumed work and sports earlier than immobilized patients there were no differences between the treatment groups in ankle stability or symptoms during activity after 1 year. Ninety-five percent of the ankles in either group were mechanically stable after treatment. Residual symptoms were present 1 year postinjury in 13% of the functionally treated ankles and in 9% of the cast-mobilized ankles. In lateral ankle ligament ruptures causing gross mechanical instability early mobilization results in a better early functional result; however, at 1 year postinjury there was no statistically significant difference in outcome as compared to cast-immobilized ankles.

Acute lateral ankle ligament injuries: a literature review

The average general orthopaedic surgeon examines and treats a considerable number of acute lateral ankle ligament sprains in a busy office practice. A cursory review of recent articles published on this subject will present a confusing picture regarding diagnosis and treatment of Grade III injuries. An air of controversy surrounds the interpretation of diagnostic x-rays, and the management of these common ankle problems. This review article is presented to summarize current thoughts on the anatomy, biomechanics, diagnosis, and treatment of acute lateral ankle ligament sprains.

Functional treatment of recent ruptures of the fibular ligament of the ankle

A prospective randomised study was undertaken to compare the results of functional and operative treatment of recent ruptures of the fibular ligament of the ankle in 80 patients, aged from 18 to 45 years, with similar injuries. The best results were obtained from functional treatment and it is to be hoped that early movement and a stable ankle will avoid later osteoarthritis.

Comparison of three different treatments for ruptured lateral ankle ligaments

Two hundred consecutive patients with arthrographically verified rupture of one or both of the lateral ankle ligaments were allocated to treatment with either an operation and a walking cast, walking cast alone, or strapping with an inelastic tape - all for 5 weeks. Eighty-seven percent of the patients attended follow-up after 1 year. Only 5 percent in each treatment group were unsatisfied with the result. There were no differences between the treatment groups in ankle stability or symptoms during different activities, regardless of rupture of the anterior talofibular ligament alone or combined with rupture of the calcaneofibular ligament. However, the patients treated with tape had fewer symptoms, fewer complaints when running, and more ankles recovered to the preinjury state. Therefore, in lateral ankle ligament rupture, tape bandages seem preferable.

[Plastic surgery of the ligament for chronic lateral instability of the ankle]

Ten patients with chronic lateral instability of the ankle have been treated by operation using a homograft of preserved skin and scar tissue to reinforce the lateral ligament complex. The technique is simple and cheap. We have analysed the functional stability of the ankles after operation by E. M. G. and Cybex studies of the appropriate muscle groups when standing on an unstable platform and during normal gait. The passive tension of the ligaments is of greater value in stabilising the ankle than active contraction of the muscles. The peroneus brevis has an important action in opposing varus stress, and should be preserved rather than used for ligament substitution.

The influence of dorsiflexion in the treatment of severe ankle sprains: an anatomical study

Cadaver studies were performed to examine the applicability of ankle position to the treatment of ruptured fibulocollateral ligaments. Nonembalmed cadaver specimens were studied with anterior drawer and talar tilt stresses before and after division of the ligaments to simulate the sprained ankle. Dorsiflexion completely reduced the anteriorly subluxed talus and apposed the ends of the anterior talofibular ligament in specimens with divided lateral collateral ligaments. The dorsiflexion angle required to reduce the unstable ankle varied from 5 degrees to 15 degrees. These studies suggest that positioning the ankle in dorsiflexion instead of neutral or plantar flexion may have advantages in promoting a stable ankle if immobilization is chosen for treating a grade III sprain.

Injuries of the lateral ligaments of the ankle joint. Operative treatment and long-term results

Between 1980 and 1984, 268 patients with recent ankle ligament ruptures were treated with primary surgical repair at the 2nd Department of Trauma Surgery, University of Vienna. The decision for immediate operative treatment was based on clinical findings as well as on a positive stress roentgenogram. Ligament ruptures were diagnosed if the talar tilt on the injured side exceeded that on the uninjured side by 5 degrees or more or if the ventral subluxability of the talus was more than 5 mm compared with the uninjured side. One hundred twenty-two patients were followed up for 2-6 years after operation; follow-up included physical examination as well as standardized and stress roentgenograms. Good results were obtained in 80% of cases, moderate results in 17%, and poor results in 3%. All of the poor results were due to persistent radiological instability and/or arthrotic joint degeneration. The incidence of infection was 1.5%.

Plication of the anterolateral capsule of the ankle with extensor digitorum brevis transfer for chronic lateral ligament instability

Thirty sportsmen and women with chronic sprain of the lateral ligament of the ankle characterized by instability and pathological talar tilt have been treated by plication of the anterolateral capsule with extensor digitorum brevis transfer and all have returned to normal sporting activity.

A prospective study of the treatment of severe tears of the lateral ligament of the ankle

A prospective randomized clinical study was undertaken to compare bandaging, plaster cast immobilisation and operative treatment for recent tears of the lateral ligament of the ankle. The follow-up period was two years. Subjectively, only the fear of giving-way showed a clear difference in favour of operative repair. Objective evaluation, including stress radiographs, demonstrated no statistical differences between the three methods of treatment. Although bandaging appeared somewhat less satisfactory with respect to the resulting stability of the ankle, the differences were not statistically significant. The lateral ligament in patients over 40 years of age showed a statistically significant tendency to heal less well than that of younger patients. Severe ankle sprains in patients under 40 years of age should preferably be treated by operation, especially in younger patients and if the person is physically active. Lateral ligament tears in patients over 40 years of age should be treated conservatively and a secondary reconstruction carried out later, if necessary.

Treatment of ankle sprains in young athletes

To study the incidence of fibulocollateral ligament ankle sprains in the young male athlete, a survey of 84 varsity basketball players was done. Seventy percent of the players had a history of an ankle sprain. Eighty percent of those with a positive history had multiple sprains. Most of the injuries were mild, but in 32% of the injuries, the athlete missed more than 2 weeks of play. No medical attention was sought in 55% of the cases. About 50% of the athletes with a sprain had residual symptoms from their injuries; 15% of the injured athletes felt that their residual symptoms compromised their playing performance. This article emphasizes the potential seriousness of the ankle sprain in the young athlete and presents a recommended method of management, including assessment of severity, treatment, and rehabilitation.

Lateral and anterior instability in acute ankle distortion. A radiologic investigation

In a prospective consecutive investigation radiologic tests for lateral and anterior instability in acute ankle distortion were found to be reliable indications of lateral ligament ruptures. Arthrography of the ankle joint was used as reference. Absence of instability, however, gives little information as to the ligamental status. The size of this group constitutes a clinical problem. Better results are achieved by combining lateral and anterior instability tests. If only one test is used, the anterior instability test should be preferred. The results of the two tests bare no relation to the degree of ligament ruptures found at operation.

Ruptured fibular ankle ligament: plaster or Pliton brace?

A prospective randomised study was performed in order to compare plaster cast with Pliton-80 cast brace with a mobile plastic shoe insert in the treatment of ruptured fibular ankle ligaments. The two treatment groups consisted of 65 patients in each and all were participating in the follow-up sixth months after the accident. There were no statistically significant differences in the overall results between the two treatment groups. Because 1) the mobile Pliton-80 bandage subjectively is more acceptable to the patients and -2) the disability time in the Pliton-80 group was considerably shorter than in the plaster group--it was concluded that the mobile Pliton-80 bandage can be recommended as the treatment of ruptures of the fibular ankle ligaments.

Arthrography of the ankle. Value in diagnosis of rupture of the calcaneofibular ligament

As part of a clinical prospective investigations 102 patients with fresh ankle injuries underwent ankle arthrography and surgery for rupture of the lateral ligaments of the ankle. Three hypotheses concerning the improvement of the arthrographic diagnosis of rupture of the calcaneofibular ligament were tested. Two were rejected. Improvement in the diagnostic specificity was possible by combining arthrography with a stress inversion test, but the sensitivity of this combination was low. It was demonstrated that absence of peroneus sheath filling was a better diagnostic sign with good rather than with poor recess filling.

Ruptures of the lateral ligaments of the ankle. Clinical diagnosis

During the 11-month period 1 October 1977 to 31 August 1978 a total of 44 patients with acute supination trauma of the ankle were examined. The clinical findings were compared with the results of arthrography. This revealed that direct and indirect tenderness of the anterior talofibular ligament and calcaneofibular ligament respectively, combined with a greater than or equal to 4 cm swelling anteriorly and over the lateral malleolus, indicated a ligament injury with great likelihood. If some of the diagnostic signs are absent, most emphasis should be laid on the swelling over the lateral malleolus and on the direct and indirect tenderness of the calcaneofibular ligament. The talar-tilt test and examination for the drawer sign were of limited diagnostic value.

Conservative treatment of injury to the fibular ligaments of the ankle

Fifty-one patients with fibular ligamentous injury of the ankle are presented. The treatment consisted of complete non-weight-bearing of the affected foot by use of elbow crutches for three weeks. All patients were seen at follow-up eighteen months after the accident. The results are discussed in the light of previous literature on conservative and operative treatment of lateral ligament injuries.