Successful Return to Sport and Daily Activities After Suture Augmentation of Both the Anterior Talofibular Ligament and Calcaneofibular Ligament

Purpose

To evaluate the return to sport and daily activities in addition to clinical outcomes after modification of the Brostöm repair, specifically using suture augmentation for concomitant fixation of both the anterior talofibular ligament and calcaneofibular ligament.

Methods

Patients who had grade III ankle sprains and lateral ankle instability, all of whom failed supervised conservative management, were included. Patients underwent a modified Broström procedure consisting of suture augmentation for both the anterior talofibular ligament and calcaneofibular ligament. For clinical outcome evaluation, Foot and Ankle Ability Measure (FAAM) and Karlsson-Peterson Scoring System for Ankle Function questionnaires coupled with questions regarding time of return to sport and level of sports activity were used.

Results

Thirty-one patients were included. The differences in preoperative and postoperative FAAM scores for both the Activities of Daily Living subscale and Sports subscale were significant (P < .001). The FAAM Activities of Daily Living score improved from an average of 46.06 preoperatively to 77.49 postoperatively (P < .001, 99% confidence interval, 26.4-36.4). The FAAM Sports score improved from an average of 4 preoperatively to 19.31 postoperatively (P < .001, 99% confidence interval, 11.6-19.0). For the Karlsson-Peterson Scoring System for Ankle Function, the surveyed population reported a mean of 82.74 points out of 100 post-op (standard deviation 20.14). The mean time to return to sport activity was 5.72 months. Mean follow-up time was 24.12 months.

Conclusions

This variant Broström procedure with suture anchors and augmentation of both the anterior talofibular ligament and calcaneofibular ligament was effective in helping patients return to their preinjury functionality level in both daily life and sports activity.

Level of Clinical Evidence

Level IV, therapeutic case series.

Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery

BACKGROUND

Grade III ankle sprains that fail conservative treatment can require surgical management. Anatomic procedures have been shown to properly restore joint mechanics, and precise localization of insertion sites of the lateral ankle complex ligaments can be determined through radiographic techniques. Ideally, radiographic techniques that are easily reproducible intraoperatively will lead to a consistently well-placed CFL reconstruction in lateral ankle ligament surgery.

PURPOSE

To determine the most accurate method to locate the calcaneofibular ligament (CFL) insertion radiographically.

METHODS

MRIs of 25 ankles were utilized to identify the "true" insertion of the CFL. Distances between the true insertion and three bony landmarks were measured. Three proposed methods (Best, Lopes, and Taser) for determining the CFL insertion were applied to lateral ankle radiographs. X and Y coordinate distances were measured from the insertion found on each proposed method to the three bony landmarks: the most superior point of the postero-superior surface of the calcaneus, the posterior most aspect of the sinus tarsi, and the distal tip of the fibula. X and Y distances were compared to the true insertion found on MRI. All measurements were made using a picture archiving and communication system. The average, standard deviation, minimum, and maximum were obtained. Statistical analysis was performed using repeated measures ANOVA, and a post hoc analysis was performed with the Bonferroni test.

RESULTS

The Best and Taser techniques were found to be closest to the true CFL insertion when combining X and Y distances. For distance in the X direction, there was no significant difference between techniques (P = 0.264). For distance in the Y direction, there was a significant difference between techniques (P = 0.015). For distance in the combined XY direction, there was a significant difference between techniques (P = 0.001). The CFL insertion as determined by the Best method was significantly closer to the true insertion compared to the Lopes method in the Y (P = 0.042) and XY (P = 0.004) directions. The CFL insertion as determined by the Taser method was significantly closer to the true insertion compared to the Lopes method in the XY direction (P = 0.017). There was no significant difference between the Best and Taser methods.

CONCLUSION

If the Best and Taser techniques can be readily used in the operating room, they would likely prove the most reliable for finding the true CFL insertion.

Analysis of retrieved agility total ankle arthroplasty systems

BACKGROUND

First generation total ankle arthroplasty (TAA) systems showed high rates of failure. The Agility (DePuy, Warsaw, IN) TAA system, a second generation design, had improved outcomes; however, implant failure due to loosening of the metallic components persisted. The purpose of this study was to analyze the damage modes and radiographic mode(s) of failure observed in retrieved Agility TAA.

MATERIALS AND METHODS

Ten devices were collected and each component was analyzed for common damage modes using microscopy. Clinical damage was analyzed with postoperative implant and preoperative revision procedure radiographs.

RESULTS

Analyses revealed damage/wear to retrieved components, including abrasion, dishing, and pitting. These third-body wear particles may be a precursor to wear debris induced osteolysis which could cause component loosening. Seven TAA systems were removed due to loosening or subsidence, suggesting component damage/wear may lead to clinically observed component loosening. Retrieval analysis indicated the polyethylene experiences edge loading, resulting in increased contact stresses to polyethylene in the primary articulation region and wear.

CONCLUSION

Since poor clinical outcomes have been associated with component instability and osteolysis, analyzing retrieved components wear and damage may be an important step toward improving implant design, thereby decreasing wear debris induced osteolysis and improving clinical outcomes.

Microvascular supply of the lateral epicondyle and common extensor origin

Lateral epicondylitis is a common condition affecting 1% to 3% of the population. Although the exact cause is still unknown, numerous theories have been put forth. One theory suggests a hypovascular zone at the origin of the common extensor mass. This study examines the microvascular supply of the lateral epicondyle and the common extensor mass, with the use of India ink injection and the Spalteholz tissue-clearing technique. Six fresh-frozen cadaveric arms underwent serial sectioning (coronal plane in five and axial plane in one) after vascular injection with India ink. Sections were cleared via a modified Spalteholz technique. Photographs were taken before and after the clearing procedure, and the microvascular pattern of the common extensor mass and lateral epicondyle was described. Two hypovascular zones were identified in the region of the lateral epicondyle. The first was noted at the proximal lateral epicondyle just distal to the supracondylar ridge and the second 2 to 3 cm distal to the lateral epicondyle on the deep surface of the common extensor tendon. Two regions of hypovascularity were noted at the lateral epicondyle and within the common extensor origin. These hypovascular regions may preclude the normal inflammatory cascade and healing response to microtearing in this region. Thus, these zones may play a role in the etiology of lateral epicondylitis.

Effect of amplitude and frequency of cyclic tensile strain on the inhibition of MMP-1 mRNA expression in tendon cells: an in vitro study

To determine the effect of cyclic strain amplitude and frequency on MMP-1 (interstitial collagenase) expression in tendon cells, rat tail tendons (RTT) were immobilized or cyclically displaced to various amplitudes (1, 3, or 6% strain at 0.017 Hz) or frequencies (1% strain at 0.017, 0.17, or 1.0 Hz) for 24 hr. Stress-deprivation for 24 hr resulted in a marked upregulation in MMP-1 expression. Cyclic tensile loading at 0.017 Hz was found to significantly inhibit, but not completely eliminate, MMP-1 expression at 1% strain. MMP-1 expression was completely eliminated at 3 and 6% strain. Increasing the frequency of application of the 1% strain to 0.17 or 1.0 Hz completely eliminated MMP-1 expression. Disruption of the actin cytoskeleton with cytochalasin D abolished all inhibitory effects of cyclic strain on MMP-1 expression. The results of our study demonstrate that MMP-1 expression in tendon cells can be modulated by varying amplitudes and frequencies of cyclic tensile strain, presumably through a cytoskeletally based mechanotransduction pathway.