Five-year clinical follow-up of arthroscopically treated chronic ankle instability

INTRODUCTION

Arthroscopic treatment of lateral ankle instability is a recent innovation. In 2014, a prospective study was initiated by the French Society of Arthroscopy demonstrating the feasibility, morbidity and short-term results of arthroscopic treatment of ankle instability.

HYPOTHESIS

The functional results of arthroscopic treatment of chronic ankle instability found after one year were maintained in the medium term.

MATERIAL AND METHODS

The prospective follow-up of the patients included in the initial cohort was continued. The Karlsson and AOFAS scores, as well as patient satisfaction, were assessed. The causes of failure underwent univariate and multivariate analyzes. The results of 172 patients were included (40.2% ligament repairs; 59.7% ligament reconstructions). The average follow-up was 5years. The average satisfaction was 8.6/10, the average Karlsson score was 85 points and the average AOFAS score was 87.5 points. The reoperation rate was 6.4% of patients. The failures were related to an absence of sports practice, a high BMI and female gender. A high BMI and the intense sports practice were associated to ligament repair failure. The absence of sports practice and the intraoperative presence of the anterior talofibular ligament were associated to ligament reconstruction failure.

DISCUSSION

Arthroscopic treatment of ankle instability confers high satisfaction in the medium term, as well as long-lasting results with a low reoperation rate. A more detailed evaluation of the failure criteria could help guide the choice of treatment between ligament reconstruction or repair.

LEVEL OF EVIDENCE

II.

Modified classifications and surgical decision-making process for chronic anterior talofibular ligament injuries based on the correlation of imaging studies and arthroscopic findings

PURPOSE

Surgical treatment of chronic ankle instability (CAI) typically includes ligament repair or reconstruction. Using preoperative ultrasonography or magnetic resonance imaging (MRI) to choose an appropriate arthroscopic procedure is still difficult. The aim of this study was to evaluate the correlation of imaging studies with arthroscopic findings and support the arthroscopic surgical decision-making process.

METHODS

One hundred twelve patients with chronic anterior talofibular ligament (ATFL) injuries were treated using the arthroscopic surgical decision-making process from November 2018 to August 2020. Preoperative imaging assessments using dynamic ultrasonography, MRI, and combined methods were applied to categorize the ATFL remnants into three quality grades ("good," "fair," and "poor"). Arthroscopic findings were classified into 6 major types (7 subtypes) and used to select an appropriate surgical procedure. Correlations between imaging studies, arthroscopic findings, and surgical methods were evaluated. Diagnostic parameters, clinical outcomes, and complications were also assessed.

RESULTS

There was a significant interobserver agreement in the evaluation of dynamic ultrasonography (0.954, P < 0.001), MRI (0.958, P < 0.001), and arthroscopy diagnosis (0.978, P < 0.001). There was a significant correlation between the modified imaging classifications, arthroscopic diagnostic types, and surgical procedures. The mean follow-up period was 33.58 ± 8.85 months. Significant improvements were documented in postoperative ankle functions when assessed with Karlson-Peterson scores and Cumberland Ankle Instability Tool scores. The risk of complications is also very low.

CONCLUSION

The modified classifications and surgical decision-making process based on dynamic ultrasonography, MRI, and arthroscopic findings, as proposed in this study, might help in selecting an appropriate arthroscopic surgical procedure for chronic ATFL injuries.

Efficacy of Platelet-Rich Plasma for Chronic Lateral Ankle Instability After Modified Broström-Gould surgery: A Randomized, Single-Blinded, Prospective Controlled Trial

Background

Modified Broström-Gould (MBG) surgery is frequently used for chronic lateral ankle instability (CLAI). However, conventional postoperative management (CPOM) due to prolonged immobilization may have adverse effects on tendons, ligaments, and joints, causing stiffness. This prospective, randomized controlled trial aimed to determine outcomes among patients randomized to receive CPOM plus ultrasonography-guided triple injections of leukocyte-rich platelet-rich plasma (LR-PRP) compared to patients who receive only CPOM after MBG surgery.

Methods

The present study included 40 patients with symptomatic CLAI who were candidates for the MBG surgery. The patients were randomized into 2 groups of 20, the control and PRP groups. In the PRP group, patients were injected with 3 doses of LR-PRP solution using ultrasonographic guidance. In the first injection, 2 mL of LR-PRP was injected near the injury site, and in the second and third injections, 4 mL of LR-PRP was injected in the tibiotalar joint. All patients received a short leg splint for 2 weeks, followed by 4 weeks in a walking boot. The primary outcome measure was the visual analog scale (VAS), and the secondary outcome measures were the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and ankle total range of motion (total ROM). The assessment was performed at baseline and 3 and 6 months after surgery.

Results

The mean VAS and AOFAS scores improved significantly in both groups 6 months after surgery (P < .001). However, the PRP group did not significantly improve in VAS or AOFAS scores compared with the control group. No clinically significant difference was observed between the 2 groups regarding the total ROM scores at month 3.

Conclusion

The application of LR-PRP after MBG surgery did not show any superior clinical or functional improvement over CPOM.

Level of Evidence

Level II, prospective randomized trial.

Outcomes of Open Versus Arthroscopic Broström Surgery for Chronic Lateral Ankle Instability: A Systematic Review and Meta-analysis of Comparative Studies

Background:

Nearly 20% of acute ankle sprains progress to chronic lateral ankle instability that requires surgical intervention. In recent years, there has been a growing interest in arthroscopic Broström techniques as an alternative to open surgery.

Purpose:

To review the most up-to-date evidence comparing the outcomes of open and arthroscopic Broström procedures for chronic lateral ankle instability.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

This review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant comparative studies in English up to May 2020 were identified. The primary outcomes were (1) functional scores (Karlsson Ankle Function Score and American Orthopaedic Foot & Ankle Society [AOFAS] score) and (2) the 10-point visual analog scale (VAS) score for pain. The secondary outcomes were differences in (1) postoperative anterior drawer and talar tilt, (2) surgical time and complication rate, and (3) time to return to sports and weightbearing.

Results:

A total of 408 patients in 8 studies met the inclusion criteria. Of these, 193 (47.3%) patients underwent open surgery, while 215 (52.7%) patients underwent arthroscopic surgery. There were significant differences between the open and arthroscopic repair groups in mean 6-month AOFAS scores (82.4 vs 92.25, respectively; mean difference [MD], 11.36; 95% CI, 0.14-2.56; I² = 90%; P = .03), 1-year AOFAS scores (80.05 vs 88.6; MD, –11.96; 95% CI, –21.26 to –2.76; I² = 82%; P = .01), 6-month VAS scores (1.7 vs 1.4; MD, –0.38; 95% CI, –0.54 to –0.21; I² = 78%; P < .001), and 1-year VAS scores (2.05 vs 1.45; MD, 0.31; 95% CI, 0.09-0.54; I² = 0%; P < .001). The mean time to weightbearing was 14.25 and 9.0 weeks in the open and arthroscopic repair groups, respectively (MD, 1.89; 95% CI, 1.24-2.54; I² = 99%; P < .001). There were no statistically significant differences in the remaining outcomes evaluated.

Conclusion:

While technically more demanding, arthroscopic Broström was superior to open Broström-Gould surgery in postoperative AOFAS scores, VAS pain scores, and time to return to weightbearing. The operative time, complication rate, talar tilt, and anterior drawer tests were excellent and statistically comparable. Long-term clinical trials are required before recommending arthroscopic Broström as the new gold standard.

Arthroscopic Versus Open Broström-Gould Repair for Chronic Ankle Instability

BACKGROUND

The open Broström-Gould procedure for the repair of lateral ankle ligament remains the gold standard in operative management of chronic ankle instability. Nevertheless, the arthroscopic technique has been gaining attention among foot and ankle surgeons in the past decade. Our study aimed to compare the clinical outcomes of patients who underwent the arthroscopic and open Brostom-Gould technique over a 12-month follow-up period.

METHODS

We retrospectively reviewed the database in a tertiary hospital foot and ankle registry from 2015 to 2019. We then performed a 1:1 matching of 26 ankles that underwent the arthroscopic Broström-Gould technique to 26 ankles with the open technique, all performed by a fellowship-trained foot and ankle surgeon, for age, sex, and body mass index. To assess clinical outcomes, visual analog scale scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form 36 Health Survey scores were collected at the preoperative and 6- and 12-month follow-up visits, respectively.

RESULTS

The arthroscopic group demonstrated significantly less pain in the perioperative period (arthroscopic, 1.0 ± 1.2; open, 2.4 ± 2.2; P = .015) and had higher AOFAS scores at 6 months (arthroscopic, 87.2 ± 11.1; open, 73.5 ± 21.9; P = .028) and 12 months (arthroscopic, 94.2 ± 10.0; open, 70.9 ± 33.1; P = .020). No complications were reported in either group. Twenty patients (76.9%) in the arthroscopic group had preoperative intra-articular abnormalities compared with 24 patients (92.3%) in the open group.

CONCLUSION

The arthroscopic Broström-Gould technique produced better clinical outcomes than the open technique at 12 months of follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Arthroscopic Versus Open Broström-Gould Repair for Chronic Ankle Instability

BACKGROUND

The open Broström-Gould procedure for the repair of lateral ankle ligament remains the gold standard in operative management of chronic ankle instability. Nevertheless, the arthroscopic technique has been gaining attention among foot and ankle surgeons in the past decade. Our study aimed to compare the clinical outcomes of patients who underwent the arthroscopic and open Brostom-Gould technique over a 12-month follow-up period.

METHODS

We retrospectively reviewed the database in a tertiary hospital foot and ankle registry from 2015 to 2019. We then performed a 1:1 matching of 26 ankles that underwent the arthroscopic Broström-Gould technique to 26 ankles with the open technique, all performed by a fellowship-trained foot and ankle surgeon, for age, sex, and body mass index. To assess clinical outcomes, visual analog scale scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form 36 Health Survey scores were collected at the preoperative and 6- and 12-month follow-up visits, respectively.

RESULTS

The arthroscopic group demonstrated significantly less pain in the perioperative period (arthroscopic, 1.0 ± 1.2; open, 2.4 ± 2.2; P = .015) and had higher AOFAS scores at 6 months (arthroscopic, 87.2 ± 11.1; open, 73.5 ± 21.9; P = .028) and 12 months (arthroscopic, 94.2 ± 10.0; open, 70.9 ± 33.1; P = .020). No complications were reported in either group. Twenty patients (76.9%) in the arthroscopic group had preoperative intra-articular abnormalities compared with 24 patients (92.3%) in the open group.

CONCLUSION

The arthroscopic Broström-Gould technique produced better clinical outcomes than the open technique at 12 months of follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

In Vivo Ankle Kinematics Revealed Through Biplane Radiography: Current Concepts, Recent Literature, and Future Directions

PURPOSE OF REVIEW

Lateral ligament repair, specifically the modified Broström-Gould (BG) procedure, has been described for patients with chronic ankle instability (CAI) after failure of nonoperative management. However, there is minimal data about native in vivo ankle bone kinematics and how repairs such as the BG procedure affect the kinematics. The objective of this review is to appraise existing literature that used biplane radiography to measure in vivo kinematics of the ankle in healthy, CAI, and BG populations.

RECENT FINDINGS

Results showed that the tibiotalar joint contributes more to dorsi/plantarflexion, the subtalar joint contributes more to inversion/eversion and internal/external rotation, and that both joints are capable of complex three-dimensional (3D) motion. Preliminary data suggests that demanding activities (as opposed to walking) are necessary to elicit kinematic differences between healthy and CAI populations. Results also indicate that the BG procedure restores static kinematics and range of motion. All but one of the studies identified in this review collected static, quasi-stance, or partial gait capture data. The strength of our current knowledge is low given the small sample sizes, exploratory nature of previous work, and lack of rigorous experimental design in previous studies. Future directions include development of an improved protocol for establishing coordinate systems in the ankle bones, continued development of a database of normal kinematics during a variety of activities, and large-scale, longitudinal studies of CAI and BG patients.

Prospective study of the " Inside-Out" arthroscopic ankle ligament technique: Preliminary result

BACKGROUND

Lateral ankle ligament injury is among the most common orthopedic injuries. The objective of this study is to present the preliminary prospective results of treatment using the "Inside-Out" variant of the fully arthroscopic Broström-Gould technique.

METHODS

Twenty six patients were included: 20 male and 6 female, aged 19-60 years, mean 41 years. All patients had positive "anterior drawer" and "talar tilt" tests. When necessary, cartilage injuries were treated with microfracture and arthroscopic resection for anterior impingement; three patients had hindfoot varus, on whom Dwyer osteotomy was performed; one patient had peroneal tendinopathy and was treated with tendoscopic debridement and another one had partial injury of the deltoid ligament, which was treated by direct repair. Two arthroscopic surgery portals were used; the anteromedial and anterolateral. After careful inspection of the joint, the anterior surface of the fibula was cleaned to resect the remains of the anterior talo-fibular ligament. An anchor with two sutures was placed on the anterior aspect of the fibula, 1cm from the distal apex of the malleolus. The sutures were passed through the remnant of the anterior talo-fibular ligament as well as the extensor retinaculum using special curved needles. Duncan knots were used to tie the ligament and the inferior extensor retinaculum while the ankle was kept in a neutral position. Patients were kept immobilized non-weight bearing for 2 weeks and were then allowed to start weight bearing in a removable protective boot for 4 weeks. The patients were able to return to sporting activities 6 months after surgery.

RESULTS

After a mean follow-up of 27 months (range 21-36 months), patients were functionally evaluated using the American Orthopedics Foot and Ankle Society (AOFAS) ankle score. The mean preoperative value was 58 points, while the mean postoperative value increased to 90 points. One patient had paresthesia in the superficial fibular nerve area, which resolved spontaneously.

CONCLUSION

Despite the limited cohort and the relatively short follow-up period, the use of the "inside-out" arthroscopic technique may be considered as a valid option for the treatment of chronic ankle instability.

[Clinical and functional results of the Broström-Gould technique for lateral ankle instability: evaluation with three scales]

BACKGROUND

The most frequent sequel to the ankle sprain is the instability of the lateral ligament complex; the results of surgical treatment have not been evaluated with multiple scales simultaneously. The objective of the study was to assess the clinical and functional results with three scales in patients with lateral instability of ankle undergoing Broström-Gould technique, using for fixation, anchors with suture to distal fibula.

MATERIAL AND METHODS

The design of the study was cross-sectional and descriptive; we included patients with lateral instability of ankle and partial or complete rupture of the APA or CP ligament subject to repair with Broström-Gould technique. Magnetic resonance imaging was performed to confirm the diagnosis; clinical and functional outcomes were determined with three scales: EVA, SF-36 and AOFAS. Patients were evaluated at six months, or more, after the surgical procedure.

RESULTS

We included 13 patients; quality of life (SF-36 questionnaire) showed a good result with average score of 90; 10 (77%) patients showed excellent results in function, absence of pain and alignment of the ankle (AOFAS 90-100). Also found significant improvement in pain (presurgical EVA: 6, compared with 1 in the postoperative period).

CONCLUSIONS

The surgical procedure showed excellent results, in the short term with resolution of pain and ankle stability.

Treatment of chronic lateral ankle instability using the Broström-Gould procedure in athletes: long-term results

PURPOSE

this study was conducted to evaluate long-term results following treatment of chronic lateral ankle instability using the Broström-Gould technique in athletes.

METHODS

eighteen athletes involved in competitive sports at different levels, who suffered from chronic lateral ankle instability, underwent Broström-Gould ligamentoplasty between 2000 and 2005. The results of the surgery were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scale.

RESULTS

the results at 10-15 years of follow-up were excellent in 94.5% of these cases and good in the remaining 5.5%. An increase of 31.2 points in the AOFAS scale score was recorded at follow-up (with the score rising to 98.8, from 67.6 preoperatively). All the athletes returned to their respective sports at the same level as prior to the surgery. Imaging at long-term follow-up showed no signs of arthritic degeneration.

CONCLUSIONS

the results of this study show that the Broström-Gould technique is an effective procedure for the treatment of chronic lateral ankle instability in the athlete, giving excellent long-term results.

LEVEL OF EVIDENCE

therapeutic case series, level IV.

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction

BACKGROUND

Outcome following foot and ankle surgery can be assessed by disease- and region-specific scores. Many scoring systems exist, making comparison among studies difficult. The present study focused on outcome measures for a common foot and ankle abnormality and compared the results obtained by 2 disease-specific and 2 body region-specific scores.

METHODS

We reviewed 41 patients who underwent lateral ankle ligament reconstruction. Four outcome scales were administered simultaneously: the Cumberland Ankle Instability Tool (CAIT) and the Chronic Ankle Instability Scale (CAIS), which are disease specific, and the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale and the Foot and Ankle Ability Measure (FAAM), which are both body region-specific. The degree of correlation between scores was assessed by Pearson's correlation coefficient. Nonparametric tests, the Kruskal-Wallis and the Mann-Whitney test for pairwise comparison of the scores, were performed.

RESULTS

A significant difference (P < .005) was observed between the CAIS and the AOFAS score (P = .0002), between the CAIS and the FAAM 1 (P = .0001), and between the CAIT and the AOFAS score (P = .0003).

CONCLUSIONS

This study compared the performances of 4 disease- and body region-specific scoring systems. We demonstrated a correlation between the 4 administered scoring systems and notable differences between the results given by each of them. Disease-specific scores appeared more accurate than body region-specific scores. A strong correlation between the AOFAS score and the other scales was observed. The FAAM seemed a good compromise because it offered the possibility to evaluate the patient according to his or her own functional demand.

CLINICAL RELEVANCE

The present study contributes to the development of more critical and accurate outcome assesment methods in foot and ankle surgery.