Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace

Modified Broström procedure in patients with chronic ankle instability is superior to conservative treatment in terms of muscle endurance and postural stability

PURPOSE

To compare muscle strength, muscle endurance, and postural stability in both the affected and unaffected ankles between patients with chronic ankle instability (CAI) who underwent conservative treatment and those who underwent the modified Broström procedure (MBP).

METHODS

A total of 67 patients (37, conservative treatment; 30, MBP) participated. Muscle strength and muscle endurance were measured using an isokinetic device, and postural stability was tested using a postural stabilometry system. We used the independent t test for continuous variables with a normal distribution and Fisher's exact test for categorical variables.

RESULTS

There was no difference in the muscle strengths of the affected and unaffected ankles between the groups. The muscle endurance of plantarflexion and inversion muscles was significantly lower in the affected ankles of the conservative treatment group than in those of the MBP group (plantarflexion: 209 ± 103.1 vs. 318 ± 162.2, p = 0.001; inversion: 93 ± 58.7 vs. 154 ± 65.9, p < 0.001). Static postural stability testing showed no significant differences between the affected and unaffected ankles of the two groups. In the dynamic postural stability test, the overall, anterior-posterior, and medial-lateral stability indices were all significantly higher in the affected ankles of the conservative treatment group than in those of the MBP group (p < 0.001, p = 0.004, p = 0.004, respectively), with no differences observed in the unaffected ankles.

CONCLUSION

The MBP may significantly improve muscle endurance and dynamic postural stability in CAI patients in whom conservative treatment has failed. Therefore, clinicians should consider using MBP instead of conservative treatment when patients show severe muscle weakness or dynamic postural instability.

LEVEL OF EVIDENCE

Case-control study, Level III.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality

PURPOSE

An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality.

METHODS

Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair.

RESULTS

Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up.

CONCLUSION

Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality.

LEVEL OF EVIDENCE

IV, retrospective case series.

[A comparative study of all-arthroscopic technique and modified open Broström technique in repair of anterior talofibular ligament with anchors]

Objective

To compare the effectiveness of all-arthroscopic technique and modified open Broström technique in repair of anterior talofibular ligament (ATFL) for lateral instability of the ankle (LIA).

Methods

A retrospective analysis was made on 65 patients who underwent ATFL repair with anchors for LIA between January 2014 and January 2017. The ATFL was repaired by all-arthroscopic technique in 35 patients (arthroscopic group) and modified open Broström technique in 30 patients (open group). There was no significant difference in age, gender, the side of injured ankle, the time from injury to operation, and preoperative anterior displacement of talus, tilt angle of talus, the Karlsson Ankle Functional (KAF) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Japanese Society for Surgery of the foot ankle-hindfoot (JSSF) scale score between the two groups (P>0.05). The operation time, the intraoperative bleeding volume, and the length of time for surgery recovery were recorded. The anterior displacement of talus, the tilt angle of talus, KAF score, AOFAS score, and JSSF scale score were evaluated at 2 weeks, 3 months, and the last follow-up.

Results

All patients were followed up 24-30 months, with an average of 26 months. The operation time, intraoperative bleeding volume, and the length of time for surgery recovery of arthroscopic group were superior to open group (P<0.05). There were 2 cases of temporary ankle and dorsum numbness and 1 case of thread reaction in arthroscopic group; and there were 2 cases of temporary ankle and dorsum numbness and 2 cases of thread reaction in open group. The AOFAS score, KAF score, and JSSF scale score in arthroscopic group were significantly higher than those in open group (P<0.05) at 2 weeks after operation; there was no significant difference between the two groups at 3 months and the last follow-up (P>0.05). There was no significant difference in the anterior displacement of talus and the tilt angle of talus between the two groups at 2 weeks, 3 months, and last follow-up (P>0.05).

Conclusion

Compared with the modified open Broström technique, the all-arthroscopic technique, as a minimally invasive technique, can achieve the same effectiveness, and has the advantages of shorter operation time, less intraoperative bleeding, and less pain in the early stage.

Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation: A Surgical Technique

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury and often is encountered in those participating in multidirectional sports. ACL reconstruction is the most commonly performed knee ligament reconstruction and employs a variety of surgical techniques but still is challenged by residual laxity and graft rupture. To help address and prevent future ACL failures, new repair and reconstruction techniques have been employed that incorporate suture augmentation (InternalBrace; Arthrex, Naples, FL), which protects the graft during healing and ligamentization. Our goal of this article is to provide a surgical technique of suture augmentation with ACL reconstruction.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.

Augmented Ligament Reconstruction Partially Restores Hindfoot and Midfoot Kinematics After Lateral Ligament Ruptures

BACKGROUND

Altered kinematics and persisting ankle instability have been associated with degenerative changes and osteochondral lesions.

PURPOSE

To study the effect of ligament reconstruction surgery with suture tape augmentation (isolated anterior talofibular ligament [ATFL] vs combined ATFL and calcaneofibular ligament [CFL]) after lateral ligament ruptures (combined ATFL and CFL) on foot-ankle kinematics during simulated gait.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five fresh-frozen cadaveric specimens were tested in a custom-built gait simulator in 5 different conditions: intact, ATFL rupture, ATFL-CFL rupture, ATFL-CFL reconstruction, and ATFL reconstruction. For each condition, range of motion (ROM) and the average angle (AA) in the hindfoot and midfoot joints were calculated during the stance phase of normal and inverted gait.

RESULTS

Ligament ruptures mainly changed ROM in the hindfoot and the AA in the hindfoot and midfoot and influenced the kinematics in all 3 movement directions. Combined ligament reconstruction was able to restore ROM in inversion-eversion in 4 of the 5 joints and ROM in internal-external rotation and dorsiflexion-plantarflexion in 3 of the 5 joints. It was also able to restore the AA in inversion-eversion in 2 of the 5 joints, the AA in internal-external rotation in all joints, and the AA in dorsiflexion-plantarflexion in 1 of the joints. Isolated ATFL reconstruction was able to restore ROM in inversion-eversion and internal-external rotation in 3 of the 5 joints and ROM in dorsiflexion-plantarflexion in 2 of the 5 joints. Isolated reconstruction was also able to restore the AA in inversion-eversion and dorsiflexion-plantarflexion in 2 of the joints and the AA in internal-external rotation in 3 of the joints. Both isolated reconstruction and combined reconstruction were most successful in restoring motion in the tibiocalcaneal and talonavicular joints and least successful in restoring motion in the talocalcaneal joint. However, combined reconstruction was still better at restoring motion in the talocalcaneal joint than isolated reconstruction (1/3 for ROM and 1/3 for the AA with isolated reconstruction compared to 1/3 for ROM and 2/3 for the AA with combined reconstruction).

CONCLUSION

Combined ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture.

CLINICAL RELEVANCE

This study shows that ligament reconstruction with suture tape augmentation is able to partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, where the classic Broström-Gould technique is followed by augmentation with suture tape, this procedure may protect the repaired ligament during healing by limiting excessive ROM after a ligament rupture.

Stabilizing lateral ankle instability by suture tape - a cadaver study

BACKGROUND

Suture tape is a recent development to augment a Brostrom repair at least during the healing phase of the native tissues used for stabilization of the lateral ankle ligaments. The purpose of this study was to evaluate whether suture tape is an effective mechanical stabilizer against anterior talar drawer in a cadaver experiment when tested with a validated arthrometer.

METHODS

Different stability conditions were created in 14 cadaveric foot and leg specimens. Following anterior talofibular ligament (ATFL) dissection, isolated suture tape ATFL reconstruction was compared to the unaltered specimens, to the condition with ATFL cut, to the ATFL plus calcaneofibular ligament (CFL) cut conditions, and to the ATFL, CFL, and posterior talofibular ligament transected specimens. Three-dimensional bone-to-bone movement between fibula and calcaneus were simultaneously recorded using bone pin markers. Anterior translation was analysed between 20 and 40 N anterior talar drawer load, applied by an ankle arthrometer. Test conditions were compared using non-parametric statistics.

RESULTS

Dissection of ATFL increased anterior talar drawer in arthrometer and bone pin marker analyses (p = 0.003 and 0.004, respectively). When the CFL was additionally cut, no further increase of the anterior instability could statistically be documented (p = 0.810 and 0.626, respectively). Following suture tape reconstruction of the ATFL, stability was not different from the unaltered ankle (p = 0.173).

CONCLUSIONS

Suture tape augmentation of the ATFL effectively protects the unstable anterolateral ankle in the sagittal plane. The CFL does not seem to stabilize against the anterior talar drawer load.

[Lateral ankle ligament bracing]

OBJECTIVE

Covering the anatomic reconstruction (Broström procedure) with suture tape for more initial stability. Seat belt principle.

INDICATIONS

Mechanical lateral ankle instability: athletes in sports at risk, patients with uncertain compliance with respect to the postoperative treatment regimen, patients with poor tissue quality, patients with generalized laxity, and patients with failed previous repairs.

CONTRAINDICATIONS

Known implant intolerance, local or systemic infection, local soft tissue affections, hemorrhagic disorders.

SURGICAL TECHNIQUE

Epimalleolar 5 cm skin incision. Anatomic repair of the lateral capsuloligamentous structures to the anterior facet of the lateral malleolus (e.g. Broström repair). Dissection down to origin and insertion of the anterior talofibular ligament (ATFL). Close proximal (fibula) and distal (talar neck) to the ATFL attachments to bone a 2.7 mm (fibular) and a 3.4 mm (talar) drill hole is created and taped with the respective tapes from the single use kit (Arthrex, Naples, FL, USA). Placement of a 3.5 mm × 15.8 mm BioComposite SwiveLock® screw, preloaded with suture tape into the fibula. The free ends of this suture tape are inserted into a 4.75 mm × 19.1 mm SwiveLock® anchor, which is screwed into the talar drill hole under moderate tension of the suture tapes.

POSTOPERATIVE MANAGEMENT

Immobilization for 4-5 days postoperatively in a leg and foot Scotchcast^TM. Then, full load bearing within 1-2 days in a stable shoe (OrthoTECH Stabil, OrthoTECH GmbH, Stockdorf, Germany) for 5 postoperative weeks for the day and a night splint (existing Scotchcast^TM). Sensorimotor training initiated in the third and running in the eighth postoperative week. Return to competition in sports at risk (football, basketball, volleyball) 10-12 weeks postoperatively.

RESULTS

Measured with the validated FAAM-G (Foot and Ankle Ability Measure-German version) questionnaire, 9 patients had a preoperative activities of daily living subscale median (minimum-maximum) of 65 (30-100) and increased to 98 (78-100) 12 months postoperatively. Preoperative FAAM-G sport subscale results were 35 (0-75) and 100 (19-100) after 12 months. With the Sefton Grading System, 7 of 8 followed patients had an excellent result and had unrestricted ankle mobility and stable ankles (talar tilt and anterior talar drawer), which is comparable to published suture tape augmentation reports.

Sternoclavicular Joint Reconstruction Fracture Risk Is Reduced With Straight Drill Tunnels and Optimized With Tendon Graft Suture Augmentation

Background:

Despite the rare entity of sternoclavicular joint (SCJ) instability, a variety of different reconstruction techniques for SCJ dislocations have been described. A technique with oblique drilling has been proposed to reduce intraoperative risks.

Purpose:

To biomechanically investigate different cerclage reconstruction techniques and the benefit of additional reinforcement using suture tape.

Study Design:

Controlled laboratory study.

Methods:

Reconstructed artificial bone specimens were mounted on a mechanical testing machine. They were subjected to anterior and posterior translation, analyzing ultimate strength, displacement, stiffness, and elongation. For stage 1, different angulations of the drill tunnels through the sternum and clavicle were compared. Straight drill tunnels from anterior to posterior were compared with 45° oblique drill tunnels. For stage 2, three different materials for cerclage reconstruction were compared: (1) suture tape alone (FT group), (2) tendon graft alone (tendon group), and (3) tendon graft with suture tape augmentation (tendon+FT group).

Results:

For the FT group, in the anterior and posterior directions, straight drill holes resulted in a significantly higher load to failure (936.9 ± 122.5 N) compared with oblique ones (434.5 ± 20.2 N) (P < .0001). During cyclic testing, all specimens with straight drill holes survived the 5- to 550-N step, while all specimens with oblique ones failed during the 5- to 450-N step. Analyzing the graft material choice, the mean load to failure was 556.6 ± 174.3 N for the tendon group, 936.9 ± 122.5 N for the FT group, and 767.0 ± 110.7 N for the tendon+FT group (P = .089). The stiffness of the tendon+FT group was significantly lower than that of the FT group and significantly higher than that of the tendon group.

Conclusion:

Oblique tunnel placement during SCJ reconstruction, while reducing the intraoperative risk, results in decreased primary stability of the construct. Tendon graft reconstruction with suture tape augmentation leads to enhanced stability and optimizes biomechanical properties of the construct.

Clinical Relevance:

The surgical technique with straight drill holes has superior initial biomechanical properties and may likewise produce superior clinical outcomes in the treatment of SCJ instability. Suture tape augmentation can provide additional stability to reconstruction procedures.

Management of foot and ankle injuries in pediatric and adolescent athletes: a narrative review

In this review, we focus on the treatment of injuries to the foot and ankle in the adolescent athlete. While many injuries in the adolescent foot and ankle are similar to or overlap with their counterparts in the adult population, the anatomy of the adolescent ankle, especially the presence of growth plates, results in different injury patterns in many cases and calls for specific management approaches. We discuss the unique anatomy of the pediatric patient as well as the diagnostic evaluation and treatment of common injuries in the young athlete.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal

BACKGROUND

Anatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström-Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability.

METHODS

We reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months.

RESULTS

The mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture.

CONCLUSIONS

Chronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

Anatomic Reconstruction of Lateral Ankle Ligaments and Both Peroneus Tendons After Open Fracture Dislocation of the Ankle: A Case Report

Extensive soft tissue defects of the ankle are an uncommon but challenging problem that require a combination of reconstructive options. We report the case of a complex injury involving the skin, lateral ankle ligaments, and peroneal tendons that were anatomically reconstructed. A 15-year-old girl was injured in an automobile accident resulting in extensive soft tissue defects and marked instability of her right ankle. The lower two-thirds of the anterior talofibular ligament (ATFL) had segmental defects, and calcaneofibular ligament (CFL) was completely torn, and both peroneal longus and brevis tendons were severely damaged. Initial debridement was performed on the day on injury. Two weeks after injury, the ATFL and CFL were reconstructed using a semitendinosus autograft and suture tape augmentation. Both peroneal tendons were reconstructed using a gracilis autograft. The skin defect (10 × 10 cm) was covered with an anterolateral thigh flap. After removing a short leg cast at 3 weeks postoperatively, the patient started range of motion exercises without using any brace. Weightbearing was allowed at 4 weeks. At the 24-month follow-up examination, she had returned to her preoperative level of work and sports activities.

Ankle Stabilization With Arthroscopic Versus Open With Suture Tape Augmentation Techniques

Ankle instability is a common problem that often leads to surgery to stabilize the ankle if conservative methods are unsuccessful in returning the patient to full activity. Surgical ankle stabilization, including arthroscopic and open methods, has been performed with overall excellent results reported. Although initial ligament strength after repair is weaker than the native ligament, new methods of augmentation with suture tape have yielded initial strength comparable to native ligament. The present study compares arthroscopic ankle stabilization and open stabilization with suture tape augmentation. A retrospective comparative trial was undertaken with a follow-up satisfaction survey. A total of 55 patients were ultimately included, consisting of 43 arthroscopic patients and 12 open with suture tape augmentation patients. Ancillary procedures are reported. The mean follow-up duration was 24.2 months in the arthroscopic group and 21 months in the open group. There was a statistically significantly faster return to activity/sports in the arthroscopic group (127.2 days vs 170 days; p = .008). Although not statistically significant, there was a trend toward favoring the open group in terms of revision surgery and patient satisfaction. Our data indicate that both methods of stabilization are reasonable for ankle instability repair.

Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up

The ulnar collateral ligament (UCL) is the primary restraint to valgus angulation at the elbow. Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing. Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation. Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. Here we present the first patient treated with this technique who achieved excellent recovery with return to college level American Football after 4 months. Five years later he has good elbow function and plays at the same level.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients

BACKGROUND

Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques.

MATERIAL AND METHODS

Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports.

RESULTS

The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients.

DISCUSSION

Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery.

CONCLUSION

Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.

Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Independent Suture Tape Reinforcement

Anterior cruciate ligament (ACL) injuries are common among adolescent athletes and are rising with increased participation in higher level athletics at earlier ages. In these young patients, often with open physes, soft tissue grafts continue to be the primary graft choice for ACL reconstruction. Reinjury continues to be a concern in this high-risk age group, with failure rates 2 to 3 times higher than in adults. Recently, primary ACL reconstruction with suture tape augmentation/reinforcement has been described in both hamstring autografts and allografts. Purported advantages include protection of the graft during the revascularization and remodeling phase of incorporation. This Technical Note details a surgical technique of independent suture tape reinforcement during primary all soft tissue quadriceps tendon autograft ACL reconstruction using an all-inside technique.

Arthroscopic Acromioclavicular Fixation With Suture Tape Augmentation After Coracoclavicular Fixation With Dog Bone Button: Surgical Technique

An arthroscopic technique for the surgical treatment of acute acromioclavicular (AC) joint injuries is presented in this study. This procedure aims to achieve both vertical and horizontal stability through the healing of both coracoclavicular (CC) and AC ligaments. As a routine maneuver, arthroscopic CC stabilization was applied using the dog bone button to obtain only vertical stability. Additional arthroscopic AC joint fixation with suture tape augmentation is simple and easy and provides a safe technique to achieve horizontal stability of the joint and to increase the vertical stability to minimize the complications of standard CC reconstruction techniques.

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.

Treatment of First-Time Traumatic Anterior Dislocation of the Sternoclavicular Joint With Surgical Repair of the Anterior Capsule Augmented With Internal Bracing

Background

Traumatic anterior dislocations of the sternoclavicular joint (SCJ) are rare. Although they can usually be treated by a closed reduction, the reported subsequent recurrence rate is 50%.

Purpose

To determine whether further instability after first-time traumatic anterior dislocation would be prevented by a minimally invasive open repair of the anterior SCJ capsule, augmented with internal bracing.

Study Design

Case series; Level of evidence, 4.

Methods

Open repair of the anterior SCJ capsule was completed on a series of patients who had sustained a first-time traumatic anterior dislocation of the SCJ. Patients with preexisting SCJ instability and recurrent dislocations were excluded. Through a transverse incision, the anterior SCJ capsule was repaired and plicated by use of sutures. The repair was then protected by use of an internal brace, bridging between the sternum and the medial end of the clavicle.

Results

Six patients (4 males, 2 females) with a mean age of 28.3 years were included. Four patients underwent surgery within 4 weeks of their dislocation, and 2 patients had ongoing symptoms of instability but had not had a further dislocation. The median follow-up was 28.2 months (range, 24-35 months). At the most recent follow-up, none of the patients had sustained further dislocation or episode of instability, and their SCJs appeared stable. The mean abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 2.3 (range, 0-4.5).

Conclusion

The medium-term results of this case series suggest that after first-time dislocation, surgical repair of the anterior SCJ capsule augmented with internal bracing can prevent recurrent instability. This may be an attractive option for individuals involved in higher risk activities, as the operative management of recurrent anterior SCJ instability usually requires a figure-of-8 tendon reconstruction, which carries a significantly higher morbidity.

An anatomical study about the arthroscopic repair of the lateral ligament of the ankle

BACKGROUND

The purpose of this anatomical study to was to determine the relationship of the structures involved in the arthroscopic repair of the anterior talofibular ligament.

METHODS

Dissection of fifteen lower leg cadaveric specimens was made and distances in the anterior direction from the reference-point at the lateral malleolus origin of the anterior talofibular ligament were measured, to the talar insertion of the ligament, to the superficial peroneal nerve at 60° and 90° in relation to the lateral malleolus axis in the sagittal plane, and to the inferior extensor retinaculum.

RESULTS

The mean±SD distance to superficial peroneal nerve from the reference-point was 25±6 (range 17-35) mm at 60°, and 32±9 (range 24-48) mm at 90° in relation to the lateral malleolus axis. The mean±SD distance to the inferior extensor retinaculum was 20±5 (range 14-29) mm. The mean±SD length of the anterior talofibular ligament was 21±4 (range 13-29) mm.

CONCLUSIONS

The superficial peroneal nerve demonstrated the greatest variance in its anatomy. An accessory incision to include the inferior extensor retinaculum in the repair should not surpass the 22mm distance from the lateral malleolus in the anterior direction, due to the risk of damaging the nerve.

Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation

The advent of suture tape augmentation has led to increased use in knee, elbow, and ankle ligament repairs and reconstructions. Recent biomechanical analysis of the use of suture tape augmentation have shown superior strength characteristics compared with repair or reconstruction alone. Despite its increased use in extra-articular ligament procedures, its use as an augment to anterior cruciate ligament reconstruction has not been widely described. This article details a simple technique to incorporate the use of suture tape augmentation during concurrent anterior cruciate ligament reconstruction using hamstring autograft.

Suture Augmentation: An Alternative to Reconstruction for Incomplete Posterior Cruciate Ligament Injuries in the Multiple Ligament-Injured Knee

Treatment of posterior cruciate ligament injuries remains controversial, particularly in the case of partial or incomplete tears in the context of a multiple ligament-injured knee. Suture augmentation, or internal bracing, has been shown in other ligament and tendon repairs or reconstructions to provide stable biomechanics and facilitate early return to activity. In the knee, suture augmentation has previously been used for the treatment of medial collateral ligament tears and in the support of anterior cruciate ligament reconstructions. We describe our arthroscopic technique for suture augmentation of incomplete posterior cruciate ligament injuries.

Syndesmotic InternalBraceTM for anatomic distal tibiofibular ligament augmentation

Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the TightRope^® system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 TightRopes^®. Therefore, we developed a new syndesmotic InternalBrace^TM technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The InternalBrace^TM technique was developed by Gordon Mackay from Scotland in 2012 using SwiveLocks^® for knotless aperture fixation of a FiberTape^® at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern, patients can either be treated by the new syndesmotic InternalBrace^TM technique alone as a single anterior stabilization, or in combination with one posteriorly directed TightRope^® as a double stabilization, or in combination with one TightRope^® and a posterolateral malleolar screw fixation as a triple stabilization. Moreover, the syndesmotic InternalBrace^TM technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an InternalBrace^TM after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic InternalBrace^TM technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.