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Rebolledo BJ, Dugas JR, Bedi A, Ciccotti MG, Altchek DW, Dines JS. Avoiding Tommy John Surgery: What Are the Alternatives? Am J Sports Med 2017; 45:3143-3148. [PMID: 28278401 DOI: 10.1177/0363546517692548] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The number of ulnar collateral ligament (UCL) reconstructions being performed has risen sharply in recent years, most notably in the young amateur athlete. While successful outcomes have been reported with reconstruction, the surgery and the associated rehabilitation timeline may be difficult for the nonelite athlete to incur. Return-to-play expectations, along with level of competition, should help guide surgeons in exploring management options. While reconstruction remains a mainstay, focused research exploring nonreconstructive options has expanded. This review discusses the clinical approach to those with UCL injury, including current support for rehabilitation, biologic strategies, and available repair or augmentation alternatives.
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Affiliation(s)
- Brian J Rebolledo
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michael G Ciccotti
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David W Altchek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
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Cho BK, Kim YM, Choi SM, Park HW, SooHoo NF. Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure. Bone Joint J 2017; 99-B:1183-1189. [PMID: 28860398 DOI: 10.1302/0301-620x.99b9.bjj-2017-0144.r1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/04/2017] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure. PATIENTS AND METHODS A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs. RESULTS The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon. CONCLUSION The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183-9.
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Affiliation(s)
- B K Cho
- College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Y M Kim
- College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - S M Choi
- College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - H W Park
- School of Medicine, University of California, Los Angeles, California, USA
| | - N F SooHoo
- School of Medicine, University of California, Los Angeles, California, USA
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Hunt KJ, Fuld RS, Sutphin BS, Pereira H, D’Hooghe P. Return to sport following lateral ankle ligament repair is under-reported: a systematic review. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000064] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cho BK, Park KJ, Park JK, SooHoo NF. Outcomes of the Modified Broström Procedure Augmented With Suture-Tape for Ankle Instability in Patients With Generalized Ligamentous Laxity. Foot Ankle Int 2017; 38:405-411. [PMID: 28367693 DOI: 10.1177/1071100716683348] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although recent biomechanical studies have reported mechanical superiority of augmented anterior talofibular ligament reconstruction using suture-tape, clinical evidence regarding the efficacy of suture-tape augmentation is still insufficient. This prospective study was performed to evaluate the outcomes of the modified Broström procedure augmented with suture-tape for chronic ankle instability with generalized ligamentous laxity, which has been known to be a poor prognostic factor for anatomic ligament repair. METHODS Twenty-eight patients with generalized ligamentous laxity were followed for more than 2 years after the augmented modified Broström procedures for chronic ankle instability. Generalized ligamentous laxity was defined as a Beighton score ≥4 points. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) score. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate mechanical ankle stability. RESULTS FAOS and FAAM scores had significantly improved from preoperative average 63.2 and 54.3 points to 90.6 and 89.5 points at final follow-up, respectively ( P < .001). Talar tilt angle and anterior talar translation had significantly improved from preoperative average 16.2° and 12.1 mm to 3.6° and 4.2 mm at final follow-up, respectively ( P < .001). Preoperative side-to-side comparison with stress radiographs was significantly different, but this returned to within nonstatistical differences at final follow-up, respectively ( P = .105, .532). Although 6 patients sustained an ankle sprain after operation, only 1 patient (3.6%) showed a recurrence of subjective and mechanical instability. CONCLUSIONS Suture-tape augmentation for the modified Broström procedure appears to be an effective operative alternative for chronic ankle instability with generalized ligamentous laxity. As one of the methods to improve the clinical outcomes in patients with relative contraindications of the modified Broström repair, this procedure provided reliable stability with the advantages of anatomic ligament repair through the augmentation using suture-tape. LEVEL OF EVIDENCE Level IV, prospective case series.
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Affiliation(s)
- Byung-Ki Cho
- 1 Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Kyoung-Jin Park
- 1 Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Ji-Kang Park
- 1 Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Nelson F SooHoo
- 2 Department of Orthopaedic Surgery, School of Medicine, University of California, Los Angeles, CA, USA
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Park KH, Lee JW, Suh JW, Shin MH, Choi WJ. Generalized Ligamentous Laxity Is an Independent Predictor of Poor Outcomes After the Modified Broström Procedure for Chronic Lateral Ankle Instability. Am J Sports Med 2016; 44:2975-2983. [PMID: 27480980 DOI: 10.1177/0363546516656183] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The modified Broström procedure for chronic lateral ankle instability (CLAI) has presented outstanding clinical results. However, after the procedure, some patients with generalized ligamentous laxity have experienced a recurrence of ankle instability. PURPOSE To understand the effect of generalized ligamentous laxity on prognosis and risk of recurrence in a cohort of patients with CLAI after the modified Broström procedure. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 199 ankles from 188 patients underwent the modified Broström procedure for CLAI with a mean follow-up of 60.1 months (range, 48-108 months). Generalized ligamentous laxity was assessed in all patients. The Karlsson-Peterson ankle score (Karlsson score), talar tilt angle, and anterior displacement of the talus were used to evaluate clinical and radiological outcomes. Risk factors associated with clinical outcomes were evaluated using bivariate analysis and logistic regression analysis. Survival outcomes were compared using Kaplan-Meier analysis. RESULTS Generalized ligamentous laxity was evident in 42 cases (21.1%). The average Karlsson score improved from 54.6 ± 7.1 preoperatively to 87.9 ± 7.2 at last follow-up (P < .001). The presence of generalized ligamentous laxity was significantly associated with poor clinical and radiological outcomes. The rates of clinical failure were 10.8% and 45.2% in the nonlaxity group and the laxity group, respectively (P < .001). According to bivariate analysis, generalized ligamentous laxity, syndesmosis widening, osteochondral lesion of the talus, high preoperative talar tilt angle (>15°), and high preoperative anterior displacement of the talus (>10 mm) were significantly associated with clinical failure. Multivariate logistic regression analysis revealed that generalized ligamentous laxity was the most important independent predictor of clinical failure after the modified Broström procedure. The cumulative success rates for the nonlaxity group were significantly superior to those for the laxity group in Kaplan-Meier curves (P < .001). CONCLUSION Generalized ligamentous laxity is an independent predictor of poor outcomes and a risk factor of recurrent instability following the modified Broström procedure for CLAI.
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Affiliation(s)
- Kwang Hwan Park
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam-si, Kyeonggi-do, South Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Wan Suh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Myung Ho Shin
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Woo Jin Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, South Korea
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Smith PA, Bley JA. Allograft Anterior Cruciate Ligament Reconstruction Utilizing Internal Brace Augmentation. Arthrosc Tech 2016; 5:e1143-e1147. [PMID: 28224069 PMCID: PMC5310189 DOI: 10.1016/j.eats.2016.06.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/22/2016] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament (ACL) tears are among the most common sports-related injuries. Although studies have reported reliable outcomes with allograft tissue, several studies have shown a higher failure rate in younger patients. Although ACL graft augmentation has been met with varying levels of success, internal bracing of an allograft represents a promising area in ACL reconstruction. The purpose of this article is to detail allograft preparation involving a collagen-coated, ultrahigh-molecular-weight polyethylene/polyester suture tape as an internal brace augmentation for ACL reconstruction using the all-inside ACL GraftLink Technique (Arthrex, Naples, FL).
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Affiliation(s)
- Patrick A. Smith
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.,Address correspondence to Patrick A. Smith, M.D., Columbia Orthopaedic Group, Department of Orthopaedic Surgery, Division Director, Sports Medicine, University of Missouri, Columbia, MO 65201, U.S.A.Columbia Orthopaedic GroupDepartment of Orthopaedic SurgeryDivision DirectorSports MedicineUniversity of MissouriColumbiaMO65201U.S.A.
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Willegger M, Benca E, Hirtler L, Hradecky K, Holinka J, Windhager R, Schuh R. Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL. Knee Surg Sports Traumatol Arthrosc 2016; 24:1015-21. [PMID: 26878851 PMCID: PMC4823330 DOI: 10.1007/s00167-016-4048-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 01/21/2016] [Indexed: 10/29/2022]
Abstract
PURPOSE Current methods of anterior talofibular ligament (ATFL) reconstruction fail to restore the stability of the native ATFL. Therefore, augmented anatomic ATFL reconstruction gained popularity in patients with attenuated tissue and additional stress on the lateral ankle ligament complex. The aim of the present study was to evaluate the biomechanical stability of the InternalBrace (Arthrex Inc., Naples, FL, USA), a tape augmentation designed to augment the traditional Broström procedure. METHODS Twelve (12) fresh-frozen human anatomic lower leg specimens were randomized into two groups: a native ATFL (ATFL) and a tape augmentation group (IB). Dual-energy X-ray absorptiometry (DEXA) scans were carried out to determine bone mineral density (BMD) of the specimens. The ligaments were stressed by internally rotating the tibia against the inverted fixated hindfoot. Torque at failure (Nm) and angle at failure (°) were recorded. RESULTS The ATFL group failed at an angle of 33 ± 10°. In the IB group, construct failure occurred at an angle of 46 ± 16°. Failure torque reached 8.3 ± 4.5 Nm in the ATFL group, whereas the IB group achieved 11.2 ± 7.1 Nm. There was no correlation between angle at ATFL or IB construct failure or torque at failure, respectively, and BMD for both groups. CONCLUSION This study reveals that tape augmentation for ATFL reconstruction shows similar biomechanical stability compared to an intact native ATFL in terms of torque at failure and angle at failure. BMD did not influence the construct stability. Tape augmentation proved an enhanced initial stability in ATFL reconstruction which may allow for an accelerated rehabilitation process. LEVEL OF EVIDENCE II.
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Affiliation(s)
- M Willegger
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - E Benca
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - L Hirtler
- Institute of Anatomy, Medical University of Vienna, Vienna, Austria
| | - K Hradecky
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - J Holinka
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - R Windhager
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - R Schuh
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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