Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws

Republication of "Fracture Through a Distal Fibular Tunnel Used for an Anatomic Lateral Ankle Ligament Reconstruction"

Anatomic lateral ankle ligament reconstruction using free tendon graft with osseous tunnels has become a popular technique for revision reconstruction of the lateral ankle ligaments. With the procedure's burgeoning popularity, an accompanying increase in postoperative complications is likely to occur. We report on one such complication: traumatic distal fibula fracture through the transosseous tunnels.

Arthroscopic and Open Procedures Result in Similar Calcaneal Tunnels for Anatomical Reconstruction of Lateral Ankle Ligaments

Purpose

The purpose of this study was to validate the accuracy and reliability of arthroscopic markers of distal insertion of the calcaneofibular ligament (CFL), and to compare the calcaneus bone tunnels of the CFL that were made under arthroscopy and open procedures.

Methods

Fifty-seven patients who underwent lateral ankle ligament reconstruction procedures were enrolled and divided into open (n = 24) and arthroscopic groups (n = 33). Lateral ankle radiography was performed postoperatively, and the calcaneus bone tunnels referenced to several landmarks, including the subtalar joint, calcaneus superior edge, fibular tip, angulation with fibula axis, cross point of the fibular and tangential line of the fibular obscure tubercle cross point of the tangential lines of the talar posterior edge and deepest point of the subtalar joint, and cross point of the fibular axis and perpendicular line across fibular tip. These results were compared between the two groups.

Results

No significant intergroup differences were observed between the parameters. When the bone tunnels of the CFL were referenced to the cross point of tangential lines of the talar posterior edge and deepest point of the subtalar joint, and the cross point of the fibular axis and perpendicular line across fibular tip, the coefficient variations were very high, which indicated that the locations of the bone tunnels were scattered over a large area in both groups.

Conclusions

Arthroscopic and open procedures achieved similar results for calcaneus bone tunnel making of the CFL. However, large variations were observed in both groups.

Level of Evidence

Level III, retrospective cohort study.

Particularities on Anatomy and Normal Postsurgical Appearances of the Ankle and Foot

The anatomy of the ankle and foot is complex, allowing for a wide range of functionality. The movements of the joints represent a complex dynamic interaction. A solid understanding of the characteristics and actions of the anatomic elements helps explain the mechanisms and patterns of injury. This article reviews the anatomy, with special focus on concepts that are the object of recent study and the features that favor the development of symptoms. Good understanding of the surgical procedures helps in providing information to guarantee a favorable outcome. We review the commonly expected postsurgical appearances and the most common postsurgical complications.

Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury

Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

Ankle Instability

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.

Effects of the Ankle Flexion Angle During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

This study aimed to evaluate the effects of the ankle flexion angle during anterior talofibular ligament (ATFL) reconstruction on ankle kinematics, laxity, and in situ force of a graft.

METHODS

Twelve cadaveric ankles were evaluated using a 6-degrees of freedom robotic system to apply passive plantar flexion and dorsiflexion motions and multidirectional loads. A repeated measures experiment was designed using the intact ATFL, transected ATFL, and reconstructed ATFL. During ATFL reconstruction (ATFLR), the graft was fixed at a neutral position (ATFLR 0 degrees), 15 degrees of plantar flexion (ATFLR PF15 degrees), and 30 degrees of plantar flexion (ATFLR PF30 degrees) with a constant initial tension of 10 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ force of the ATFL and reconstructed grafts were calculated using the principle of superposition.

RESULTS

The in situ forces of the reconstructed grafts in ATFLR 0 degrees and ATFLR PF 15 degrees were significantly higher than those of intact ankles. The ankle kinematics and laxity produced by ATFLR PF 30 degrees were not significantly different from those of intact ankles. The in situ force on the ATFL was 19.0 N at 30 degrees of plantar flexion. In situ forces of 41.0, 33.7, and 21.9 N were observed at 30 degrees of plantar flexion in ATFLR 0, 15, and 30 degrees, respectively.

CONCLUSION

ATFL reconstruction with the peroneus longus (PL) tendon was performed with the graft at 30 degrees of plantar flexion resulted in ankle kinematics, laxity, and in situ forces similar to those of intact ankles. ATFL reconstructions performed with the graft fixed at 0 and 15 degrees of the plantar flexion resulted in higher in situ forces on the reconstructed graft.

CLINICAL RELEVANCE

Fixing the ATFL tendon graft at 30 degrees of plantar flexion results in an in situ force closest to that of an intact ankle and avoids the excessive tension on the reconstructed graft.

High return to sports and return to work rates after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability

PURPOSE

To evaluate clinical outcomes as well as return to sports (RTS) and return to work (RTW) rates following anatomic lateral ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability (CLAI) in a high-risk population, and to compare these outcome parameters between patients having received a gracilis tendon autograft (GT) and free split peroneus brevis tendon (PBT) autograft.

METHODS

Twenty-eight consecutive patients, who were diagnosed with CLAI, presenting with ≥ 1 risk factor (ligamentous hyperlaxity, insufficient substance of native ligament and/or high-demand athlete), who underwent ankle ligament reconstruction with a tendon autograft between January 2011 and December 2018, were included in this retrospective study. At 63.7 ± 28.0 months (24-112), 23 patients with a mean age of 29.7 ± 10.9 years were available for follow-up. The Karlsson Score, the Foot and Ankle Outcome Score (FAOS), the Tegner Activity Scale and the visual analog scale (VAS) for pain were collected at a minimum follow-up of 24 months. RTS and RTW were evaluated by questionnaire. A subgroup analysis with regard to the graft used for ankle ligament reconstruction (GT versus PBT) was performed.

RESULTS

Patients reported a Karlsson score of 82.1 ± 17.5 (37-100), a FAOS score of 87.8 ± 8.4 (73-99), a median Tegner activity scale of 5.0 (IQR 4-6) and a VAS for pain of 0.5 ± 0.9 (0-4) at rest and of 2.0 ± 2.1 (0-7) during activities at final follow-up. Postoperatively, 96% of patients had returned to sports after 8.3 ± 6.2 months. All patients (100%) had returned to work at 3.5 ± 5.7 (0-24) months, with 87% reporting an equal or improved working ability compared to that preoperatively. Postoperatively, exercise hours per week were significantly reduced compared to preoperatively in patients with a split PBT (n = 12; 13.0 ± 12.9 to 5.6 ± 6.4 h, p = 0.038) autograft as opposed to patients with a GT autograft (n = 11; 13.1 ± 8.7 to 12.4 ± 7.1 h, n.s.). No other group differences were observed.

CONCLUSION

Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory.

LEVEL OF EVIDENCE

IV.

Anatomic reconstruction of lateral ankle ligaments: is there an optimal graft option?

PURPOSE

Different graft options are available for the reconstruction of lateral ankle ligaments to treat chronic ankle instability (CAI), which fall in two categories: allografts and autografts. This study aims to provide an updated comparison of the clinical outcomes after stabilisation procedures using allografts and autografts, to correctly advise the clinician during the choice of the best material to be used for the reconstruction of the lateral ligamentous complex of the ankle.

METHODS

A systematic review was performed to analyse the use of autografts and allografts for anatomic reconstruction of the lateral ligamentous complex of the ankle in CAI patients. The presence of a postoperative assessment through outcome measures with proofs of validation in the CAI population or patient's subjective evaluation on the treatment were necessary for inclusion. The quality of the included studies was assessed through the modified Coleman Methodology Score (mCMS). Relevant clinical outcome data were pooled to provide a synthetic description of the results in different groups or after different procedures.

RESULTS

Twenty-nine studies (autograft: 19; allograft: 9; both procedures: 1) accounting for 930 procedures (autograft: 616; allograft: 314) were included. The average mCMS was 55.9 ± 10.5 points. The Karlsson-Peterson scale was the most frequently reported outcome scale, showing a cumulative average post- to preoperative difference of 31.9 points in the autograft group (n = 379, 33.8 months follow-up) and of 35.7 points in the allograft group (n = 227, 25.8 months follow-up). Patient satisfaction was good or excellent in 92.8% of autograft (n = 333, 65.2 months follow-up) and in 92.3% of allograft procedures (n = 153, 25.0 months follow-up). Return to activity after surgery and recurrence of instability were variably reported across the studies with no clear differences between allograft and autograft highlighted by these outcomes.

CONCLUSIONS

The systematic analysis of validated CAI outcome measures and the patient's subjective satisfaction does not support a specific choice between autograft and allograft for the reconstruction of the ankle lateral ligamentous complex in CAI patients. Both types of grafts were associated to a postoperative Karlsson-Peterson score superior to 80 points and to a similar rate of patient's subjective satisfaction.

LEVEL OF EVIDENCE

Level IV.

Lack of Definition of Chronic Ankle Instability With Arthrometer-Assisted Ankle Joint Stress Testing: A Systematic Review of In Vivo Studies

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability.

No tunnel widening following arthroscopic anatomical reconstruction of the lateral ankle ligaments

INTRODUCTION

Arthroscopic anatomical reconstruction of the lateral ankle ligaments is an emerging technique for treating chronic ankle instability. One of the known complications of arthroscopic anterior cruciate ligament reconstruction is tunnel widening; this makes revision more complicated. The aim of this study was to look for tunnel widening in the postoperative course of arthroscopic ankle ligament reconstruction. We hypothesized that significant widening of the bone tunnels is present 1 year after anatomical ankle ligament reconstruction.

MATERIALS AND METHODS

Twenty-one patients who underwent arthroscopic anatomical reconstruction of the lateral ankle ligaments with a gracilis graft were included prospectively. A CT-scan with 1-mm thick slices with multiplanar reconstruction was done 1 year after the surgery. The size and shape of the tunnels was analyzed, and the ratio of the preoperative to postoperative diameter was calculated. Based on this ratio, the tunnels were given a grade as described by Struewer. Tunnel widening was defined as a grade III tunnel, thus a ratio ≥ 1.3. The tunnel shape was classified as described by Peyrache as cone type, cavity type, line type.

RESULTS

None of the tunnels had widened 1 year after arthroscopic anatomical reconstruction of the lateral ankle ligaments. At the fibula, 81% of tunnels were grade I and 19% were grade II; 57% were cone type and 43% were line type. At the talus, 86% of tunnels were grade I and 14% were grade II. All were line type. At the calcaneus, 86% of tunnels were grade I and 14% were grade II; 57% were cone type and 43% were line type.

DISCUSSION

The main finding of this study was the absence of tunnel widening 1 year after arthroscopic reconstruction of the lateral ankle ligaments.

LEVEL OF EVIDENCE

IV; retrospective study.

Lateral Ligament Reconstruction With Hamstring Graft for Ankle Instability: Outcomes for Primary and Revision Cases

BACKGROUND

Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device.

RESULTS

A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (-4.94° vs -7.03°; P = .415).

CONCLUSION

Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

Modified Broström-Gould With Gracilis Autograft Augmentation Surgery and Accelerated Noncasted Rehabilitation in High Demand Patients With Lateral Ankle Instability

Lateral ankle instability that has failed conservative management can be physically debilitating. Good outcomes are obtained from Broström-Gould augmented repair techniques, however there are few studies evaluating the use of a gracilis autograft augmentation coupled with an accelerated rehabilitation program in high functional demand patients. We believe that the modified Broström-Gould technique utilizing a Gracilis autograft will provide significant improvements in stability while maintaining normal ankle biomechanics in young, high demand patients. The prospective cohort study involved 19 patients (20 ankles) who underwent surgery for chronic lateral ankle instability by a single surgeon, at a single institution between October 2014 and April 2016. Patients were followed for 33.8 ± 11.7 (range 12-48) months. Patients were assessed both pre- and postoperatively for talar tilt angle radiographically and with both American Orthopaedic Foot and Ankle Society Ankle and Hindfoot scores and Karlsson-Peterson scores. A Tegner activity score was taken at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score increased from 68.85 ± 10.57 to 91.56 ± 5.31 points (p < .01) and mean Karlsson-Peterson score increased from 50.9 ± 15.53 to 88.11 ± 8.64 points (p value <.01) when compared preoperatively to mean postoperative follow-up of 33.8 months. Tegner activity score was 7.05 ± 0.89 at last follow-up. The technique was found to be effective in treating chronic lateral ankle instability and in combination with an accelerated rehabilitation protocol, patients returned to their premorbid level of activity with improved stability and no significant effect on donor graft site morbidity.

Hamstring autograft and anatomical footprint evaluation for anterior talofibular ligament reconstruction: Cadaveric study

PURPOSE

The aim of the study was to evaluate whether or not there was any incompatibility between two-strand hamstring tendons taken from the same knee and the ATFL and it was the determination of suitable footprint points in the fibula and talus for anatomical ATFL reconstruction.

METHODS

16 fresh frozen cadaver specimens were dissected to gracilis and semitendinosus tendons and the anterior talofibular ligament. The origins, insertions, distances from osseous landmarks of fibular talus of ATFL were determined. The diameters of gracilis, semitendinosus and ATFL were calculated. There was a moderate correlation between body height and the distance between the distal of inferior lateral malleolus and the fibular adhesion site of ATFL (r: 36.5 p: 0.036). There was a weak correlation between body height and the distance between the apex of the lateral talar process and the talus adhesion site of ATFL in a single bundle (r: 28.4 p: 0.002). There was no correlation between the distance from proximal and distal adhesion side of ATFL and body height in the double bundle (p: 0.241).

RESULTS

There was no significant relationship between ATFL diameter and gracilis, semitendinosus and both hamstring in women. A significant relationship at 80.5% was determined between the ATFL and the gracilis diameter in man. A significant relationship at 92.6% was determined between the ATFL and the semitendinosus diameter in man.

CONCLUSION

It was determined that there is not compatibility between the gracilis tendons, the semitendinosus tendon and ATFL in women. It should be supported by biomechanical and clinical studies whether this incompatibility has a clinical effect or not.

A four-step approach improves long-term functional outcomes in patients suffering from chronic ankle instability: a retrospective study with a follow-up of 7-16 years

PURPOSE

The aim of the present study was to assess the long-term outcomes of the treatment of chronic ankle instability (CAI) with a four-step protocol.

METHODS

Fifty-four patients with isolated anterior talo-fibular ligament (ATFL) lesion suffering from CAI who underwent surgical treatment between 2000 and 2009 were assessed. All the patients underwent a four-step protocol including synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Median age at surgery was 31.6 years (18-48). Patients were examined preoperatively and at follow-up. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion (ROM) and manual laxity tests.

RESULTS

AOFAS (preoperative, 64.8; postoperative, 92.4; p < 0.001) and Karlsson-Peterson score (preoperative, 62.5; postoperative, 88.8; p < 0.001) significantly improved after a median 11 years follow-up (7-16 years). Similarly median Tegner activity level significantly increased at follow-up compared to pre-operatory status (6.0 and 4.0 respectively, p < 0.001). Objective examination documented a statistically significant improvement in terms of ankle stability compared to pre-operative manual laxity tests, with negative anterior drawer test observed in 48 (88.9%) patients (p < 0.001). Sagittal ROM was full in 50 patients (92%). Nine patients had subsequent ankle sprains (15.6%), two patients required further surgery, while seven were treated conservatively. No major complications were reported.

CONCLUSION

Satisfying subjective and objective clinical outcomes in selected patients with isolated ATFL lesion suffering from CAI were reported with a treatment protocol including arthroscopic synovectomy, debridement of ATFL remnants, capsular shrinkage, and immobilization. These findings are of clinical relevance because they provide a suitable minimally invasive method for the treatment of mild to moderate ankle instability.

LEVEL OF EVIDENCE

Level IV.

All-inside endoscopic anatomic reconstruction leads to satisfactory functional outcomes in patients with chronic ankle instability

PURPOSE

Ankle sprain is a common injury that can be treated conservatively, though many injured patients do not seek treatment or are not adequately managed, both of which can lead to subsequent chronic ankle instability (CAI). The purpose of this study was to evaluate the functional scores and complication rates of an all-inside anatomic reconstruction technique to treat CAI at a minimum follow-up of 24 months.

METHODS

The authors retrospectively collected the records of 41 patients that underwent all-inside endoscopic anatomic reconstruction of the ATFL and CFL including demographics, complications, satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson score, and ankle activity score (AAS), at a minimum follow-up of 24 months.

RESULTS

The study cohort, comprised 34 patients aged 35.6 ± 10.8 years, were assessed at 48.7 ± 19.0 months. AOFAS scores improved from 60.3 ± 11.9 to 94.3 ± 6.2 postoperatively. Karlsson scores improved from 49.0 ± 10.9 to 87.2 ± 10.1 postoperatively. Thirty-three (97%) patients returned to the same AAS (5.6 ± 3.1) and rated their overall satisfaction ≥ 7. One patient (3%) was reoperated to treat a hematoma, while five patients (15%) were reoperated to remove the cortical fixation device that caused discomfort.

CONCLUSION

The novel all-inside endoscopic technique for anatomic reconstruction of the ATFL and CFL grants satisfactory functional outcomes at a minimum of 24 months, and the improvements in AOFAS and Karlsson scores compared favourably to those reported for other techniques in the literature.

LEVEL OF EVIDENCE

IV.

The Location of the Fibular Tunnel for Anatomically Accurate Reconstruction of the Lateral Ankle Ligament: A Cadaveric Study

We aimed to describe the location of fibular footprint of each anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), as well as their common origin in relation to bony landmarks of the fibula in order to determine the location of the fibular tunnel. In 105 ankle specimens, the center of the footprints of the ATFL and CFL (cATFL and cCFL, respectively) and the intersection point of their origin (intATFL-CFL) were investigated, and the distances from selected bony landmarks (the articular tip (AT) and the inferior tip (IT) of the fibula) were measured. Forty-two (40%) specimens had single-bundle ATFL, and 63 (60%) had double-bundle patterns. The distance between intATFL-CFL and IT was 12.0 ± 2.5 mm, and a significant difference was observed between the two groups (p = 0.001). Moreover, the ratio of the intATFL-CFL location based on the anterior fibular border for all cadavers was 0.386. The present study suggests a reference ratio that can help surgeons locate the fibular tunnel for a more anatomically accurate reconstruction of the lateral ankle ligament. Also, it may be necessary to make a difference in the location of the fibular tunnel according to the number of ATFL bundles during surgery.

Clinical Outcomes and Return to Sport After Minimally Invasive Reconstruction of the Lateral Ligament Complex with Semitendinosus Tendon Autograft in Chronic Lateral Ankle Instability

BACKGROUND

Ankle sprains are common, affecting especially the lateral ligament complex of the ankle, often leading to chronic symptoms and instability. Many procedures have been described for chronic ankle instability. This study analyzes clinical outcomes and return to sport in patients who underwent minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus tendon autograft.

METHODS

Twenty-three patients (mean age, 33.9 years) with grade 3 lesions of both the anterior talofibular and calcaneofibular ligaments underwent minimally invasive reconstruction of the anterior talofibular and calcaneofibular ligaments with an ipsilateral semitendinosus tendon autograft. They were retrospectively reviewed, and return to sport was evaluated with the Halasi ankle activity scale.

RESULTS

Mean follow-up was 30 months (range, 26-53 months). The mean American Orthopaedic Foot and Ankle Society score increased from 68.6 to 95.3. The average visual analog scale score decreased from 3.6 to 1.3. The Halasi score changed from 5.0 to 5.1. Except for the Halasi score, the differences were significant (P < .001). Nineteen patients judged the received treatment as excellent, 2 as good. No revision procedures were performed. No major complications were reported.

CONCLUSIONS

This study confirms good clinical and sport outcomes after minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus autograft.

Recognition of Failure Modes of Lateral Ankle Ligament Reconstruction: Revision and Salvage Options

Primary lateral ankle ligament reconstruction has a high success rate, but failures may lead to recurrent instability. In patients with recurrent lateral ankle instability, it is important to determine the mode of failure. Underlying cavovarus deformity and joint hypermobility must be identified and addressed at the time of revision surgical stabilization. The modified Brostrom-Gould procedure is typically performed for primary lateral ankle ligament reconstruction, but it may be used in revision stabilization procedures utilizing suture-tape augmentation. Revision lateral ankle stabilization surgery can also be addressed with anatomic allograft reconstruction of the ATFL and CFL, and is the authors'preferred technique.

Autograft versus allograft tenodesis for chronic ankle instability: a single-center retrospective comparative study

Aim: To compare the outcomes of patients who underwent autograft tenodesis with those who underwent allograft tenodesis for the treatment of chronic mechanical ankle instability. Patients & methods: Ten patients who underwent allograft lateral tenodesis were compared with 15 patients who underwent lateral tenodesis using a split peroneus brevis tendon. Patients were followed up after an average time of 10.5 years. Results: No statistically significant differences concerning American Orthopaedic Foot and Ankle Society and Karlsson-Peterson scores were reported (p = n.s.). A reduced average radiographic anterior talar translation was observed in the autograft group compared with the allograft group (1.4 and 4.0 mm respectively, p < 0.001). Conclusion: Both surgical techniques significantly improved subjective and objective outcomes in patients suffering from chronic ankle instability compared with pre-operatory status. Autograft stabilization provided reduced post-operative anterior talar translation compared with allograft tenodesis.

Biomechanics of Ankle Ligament Reconstruction: A Cadaveric Study to Compare Stability of Reconstruction Techniques Using 1 or 2 Fibular Tunnels

Background

Anatomic lateral ankle ligament reconstruction has been proposed for patients with chronic ankle instability. A reliable approach is a reconstruction technique using an allograft and 2 fibular tunnels. A recently introduced approach that entails 1-fibular tunnel reconstruction might reduce the risk of intraoperative complications and ultimately improve patient outcome.

Hypothesis

We hypothesized that both reconstruction techniques show similar ankle stability (joint laxity and stiffness) and are similar to the intact joint condition.

Study Design

Controlled laboratory study.

Methods

A total of 10 Thiel-conserved cadaveric ankles were divided into 2 groups and tested in 3 stages-intact, transected, and reconstructed lateral ankle ligaments-using either the 1- or the 2-fibular tunnel technique. To quantify stability in each stage, anterior drawer and talar tilt tests were performed in 0°, 10°, and 20° of plantarflexion (anterior drawer test) or dorsiflexion (talar tilt test). Bone displacements were measured using motion capture, from which laxity and stiffness were calculated together with applied forces. Finally, reconstructed ligaments were tested to failure in neutral position with a maximal applicable torque in inversion. A mixed linear model was used to describe and compare the outcomes.

Results

When ankle stability of intact and reconstructed ligaments was compared, no significant difference was found between reconstruction techniques for any flexion angle. Also, no significant difference was found when the maximal applicable torque of the 1-tunnel technique (9.1 ± 4.4 N·m) was compared with the 2-tunnel technique (8.9 ± 4.8 N·m).

Conclusion

Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach.

Clinical Relevance

Demonstrating similar stability in a cadaveric study and given the potential to reduce intraoperative complications, the 1-fibular tunnel approach should be considered a viable option for the surgical therapy of chronic ankle instability. Clinical randomized prospective trials are needed to determine the clinical outcome of the 1-tunnel approach.

Ligament stabilization improved clinical and radiographic outcomes for individuals with chronic ankle instability and medial ankle osteoarthritis

PURPOSE

Chronic ankle instability with a long symptom duration is often accompanied by medial compartment ankle osteoarthritis (OA). However, the outcomes of individuals after ligament stabilization have rarely been reported. The radiographic and clinical outcomes after ligament stabilization in individuals with chronic ankle instability and medial compartment OA were investigated.

METHODS

The study investigated 27 ankles with chronic ankle instability and medial compartment OA that underwent lateral ankle ligament reconstruction from 2007 to 2015 with a follow-up period of at least 1 year. Ligament stabilization was performed via either the modified Broström procedure (MBP) or lateral ankle reconstruction (LAR) using semitendinosus tendon allografts.

RESULTS

The median instability duration was 60 (range 12-480) months, and the median follow-up period was 39 (range 12-108) months. The preoperative Takakura ankle OA stage was predominantly stage I (20 patients (74.1%)), followed by stage II (five patients (18.5%)). Ankle MRI (20 ankles) revealed medial cartilage denudation in three cases (15%), cartilage thinning in nine cases (45%), osteophyte formation in ten cases (50%), and loose body formation in six cases (30%). According to the arthroscopic results, the modified Outerbridge grade was two in nine cases and four in ten cases, so these grades were the most common (37.5% and 41.7%, respectively). The MBP was performed in 14 patients, and LAR was performed in 13 patients (52% and 48%, respectively); the bone marrow stimulation procedure was performed in 15 patients (55%). The visual analogue scale score decreased from 6.0 (SD 1.6) preoperatively to 1.8 (SD 1.6) postoperatively (p = 0.000). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 61.9 (SD 14.2) to 89.7 (SD 6.2), and the Karlsson-Peterson score improved from 54.7 (SD 13.9) to 88.3 (SD 9.0) (p = 0.000). There were no serious complications, and all patients were satisfied.

CONCLUSIONS

Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement.

LEVEL OF EVIDENCE

IV.

Anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up

PURPOSE

The aim of this study was to compare long-term outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) repair and reconstruction at 5-10 years after surgery.

METHODS

Forty-five patients who underwent surgical repair or reconstruction of both ATFL and CFL were retrospectively investigated in this study. American Orthopedic Foot and Ankle Society (AOFAS), Karlsson Score, and Tegner activity scale were used to evaluate the ankle function at a follow-up of 5-10 years. Ultrasound examination was used to evaluate the ATFL and CFL, and MRI was used to evaluate the cartilage.

RESULTS

At final follow-up, no patient had recurrent ankle instability. There were no significant differences in AOFAS (92.6 ± 6.5 vs 89.6 ± 3.4; n.s.) or Karlsson Score (93 ± 8.2 vs 90.6 ± 5.0; n.s.) between the reconstruction group (twenty patients) and the repair group (twenty-five patients) postoperatively. There were also no significant differences in activity level as measured by the Tegner activity score (6 (range 4 to 8) vs 6 (range 5 to 7); n.s.). Five patients in the reconstruction group complained of some tightness of the ankles. Ultrasound showed the reconstructed ligaments maintained good continuity and were thicker than the repaired ligaments.

CONCLUSION

Patients in both the repair and the reconstruction cohort had high patient satisfaction with the outcomes and high function and activity levels that indicated recreational sports participation over a long period.

LEVEL OF EVIDENCE

III.

[Lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability]

OBJECTIVE

To assess the effectiveness of lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability.

METHODS

Between September 2014 and November 2018, 32 patients (32 sides) with chronic lateral ankle instability were treated with lateral ankle ligament reconstruction by using autogenous anterior half of the peroneus longus tendon. There were 25 males and 7 females, with an average age of 28.5 years (range, 20-51 years). The disease duration was 6-41 months (mean, 8.9 months). The preoperative Karlsson-Peterson ankle score was 53.7±9.7. The talar tilt angle was (14.9±3.7)°, and the anterior talar translation was (8.2±2.8) mm. Six patients combined with osteochondral lesion of talus and 4 patients combined with bony impingement.

RESULTS

All incisions healed by first intention postoperatively. All patients were followed up 12-53 months (mean, 22.7 months). At last follow-up, the Karlsson-Peterson ankle score was 85.2±9.6; the talar tilt angle was (4.3±1.4)°; the anterior talar translation was (3.5±1.1) mm. There were significant differences in all indexes between pre- and post-operation ( P<0.05). Seventeen patients were very satisfied with the results, 10 patients were satisfied, 4 patients were normal, and 1 patient was unsatisfied. After operation, the ankle sprain occurred in 7 cases, the tenderness around the compression screws at calcaneus in 5 cases, the anterolateral pain of ankle joint over 6 months in 4 cases. No patient had discomfort around the reciepient sites. At last follow-up, the ultrasonography examination showed that there was no significant difference in the density and diameter between bilateral peroneus longus tendons in 12 cases.

CONCLUSION

For chronic lateral ankle instability, the lateral ankle ligament reconstruction with the autogenous partial peroneus longus tendon is a safe and effective surgical option.

Outcomes After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for Chronic Ankle Instability: A Systematic Review and Meta-analysis

The purpose of this study was to systematically review the current evidence in the literature to ascertain whether the anatomic ankle ligament reconstruction procedure with allograft resulted in improved patient outcomes after ≥2 years of follow-up. A literature search of Medline, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Clinical studies investigating anatomic lateral ankle ligament reconstruction procedures for chronic ankle instability with a mean of >2 years' follow-up were included. Means were calculated for population size, age, follow-up duration, and postoperative Tegner scores. Pooled estimates were calculated for postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion, return to sports, risk of postoperative instability, and complications. Six clinical trials with 153 patients were included. The pooled estimated mean for the postoperative AOFAS score was 89.4 points (95% confidence interval [CI], 86.0 to 92.9; I² = 88.7%). The pooled proportion of patients who returned to sports after surgery was 80% (95% CI 57.0% to 100%; I² = 88.7%). The pooled total risk of recurrent instability after surgery was 6% (95% CI 1% to 12%; I² = 0%). No rejection was reported. Anatomic lateral ankle ligament reconstruction procedure results in significant improvements in patient function and outcome scores, with low rates of recurrent instability.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment.

METHODS

Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018.

RESULTS

One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies.

CONCLUSIONS

There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data.

LEVEL OF EVIDENCE

Level IV, review of level I, II, III and IV studies.

Lateral ankle ligament anatomic reconstruction for chronic ankle instability: Allograft or autograft? A systematic review

BACKGROUND

To investigate if there is any evidence in favour of autograft or allograft use for anatomic reconstruction of lateral ankle ligaments in patients with symptomatic chronic ankle instability.

METHODS

A literature search was performed in PubMed MEDLINE, Cochrane Library, EMBASE and Google Scholar databases, over the years 1994-2017, to identify the studies presenting clinical results of anatomic lateral ankle ligaments reconstruction using various combinations of the keywords "lateral ankle ligaments reconstruction", "anatomic reconstruction", "chronic ankle instability", "allograft", "autograft". The surgical procedure was considered anatomic if consistent with the description of lateral ankle ligaments made by Burks and Morgan in 1994.

RESULTS

Among the 89 papers matching the search terms, only 12 could be included in which 357 anatomic lateral ankle ligaments reconstructions were performed. One was a comparative case series (level of evidence III - LOE III) while other papers were retrospective case series (LOE IV), the mean Modified Coleman Methodology Score (MCMS) was fair: 56.7 (SD±5.2). Due to the low level of evidence of the available literature only a qualitative analysis was performed. The limited evidence from the studies analysed suggests that there is no difference in graft survivorship, graft-dependent variables, patient's satisfaction, clinical outcome measures and radiographic results between allograft and autograft.

CONCLUSIONS

Given the low number of studies, their poor methodology score and their low level of evidence it is not possible to determine if allograft is better or safer than autograft.

LEVEL OF EVIDENCE

Level IV, review paper of level III and level IV studies.

Absence of ATFL remnant does not affect the clinical outcomes of the modified broström operation for chronic ankle instability

PURPOSE

The modified Broström operation for chronic ankle instability has demonstrated good clinical results. Absence of ligamentous tissue is a risk factor for recurrence of ankle instability after surgery. This study evaluated the effect of quality of ligament tissue (anterior talofibular ligament, ATFL) on prognosis, in a cohort of patients with chronic ankle instability after the modified Broström operation.

METHODS

This was a retrospective case series. Overall, 60 patients underwent the modified Broström operation for chronic ankle instability (mean follow-up, 30.1 [range, 24-47] months). Presence of ATFL remnant was assessed on ultrasound, magnetic resonance imaging, and arthroscopy in all patients. Foot and ankle outcome score (FAOS) was used to evaluate functional outcomes. Clinical outcomes were compared by the condition of the ligament remnant. Association with other risk factors was evaluated using multiple linear regression analysis.

RESULTS

ATFL was visible in 51/60 cases on ultrasound. Thirty, 22, and eight patients had thin or absent; normal thickness; and thick ATFL on magnetic resonance imaging, respectively. ATFL was visible in 15 patients on arthroscopy and nonvisible or not clear in 45. No significant differences occurred in FAOS with the presence of ATFL remnant on ultrasound, arthroscopy, and the grade of ATFL thickness on magnetic resonance imaging. No correlation was found between FAOS and the thickness of ATFL.

CONCLUSION

The results suggest that the modified Broström operation for patients with chronic ankle instability was good, regardless of the presence or absence of ATFL remnant.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Lateral ligament reconstruction and augmented direct anatomical repair restore ligament laxity in patients suffering from chronic ankle instability up to 15 years from surgery

PURPOSE

The purpose of the present study was to compare the outcomes of patients who underwent augmented direct anatomical repair using a Broström-Gould procedure with those who underwent lateral ligament reconstruction using a split peroneus brevis tendon for the treatment of chronic ankle instability.

METHODS

Forty patients aged 18-40 years underwent surgical treatment for chronic lateral ankle instability between 1997 and 1998: 20 patients underwent direct anatomical repair using Broström-Gould procedure (Group A); 20 patients underwent lateral tenodesis using a split peroneus brevis tendon (Group B). Median age at surgery was 22.6 years (range 18-40). Patients were assessed pre-operatively and 15 years after surgery with functional assessment including AOFAS scale, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending ROM, anterior drawer sign and talar tilt test. Telos Stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

No major complications were reported. Mean overall AOFAS, Karlsson-Peterson and Tegner scores significantly increased at follow-up compared to pre-operatory status, although no statistically significant differences concerning these variables were reported between the two groups. Sagittal ROM was full in 36 patients: 4 subjects in the Group B experienced 5 degrees dorsiflexion limitation compared to the contralateral side. Patients treated with lateral tenodesis reported a statistically significant reduction in the values of radiographic anterior talar translation (1.4 mm, SD: 0.9) compared to patients in Group A (5.7 mm, SD: 1.1, p < 0.001).

CONCLUSION

Augmented direct anatomical repair and lateral tenodesis provide satisfying long-term outcomes in terms of subjective and objective parameters up to 15 years from surgery in patients with chronic ankle instability without leading to significant artrhitic changes. Objectively, lateral tenodesis appears to improve more effectively restoration of laxity; the reduced ROM reported in 20% of patients did not considerably affect the overall functional outcome.

LEVEL OF EVIDENCE

Comparative case series, Level III.

Anatomic reconstruction of anterior talofibular ligament with tibial tuberosity-patellar tendon autograft for chronic lateral ankle instability

INTRODUCTION

Anatomic repair of the anterior talofibular ligament (ATFL) is challenging when the local ligamentous tissue is severely attenuated. Anatomic reconstruction of the ATFL with tibial tuberosity-patellar tendon (TT-PT) autograft is a feasible choice that can avoid the complicated tendon-bone healing and restore ankle stability.

MATERIALS AND METHODS

From 2009 to 2015, 31 chronic lateral ankle instability (CLAI) patients (31 ankles), who had a serious injury on the ATFL only, were treated with anatomic reconstruction of ATFL with TT-PT. American orthopedic foot and ankle society ankle-hindfoot score (AHS), visual analog scale for pain score (VAS), Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion were used to evaluate the clinical outcomes before and after operation. Radiographically, talar tilt angles and anterior drawer were assessed in pre- and postoperative ankle stress views.

RESULTS

Among the 31 ankles, 17 ankles with single-bundle ATFL and 14 ankles with double-bundle ATFL were found at operation. At a mean follow-up of 42 months (24-82 months), all patients were satisfied with the procedure. Mean AHS significantly increased from 60.5 ± 8.2 to 93.5 ± 4.8. Mean Karlsson-Peterson score significantly increased from 55.2 ± 11.0 preoperatively to 91.2 ± 6.9 at final follow-up. Average VAS significantly decreased from 5.9 ± 1.6 preoperatively to 1.4 ± 1.0 at the latest follow-up. Mean Tegner activity level was 3.7 ± 0.9 before operation, compared with 7.0 ± 0.8 after operation. On stress radiographs, mean talar tilt angle was 17.0 ± 3.4° before operation and 3.8 ± 2.1° at the latest follow-up. In addition, mean anterior tibiotalar translation was 7.5 ± 2.2 mm before operation and 1.8 ± 1.1 mm at the latest follow-up.

CONCLUSION

Anatomic reconstruction of the ATFL using a TT-PT autograft allows bone-bone healing in talus and tendon-tendon/periosteum healing in fibula rather than requiring tendon-bone healing, which is an alternative choice for treating CLAI caused by single ATFL insufficiency.

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.

Currently used imaging options cannot accurately predict subtalar joint instability

PURPOSE

To give a systematic overview of current diagnostic imaging options and surgical treatment for chronic subtalar joint instability.

METHODS

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, and SpringerLink. Twenty-three imaging studies and 19 outcome studies were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the methodologic quality of the imaging articles, while the modified Coleman Score was used to assess the methodologic quality of the outcome studies.

RESULTS

Conventional radiographs were most frequently used to assess chronic subtalar joint instability. Talar tilt, anterior talar translation, and subtalar tilt were the three most commonly used measurement methods. Surgery often included calcaneofibular ligament reconstruction.

CONCLUSION

Current imaging options do not reliably predict subtalar joint instability. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. Recognition of subtalar joint instability as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases

INTRODUCTION

Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results.

HYPOTHESIS

We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately.

MATERIALS AND METHODS

Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs.

RESULTS

The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability.

DISCUSSION

Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination.

LEVEL OF EVIDENCE

IV, Case-series.

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.

Differences Between Subtalar Instability and Lateral Ankle Instability Focusing on Subtalar Ligaments Based on Three Dimensional Isotropic Magnetic Resonance Imaging

OBJECTIVE

The purpose of this study was to assess the differences between subtalar instability (STI) and lateral ankle instability (LAI) focusing on subtalar ligaments using 3-dimensional (3D) isotropic magnetic resonance imaging (MRI).

METHODS

Preoperative MRIs of 10 patients with STI who failed nonoperative treatment and consequently underwent arthroscopic subtalar reconstruction were compared with preoperative MRIs of 23 patients with LAI who underwent ligament repair or reconstruction. Dimensions of anterior capsular ligament (ACL), interosseous talocalcaneal ligament (ITCL), calcaneofibular ligament (CFL), and anterior talofibular ligament (ATFL) were measured. Tears of ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed.

RESULTS

Patients with subtalar instability had significantly lower ACL thickness and width than patients with LAI (thickness: 1.48 vs 2.12 mm, P = 0.045; width: 7.30 vs 8.64 mm, P = 0.029). An ACL thickness of 1.8 mm or less had sensitivity and specificity both at 75.0%, and an ACL width of 8 mm or less had sensitivity of 75.0% and specificity of 85.0% for discriminating STI from LAI. Absence or complete tear of ACL was more frequent in patients with STI than in patients with LAI (60.0% vs 13.0%, P = 0.010). The ATFL thickness was significantly greater in patients with LAI (P = 0.001). Complete tear of ATFL was more common in patients with LAI (P = 0.008). Complete tear of CFL was common in both the STI and LAI groups without significant difference (20.0% vs 21.7%). There was no significant difference in thickness and width of ITCL and in CFL thickness. Complete tear of ITCL, cervical ligament, and inferior extensor retinaculum were rare without significant difference.

CONCLUSION

In patients with STI, the ACL is thin and narrow and more commonly absent or torn compared with patients with LAI. Complete tear of ATFL was more common in patients with LAI. Complete tear of CFL was commonly encountered in both the STI and LAI groups.

Lateral Ligament Reconstruction for Ball-and-Socket Ankle Accompanying Lateral Ankle Instability: A Case Report and Literature Review

The ball-and-socket ankle joint is a rare deformity characterized by the loss of concavity in the trochlear surface of the talus with rounding of the articular surfaces of the distal fibula and tibia. Frequently, tarsal coalitions, fibular hypoplasia, and shortening of the limb accompany this deformity. To date, no data have been reported on surgical treatment of lateral ankle joint instability and peroneal tendon dislocation concomitant with a ball-and-socket ankle joint. In the present study, we report the case of a 43-year-old male patient with right lateral ankle joint instability and peroneal tendon dislocation in a ball-and-socket ankle joint, with accompanying tarsal coalition. This was surgically treated by lateral ankle joint ligament reconstruction and tenodesis.

Fracture Through a Distal Fibular Tunnel Used for an Anatomic Lateral Ankle Ligament Reconstruction

Anatomic lateral ankle ligament reconstruction using free tendon graft with osseous tunnels has become a popular technique for revision reconstruction of the lateral ankle ligaments. With the procedure’s burgeoning popularity, an accompanying increase in postoperative complications is likely to occur. We report on one such complication: traumatic distal fibula fracture through the transosseous tunnels.

The effect of smoking on the outcomes of lateral ankle ligament reconstruction

BACKGROUND

Although smoking is known to be harmful to the musculoskeletal system, no studies have investigated its effects on the outcomes of ankle ligament surgery. We determined the effects of smoking on the clinical and radiological outcomes of lateral ankle ligament reconstruction using tendon allografts according to smoking status.

METHODS

From among 105 patients with chronic ankle instability who were treated with anatomical reconstruction of the anterior talofibular ligament and the calcaneofibular ligament using semitendinosus tendon allografts and bio-tenodesis screws, 70 ankles, from 23 smokers and 47 non-smokers, were analyzed. Visual analog scale (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, Karlsson scores and complications were routinely determined at each follow-up visit. Anterior translation and the talar tilt angle on radiographic stress views were also assessed.

RESULTS

The mean follow-up period was 21.8 months (12-68 months). No significant differences were observed between the two groups with respect to age, gender, body mass index, or the duration of preoperative symptoms. The mean preoperative pain VAS scores were 5.8 and 5.3 among non-smokers and smokers, respectively. Postoperatively, the mean pain VAS score improved to 1.4 in both groups (p < 0.001). Clinical and radiographic measures did not show significant changes according to the presence of smoking after surgery. However, two wound complications, 1 delayed healing and 1 superficial necrosis, occurred in non-smokers, whereas five, 2 delayed healing, 2 superficial infections and 1 superficial necrosis in smokers (p = 0.035).

CONCLUSION

The radiographic outcomes of smokers were comparable to those of non-smokers in the short term, whereas wound complications were more common in the smoker group.

A new minimally invasive method for anatomic reconstruction of the lateral ankle ligaments with a Tightrope system

BACKGROUND

Several minimally invasive anatomic reconstruction techniques of the lateral ligaments have been introduced for the treatment of chronic lateral ankle instability. However, these strategies may not always follow accurate ligament anatomic attachments, especially in the construction of the fibular bone tunnels.

OBJECTIVES

This study reported a new percutaneous technique for reconstruction of the ligaments of lateral ankle anatomically with a Tightrope system.

METHODS

From April 2016 to August 2016, 25 ankles of 24 patients with chronic ankle instability underwent our new percutaneous anatomic reconstruction of the lateral ligaments with a Tightrope system. The operation was performed through several small incisions. The fibular tunnel was made obliquely from the anteromedial side of lateral malleolus tip towards retro-malleolar cortex. The graft was fixed in the tunnel with the help of a Tightrope system. The calcaneal tunnel and talar tunnel were made as our previous method. The mean final follow-up was 12.2 months (range 10-14). Visual Analogue Scale for pain, American Orthopaedic Foot and Ankle Society score, and patients' subjective satisfaction were used to measure clinical outcomes. Preoperative and postoperative stress tests were performed and radiographic parameters were measured.

RESULTS

The Visual Analogue Scale decreased from 3.0 ± 1.4 to 1.3 ± 0.8 at the last follow-up (p < 0.01). The American Orthopaedic Foot and Ankle Society score was improved from 70.2 ± 5.4 preoperatively to 92.4 ± 5.3 at the final follow-up (p < 0.01). Radiologically, the mean anterior talar displacement was 13.1 ± 2.7 mm preoperatively versus 5.6 ± 1.3 mm at last follow-up (p < 0.01),and the mean varus talar tilt angle was 15.0° ± 2.4° preoperatively versus 5.6° ± 1.9° at the last follow-up (p < 0.01). Patients were satisfied ('excellent' or 'good') in 23 ankles (92%). Two patients reported residual instability but less apprehension than the preoperative condition.

CONCLUSIONS

Percutaneous anatomic reconstruction of the lateral ligaments of the ankle with a Tightrope system is an anatomic and effective procedure for the treatment of chronic lateral ankle instability.

Modified Broström Procedure Using Distal Fibular Periosteal Flap Augmentation vs Anatomic Reconstruction Using a Free Tendon Allograft in Patients Who Are Not Candidates for Standard Repair

BACKGROUND

The modified Broström procedure (MBP) is widely accepted as the primary operative treatment for chronic lateral ankle instability (CLAI). However, the MBP does not produce good clinical results in all patients, and anatomic reconstruction using a free tendon graft may be considered in those patients. The purpose of this study was to evaluate the efficacy of the MBP using distal fibular periosteal flap augmentation for CLAI in patients who were not candidates for standard repair.

METHODS

Thirty-eight patients (39 ankles) who underwent surgery for CLAI were retrospectively analyzed. The patients were divided into 2 groups: an anatomic lateral ligament reconstruction group (reconstruction group) consisting of 17 ankles and an MBP group using distal fibular periosteal flap augmentation (augmentation group) consisting of 22 ankles. Preoperative and postoperative clinical evaluations were performed using the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS), and Karlsson-Peterson (Karlsson) scores.

RESULTS

The mean VAS, AOFAS, and Karlsson scores significantly improved from 4.0 to 1.8, 54.7 to 92.9, and 46.4 to 92.7, respectively, in the reconstruction group ( P < .001, P < .001, P < .001), and from 4.1 to 1.5, 60.1 to 94.9, and 52.6 to 94.1, respectively, in the augmentation group ( P < .001, P < .001, P < .001). There were no significant differences in the mean postoperative AOFAS and Karlsson scores between the groups ( P = .214, P = .299).

CONCLUSION

The MBP using distal fibular periosteal flap augmentation was also an effective option for CLAI in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity.

LEVEL OF EVIDENCE

Level III, comparative series.

CT and MR Imaging of the Postoperative Ankle and Foot

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ^©RSNA, 2016.

Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure

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.

Use of three-dimensional finite element models of the lateral ankle ligaments to evaluate three surgical techniques

Objective To compare three surgical techniques for lateral ankle ligament reconstruction using finite element (FE) models. Methods A three-dimensional FE model of the left foot of a healthy volunteer and lateral collateral ligament injury models were developed. Three tendons [one-half of the autologous peroneus longus tendon (PLT), one-half of the peroneus brevis tendon (PBT), and an allogeneic tendon] were used for lateral collateral ligament reconstruction. The ankle varus stress and anterior drawer tests were performed to compare the three surgical techniques. Results The ankle varus stress test showed that the equivalent stresses of the anterior talofibular ligament (ATFL) (84.00 MPa) and calcaneofibular ligament (CFL) (27.01 MPa) were lower in allogeneic tendon reconstruction than in the other two techniques but similar to those of normal individuals (138.48 and 25.90 MPa, respectively). The anterior drawer test showed that the equivalent stresses of the ATFL and CFL in autologous PLT reconstruction (31.31 and 28.60 MPa, respectively) and PBT reconstruction (31.47 and 29.07 MPa, respectively) were lower than those in allogeneic tendon reconstruction (57.32 and 52.20 MPa, respectively). Conclusions The allogeneic tendon reconstruction outcome was similar to normal individuals. Allogeneic tendon reconstruction may be superior for lateral ankle ligament reconstruction without considering its complications.

Anthropometric and Skeletal Parameters Predict 2-Strand Semitendinosus Tendon Size in Double-Bundle Anterior Cruciate Ligament Reconstruction

Background:

Few studies have examined whether skeletal parameters predict hamstring graft size during anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis:

The purpose of this study was to examine whether preoperative anthropometric and radiographic skeletal parameters could predict hamstring graft size during ACLR. We hypothesized that both anthropometric and skeletal parameters can be used to predict graft size in our double-bundle procedure and that the use of skeletal parameters will improve the accuracy of graft size prediction.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 200 patients were recruited and underwent double-bundle ACLR using a semitendinosus (ST) graft. The harvested tendon was measured to determine graft length (GL) and then split at its midpoint. The graft diameters of the anteromedial (GD_AM) and posterolateral bundles (GD_PL) were measured at the femoral aspect of the 2-stranded graft. The mean diameters of both bundles were included in the analysis. On the coronal radiograph, femorotibial angle (FTA), femoral interepicondylar distance (IED), and tibial plateau width (coronal tibial width [CTW]) were measured. Blumensaat line length (BLL) and the lateral tibial width (LTW) were measured on the lateral radiograph. A linear regression analysis was conducted using graft size as the dependent variable and age, sex, height, weight, Tegner activity score, and skeletal parameters as the independent variables.

Results:

Mean GL was 258.9 ± 21.9 mm, GD_AM was 5.9 ± 0.5 mm, and GD_PL was 5.7 ± 0.6 mm. Single regression analysis showed that GL was significantly predicted by sex, height, weight, Tegner activity score, IED, CTW, BLL, and LTW (R² range, 0.033-0.342). GD was predicted by sex, height, weight, IED, CTW, BLL, and LTW (R² range, 0.094-0.207). Stepwise multiple linear regression analysis significantly confirmed sex, height, and age as the variables to comprehensively predict GL (R² = 0.384). With regard to GD, stepwise multiple regression confirmed height and IED as significant variables (R² = 0.224).

Conclusion:

Both preoperative anthropometric and radiographic parameters on plain radiographs were able to predict harvested GL and 2-strand GD. Multivariate regression slightly improved the prediction of graft dimensions compared with univariate regression.

Magnetic Resonance Imaging and Stress Radiography in Chronic Lateral Ankle Instability

BACKGROUND

Studies regarding magnetic resonance imaging (MRI) findings of the lateral ankle ligaments in chronic lateral ankle instability and their clinical relevance for surgery are lacking. This study classified the lateral ankle ligament MRI findings of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in chronic lateral ankle instability (CLAI) and correlated these findings with ankle stress radiographs.

METHODS

We included 132 ankles with CLAI that underwent ligament reconstructions from 2006 to 2013. The distributions of the ATFL and CFL morphologies were evaluated using the following categories: (1) the amount of thickness: normal/thickened/attenuated/non-visualized, (2) the presence of discontinuity, (3) wavy or irregular contour, and (4) increased signal intensity on T2-weighted images. The relationships between the ligament morphologies and stress radiographs were analyzed.

RESULTS

The ATFL was normal in 5 (4%) ankles, thickened in 35 (27%), attenuated in 76 (58%), and non-visualized in 16 (12%), while the CFL was normal in 39 (30%) ankles, thickened in 42 (32%), attenuated in 44 (33%), and non-visualized in 7 (5%). Discontinuity of the ATFL or CFL was observed in 46 (35%) ankles. Wavy or irregular contours were observed in 55 (42%) ATFLs and 37 (28%) CFLs, and signal intensity of both ligaments was increased in 19 (14%) ankles. ATFL ( P < .001) and CFL thickness ( P = .007) correlated with the talar tilt angle.

CONCLUSIONS

The MRI findings of CLAI showed several morphologies and specific incidences for each morphology. Attenuated, wavy appearance was the most frequent MRI pattern. Thickness was related to the degree of instability.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Outcomes of the Modified Broström Procedure Augmented With Suture-Tape for Ankle Instability in Patients With Generalized Ligamentous Laxity

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.

Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft

BACKGROUND

The anterior half of the peroneus longus tendon (AHPLT) has been reported to be an effective autograft for ligament reconstruction with respect to strength and safety. However, there is little information regarding donor site morbidity after harvesting the AHPLT. Furthermore, to the best of our knowledge, there has not been a study on the isokinetic evaluation of ankle plantar flexion and eversion after AHPLT harvesting.

PURPOSE

To evaluate the clinical and radiographic results after lateral ankle ligament reconstruction using the AHPLT. We further investigated whether harvesting the AHPLT for lateral ankle ligament reconstruction decreases the strength of ankle plantar flexion and eversion.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty consecutive patients (31 cases) were treated by anatomic lateral ligament reconstruction using the AHPLT. For the clinical assessment, visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson-Peterson scores were evaluated preoperatively and at the last follow-up. For the radiographic assessment, talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up. The peak isokinetic torques for ankle plantar flexion at angular velocities of 30 and 120 deg/s and eversion at angular velocities of 30 and 60 deg/s were measured at a minimum of 1 year after surgery.

RESULTS

The mean VAS score improved significantly from 6.4 ± 1.7 preoperatively to 1.6 ± 1.5 at the last follow-up ( P < .001). The mean respective AOFAS and Karlsson-Peterson scores improved significantly from 57.2 ± 12.8 and 66.9 ± 13.6 preoperatively to 89.0 ± 10.0 and 93.3 ± 5.7 at the last follow-up ( P < .001). The mean talar tilt angle improved significantly from 15.3° ± 6.2° preoperatively to 3.4° ± 3.0° at the last follow-up ( P < .001), and the mean anterior talar displacement improved significantly from 10.2 ± 3.3 mm preoperatively to 6.3 ± 1.9 mm at the last follow-up ( P < .001). No significant differences were observed between the uninvolved and involved legs in the mean peak torque for plantar flexion at angular speeds of 30 deg/s ( P = .517) and 120 deg/s ( P = .347) or for eversion at angular speeds of 30 deg/s ( P = .913) and 60 deg/s ( P = .983).

CONCLUSION

Anatomic lateral ligament reconstruction using the AHPLT showed good clinical and radiographic results without a significant decrease in the peroneus longus strength. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability.

Endoscopic Ankle Lateral Ligament Graft Anatomic Reconstruction

Chronic instability is a common complication of lateral ankle sprains. If nonoperative treatment fails, a surgical repair or reconstruction may be indicated. Today, endoscopic techniques to treat ankle instability are becoming more popular. This article describes an endoscopic technique, using a step-by-step approach, to reconstruct the ATFL and CFL with a gracilis graft. The endoscopic technique is reproducible and safe with regard to the surrounding anatomic structures. Short and midterm results confirm the benefits of this technique.