Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon

Anterior Talofibular Ligament Repair in Combination With Anterior Tibiofibular Ligament Distal Fascicle Transfer for The Treatment of Chronic Lateral Ankle Instability: A Finite Element Analysis

In recent years, anterior tibiofibular ligament-distal fascicle transfers for anterior talofibular ligament augmentation repair have proposed. However, a comprehensive biomechanical study on the anterior tibiofibular ligament-distal fascicle transfer is still lacking. We are established four distinct groups, namely the normal, the anterior talofibular ligament rupture, the anterior talofibular ligament repair, and the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer. We assessed the anterior drawer test and varus stress test of the ankle in each group. Moreover, we employed the model to simulate and compute the total displacement and von-Mises stress of the talus cartilage at varying gait phases, including foot strike, tibia vertical, and toe-off phases. The results of the anterior drawer test and varus stress test revealed that the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group exhibited greater closeness to the normal group. Regarding von-Mises stress in cartilage, the three gait instants had higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Nevertheless, regarding total displacement, the toe-off phases exhibited higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Using ATiFL-DF transfer to augment ATFL repair is a potential feasible procedure. However, this procedure could potentially compromise the anterior tibiofibular ligament's contribution to the dynamic stability of the ankle. Therefore, we recommend conducting further in-depth research to ensure the suitability and success of this technique in a clinical environment.

Return to sports after ankle reconstruction with tendon grafts in chronic lateral ankle instability: A systematic review and meta-analysis

Purpose

Anatomic reconstruction using grafts is being performed more frequently in athletes experiencing recurrent chronic lateral ankle instability (CLAI). The purpose of the study was to systematically review the current literature to determine the rates of return to sports (RTS) along with timing in patients with CLAI undergoing ligament reconstruction.

Methods

The databases PubMed, Scopus, Cochrane, and Embase were searched based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles quoting on the return to sports rate after lateral ankle reconstruction were included. The rates of return to any sports, return to pre-injury sports, and return to competitive sports along with the timing of return were evaluated and a proportion meta-analysis was performed.

Results

A total of 720 patients in 20 studies met our inclusion criteria. The RTS rates for any sports were 95.3%, and 84.3% for pre-injury sports The average time taken for return to sports was 17 weeks. Postoperative functional outcomes, ankle stability, and ROM were significantly improved in comparison to preoperative status.

Conclusion

The RTS rates following lateral ankle reconstruction in CLAI showed a high return to any sports, but moderate to high rates for the pre-injury or competitive level of sports.

Level of evidence

Level of evidence II.

Peroneus Longus Graft Harvest: A Technique Note

Multiple graft options are available for knee ligament surgeries, one of the latest being peroneus longus grafts. Despite, an increasing usage of PL for graft harvest there is a scarcity of technique guides for its harvest, finding mention in only a few case studies. The following is a technical note dedicated to peroneous longus graft harvest.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00847-0.

Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review

BACKGROUND

"Failure" is a term that is frequently used to describe an unfavorable outcome for patients who undergo surgical treatment for lateral ankle instability (LAI). A standard definition of failure for the surgical treatment of ankle instability has not been established by clinicians and researchers.

PURPOSE

To identify the definitions of ankle instability treatment failure that are currently in the literature and to work toward the standardization of the definition.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of MEDLINE, SPORTDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for LAI and included information about surgical failure. Studies with level of evidence 1 to 4 were included in this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinions were excluded. The included studies were then reviewed for definitions of failure of any surgical procedure that was performed to correct LAI.

RESULTS

Of the 1200 studies found, 3.5% (42/1200) published between 1984 and 2021 met the inclusion criteria and were analyzed. After reviewing the data, we found numerous definitions were reported in the literature for LAI surgical failure. The most common was recurrent instability (40% [17/42]), followed by rerupture (19% [8/42]). For the original surgical procedure, the anatomic Broström-Gould technique was used most frequently (57% [24/42]). The failure rate of the Broström-Gould technique ranged from 1.1% to 45.2% depending on the definition of failure.

CONCLUSION

There were multiple definitions of failure for the surgical treatment of LAI, which is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. This definition should include specific, objective physical examination findings that eliminate the ambiguity surrounding failure.

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.

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.

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.

PT4: New arthroscopic technique for isolated reconstruction of the anterior talofibular ligament using a quadrupled plantaris tendon

The strategy for surgical treatment of chronic ankle instability is becoming increasingly refined. In instances of isolated symptomatic non-repairable anterior talofibular ligament (ATFL) injury, there is a surgical indication for isolated ATFL reconstruction. However, we feel that the typical gracilis tendon graft is not always appropriate. Interest in using the plantaris tendon as a graft has picked up since a biomechanics study found the tensile strength of a quadrupled plantaris tendon is comparable to that of the ATFL. Here, we describe an original arthroscopic technique for isolated ATFL reconstruction using a quadrupled plantaris tendon (PT4) graft.

Is arthroscopic surgery as successful as open approach in the treatment of lateral ankle instability?

PURPOSE

To evaluate the clinical results of arthroscopic repair and open Ahlgren-Larsson method in patients with chronic lateral ankle instability.

METHODS

We retrospectively evaluated 60 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS, and VAS scores.

RESULTS

Sixty patients with chronic lateral ankle instability were evaluated. 28 patients were treated with Ahlgren-Larsson method, and 32 patients were treated with arthroscopic repair. Follow-up duration was 35 ± 12 months for the open surgery group and 19 ± 2 months for the arthroscopic surgery group. The mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, BMI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in VAS in terms of pain and patient satisfaction in favor of arthroscopy group.

CONCLUSIONS

Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid.

LEVEL OF EVIDENCE

II.

Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

This review aimed to assess whether peroneus longus tendon (PLT) autograft would have comparable functional outcomes and graft survival rates when compared to hamstring tendon (HT) autograft for anterior cruciate ligament (ACL) reconstruction.

METHODS

PubMed, Web of Science, Cochrane Library, Ovid (MEDICINE), and EMBASE databases were queried for original articles from clinical studies including the keywords: ACL reconstruction and PLT autograft. Studies comparing PLT autograft versus HT autograft were included in this analysis and the following data were extracted from studies meeting the inclusion criteria: graft diameter, functional outcomes (Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score), knee laxity (Lachman test), and complications (donor site pain or paresthesia, graft failure). Besides, the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the Foot and Ankle Disability Index (FADI) pre-operation and at last follow-up were also compared among patients using PLT autograft. Meta-analysis was applied using Review Manager 5.3 and p < 0.05 was considered statistically significant.

RESULTS

Twenty-three studies including 925 patients with ACL reconstruction met inclusion criteria. Of these, 5 studies included a direct comparison of PLT autograft (164 patients) versus HT autograft (174 patients). No significant difference was observed between PLT and HT autografts for Tegner activity scale, Lachman test, donor site pain, or graft failure. However, PLT groups demonstrated better Lysholm score (mean difference between PLT and HT groups, 1.55; 95% CI 0.20-2.89; p = 0.02) and IKDC subjective score (mean difference between PLT and HT groups, 3.24; 95% CI 0.29-6.19; p = 0.03). No difference of FADI was found (n.s.) but AOFAS was slightly decreased at last post-operative follow-up for patients with PLT autograft compared with pre-operative scores (mean difference of 0.31, 95% CI 0.07-0.54, p = 0.01).

CONCLUSION

PLT autograft demonstrated comparable functional outcomes and graft survival rates compared with HT autograft for ACL reconstruction. However, a slight decrease in AOFAS score should be considered during surgical planning. Hence, the PLT is a suitable autograft harvested outside the knee for ACL reconstruction to avoid the complication of quadriceps-hamstring imbalance which can occur when harvesting autografts from the knee.

LEVEL OF EVIDENCE

Level II.

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.

Comparison of the effects of reconstruction of the lateral ankle ligaments using peroneus longus and peroneus brevis tendon graft

Peroneus longus and peroneus brevis tendon grafts have been frequently used to reconstruct the lateral ankle ligaments. However, there is no literature comparing the effect of the 2 methods. The purpose of this study was to compare the effects of 2 autologous tendon transplants on ankle joint activity.This retrospective study included 100 adult patients with chronic lateral ankle instability (CLAI) who underwent surgery from January 2014 to December 2017. Group A (50 patients): Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft; Group B (50 patients): Using the anterior half of peroneus brevis tendon graft. Outcomes were assessed by comparing pre- and postoperative AOFAS scores, VAS pain scores, and Karlsson scores, and the radiographic assessment included talar tilt and anterior talar translation. A sensitive dynamometer was used before and after surgery to assess inversion, valgus, plantarflexion, and dorsiflexion strength to evaluate changes in muscle strength in the patients feet.Postoperatively, 88 patients were followed up for 12 to 24 months, including 46 cases in group A and 42 in group B. No severe complications were recorded in the 2 groups. There were significant pre- to post-operative differences between the groups. No significant differences were observed in the postoperative scores and muscle strength changes between the groups. However, the number of patients with decreased valgus strength in group B was statistically significant compared with group A.Both methods can improve the stability of the ankle joint, but the peroneus longus tendon has little effect on the postoperative muscle strength of the foot and should be used as the preferred surgical treatment for the treatment of CLAI.

The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis

Chronic ankle instability predominantly occurs due to multiple exercise-related diseases. Conservative treatment methods regarding this condition have not effectively improved in recent years, which is why more focus has been put on exploring different novel reconstruction procedures of the lateral ankle ligament for the treatment of chronic ankle instability.

OBJECTIVES

This study aims to obtain the overall effectiveness of various lateral ankle ligament reconstruction methods for chronic ankle ligament instability.

METHODS

We gathered data from PubMed and EMBASE databases using the keywords: ankle, malleolar, and reconstruction. Newcastle - Ottawa quality assessment was carried out for the obtained studies; effect volume combination and image drawing were performed by Stata14, and Excel was used for data statistics.

RESULTS

A total of 12 articles were included in the quantitative analysis by performing full-text reading and data inclusion. Among them, 476 patients (485 ankle joints) were treated. The results showed that the overall valid efficiency of "excellent" was 59% and "good" lateral ligament reconstruction was 26%, I²=87.3%, P = 0.000; the subgroup analysis anatomic reconstruction group I²=0.0%, P = 0.993; the autograft group I²=0.0%, P = 1.000; allograft group I²=0.0%, P = 0.993.

CONCLUSION

Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability.

Tendon Regeneration After Partial-Thickness Peroneus Longus Tendon Harvesting: Magnetic Resonance Imaging Evaluation and In Vivo Animal Study

BACKGROUND

In recent years, the use of the anterior half of the peroneus longus tendon (AHPLT) as an autograft source for ligament reconstruction has gained popularity. However, no reports are available regarding tendon regeneration after harvesting of the AHPLT.

HYPOTHESIS

When half of the tendon is preserved during tendon harvesting, the quality of the regenerated tendon is better than that of the regenerated tendon after full-thickness harvesting.

STUDY DESIGN

Case series; Level of evidence, 4; controlled laboratory study.

METHODS

A total of 21 patients who underwent AHPLT harvesting for lower extremity ligament reconstruction participated in the magnetic resonance imaging (MRI) study to evaluate tendon regeneration 1 year after the harvesting. An in vivo animal study was performed to compare the quality of the regenerated tendon after partial-thickness and full-thickness tendon harvesting. A total of 30 adult female Sprague-Dawley rats were allocated to 2 groups-15 rats underwent partial-thickness Achilles tendon harvesting (partial-thickness harvesting [PTH] group), and 15 rats underwent full-thickness Achilles tendon harvesting (full-thickness harvesting [FTH] group). The quality of the regenerated tendons was compared 180 days after tendon harvesting.

RESULTS

All 21 patients showed regeneration of the peroneus longus tendon (PLT) (homogeneously dark on both T1- and T2-weighted sequences). The cross-sectional area of the regenerated tendon divided by that of the preoperative tendon was 92.6% and 84.5% at 4 cm and 9 cm proximal to the tip of the distal fibula, respectively. In the animal study, the mean histologic score was better for the PTH group compared with the FTH group (9.17 ± 1.35 vs 14.72 ± 0.74; P < .001). The ultimate strength and the stiffness of the regenerated Achilles tendon were significantly higher for the PTH group compared with the FTH group (35.5 ± 8.3 vs 22.4 ± 8.3 N, P = .004; and 31.6 ± 7.7 vs 23.5 ± 4.8 N/mm, P = .016).

CONCLUSION

The PLT was found to regenerate after partial-thickness harvesting on MRI. In the animal study, the quality of the regenerated tendon when half of the tendon was preserved during tendon harvesting was better than that after full-thickness tendon harvesting.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.

PURPOSE/HYPOTHESIS

This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.

RESULTS

Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.

CONCLUSION

Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.

CLINICAL RELEVANCE

This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft

AIMS

To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

METHODS

A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls.

RESULTS

Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides.

CONCLUSION

The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205-211.

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare

PURPOSE

To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare.

METHODS

A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined.

RESULTS

31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks.

CONCLUSION

Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.

Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair

PURPOSE

Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament's (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL's distal fascicle transfer for the treatment of chronic ankle instability.

METHODS

Five unpaired cadaver ankles underwent arthroscopic ATiFL's distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL's distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported.

RESULTS

All specimens revealed successful transfer of the tibial origin of the ATiFL's distal fascicle onto the talar insertion of anterior talofibular ligament's (ATFL) superior fascicle. The fibular origin of the ATiFL's distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8 mm. The median distance between the distal AL portal and SPN was 3.9 mm.

CONCLUSION

An all-arthroscopic approach to an ATiFL's distal fascicle transfer is a reliable method to reconstruct the ATFL's superior fascicle. Transfer of ATiFL's distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL's distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.

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.

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.

Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft

BACKGROUND

This study aimed to report our institution's experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament.

METHODS

This retrospective study included 32 consecutive patients with chronic lateral ankle instability who underwent surgery from January 2013 to December 2014. All patients had failed to resolve with conservative treatment. A total of 32 ankles underwent AHPLT transfer. Patients returned for a clinical and radiologic follow-up evaluation at an average of 28 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, and Karlsson scores, and the radiographic assessment including talar tilt and anterior talar translation.

RESULTS

Thirty-two patients (32 ankles) (100%) returned for final evaluation. All patients had an excellent or good outcome on patient subjective self-assessment, pain scores, AOFAS scores, and Karlsson scores at final follow-up. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was significantly reduced from a preoperative mean of 14.1±4.2° to 3.4±1.3° postoperatively (P<.001), and the anterior drawer was significantly reduced from a preoperative mean of 13.8±3.4mm to 3.6±1.5mm after lateral ankle ligamentous reconstruction (P<.001).

CONCLUSIONS

AHPLT transfer to reconstruct the lateral ligament resulted in a high percentage of successful results, with excellent ankle stability and not affected of ankle motion.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Effect of Initial Graft Tension During Calcaneofibular Ligament Reconstruction on Ankle Kinematics and Laxity

BACKGROUND

Although a variety of surgical procedures for lateral ankle ligament reconstruction have frequently been reported, little is known about the effects of initial graft tension. Purpose/Hypothesis: The purpose was to investigate the effects of initial graft tension in calcaneofibular ligament (CFL) reconstruction. It was hypothesized that a high degree of initial graft tension would cause abnormal kinematics, laxity, and excessive graft tension.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a 6 degrees of freedom robotic system to apply passive plantarflexion-dorsiflexion motion and multidirectional loads. A repeated-measures experiment was designed with the CFL intact, CFL transected, and CFL reconstructed with 4 initial tension conditions (10, 30, 50, and 70 N). The 3-dimensional path and reconstructed graft tension were simultaneously recorded.

RESULTS

The calcaneus in CFL reconstruction with an initial tension of 70 N had the most eversion relative to the intact condition (mean eversion translations of 1.2, 3.0, 5.0, and 6.2 mm were observed at initial tensions of 10, 30, 50, and 70 N, respectively). The calcaneus also moved more posteriorly with external rotation as the initial tension increased. The reconstructed graft tension tended to increase as the initial tension increased.

CONCLUSION

Ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. Moreover, excessive initial graft tension caused excessive tension on the reconstructed graft.

CLINICAL RELEVANCE

This study indicated the importance of initial graft tension during CFL reconstruction. Overtensioning during CFL reconstruction should be avoided to imitate a normal ankle.

A prospective study of coracoclavicular ligament reconstruction with autogenous peroneus longus tendon for acromioclavicular joint dislocations

BACKGROUND

Anatomic coracoclavicular (CC) ligament reconstruction (ACCR) provides good outcomes for Rockwood type III and VI acromioclavicular (AC) joint dislocations. Various grafts have been used, but complications from graft harvesting are not uncommon. This study examined the clinical and radiographic outcomes of patients with AC joint dislocations repaired with the autogenous anterior half of the peroneus longus tendon (AHPLT) to achieve ACCR.

METHODS

Patients with a Rockwood type III to V AC joint dislocation and magnetic resonance imaging of the disruption of the CC ligaments, as well as the AC capsule, were prospectively recruited. Patients received ACCR using an autogenous AHPLT graft and were evaluated clinically and radiographically preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

A total of 18 patients (mean age, 51 years) were prospectively recruited and received an autogenous AHPLT graft ACCR. Fifteen patients completed clinical and radiographic follow-up examinations at 12 months. The mean Constant score (CS) was 51 preoperatively and 93 at 12 months (P <.005). No significant difference was noted at 12 months between the CS of the injured and contralateral shoulder. The mean American Orthopedic Foot and Ankle Society score at 12 months was 99, and this was not different from the value at any other time point. Loss of reduction occurred in 10 patients (56%), and tunnel widening was observed in 9 (50%), but neither was significantly correlated with functional outcome.

CONCLUSION

Autogenous AHPLT appears to be a reliable tendon graft source for CC ligament reconstruction.

Comparative Evaluation Between Anatomic and Nonanatomic Lateral Ligament Reconstruction Techniques in the Ankle Joint: A Computational Study

Biomechanical studies have indicated that the conventional nonanatomic reconstruction techniques for lateral ankle sprain (LAS) tend to restrict subtalar joint motion compared to intact ankle joints. Excessive restriction in subtalar motion may lead to chronic pain, functional difficulties, and development of osteoarthritis (OA). Therefore, various anatomic surgical techniques to reconstruct both the anterior talofibular and calcaneofibular ligaments (CaFL) have been introduced. In this study, ankle joint stability was evaluated using multibody computational ankle joint model to assess two new anatomic reconstruction and three popular nonanatomic reconstruction techniques. An LAS injury, three popular nonanatomic reconstruction models (Watson-Jones, Evans, and Chrisman–Snook) and two common types of anatomic reconstruction models were developed based on the intact ankle model. The stability of ankle in both talocrural and subtalar joint were evaluated under anterior drawer test (150 N anterior force), inversion test (3 N·m inversion moment), internal rotational test (3 N·m internal rotation moment), and the combined loading test (9 N·m inversion and internal moment as well as 1800 N compressive force). Our overall results show that the two anatomic reconstruction techniques were superior to the nonanatomic reconstruction techniques in stabilizing both talocrural and subtalar joints. Restricted subtalar joint motion, which is mainly observed in Watson-Jones and Chrisman–Snook techniques, was not shown in the anatomical reconstructions. Evans technique was beneficial for subtalar joint as it does not restrict subtalar motion, though Evans technique was insufficient for restoring talocrural joint inversion. The anatomical reconstruction techniques best recovered ankle stability.

Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques

PURPOSE

To determine the best surgical treatment for chronic ankle instability (CAI) a systematic review was performed to compare the functional outcomes between various surgical stabilization methods.

METHODS

A systematic search was performed from 1950 up to April 2016 using PubMed, EMBASE, Medline and the Cochrane Library. Inclusion criteria were a minimum age of 18 years, persistent lateral ankle instability, treatment by some form of surgical stabilization, described functional outcome measures. Exclusion criteria were case reports, (systematic) reviews, articles not published in English, description of only acute instability or only conservative treatment, medial ankle instability and concomitant injuries, deformities or previous surgical treatment for ankle instability. After inclusion, studies were critically appraised using the Modified Coleman Methodology Score.

RESULTS

The search resulted in a total of 19 articles, including 882 patients, which were included in this review. The Modified Coleman Methodology Score ranged from 30 to 73 points on a scale from 0 to 90 points. The AOFAS and Karlsson Score were the most commonly used patient-reported outcome measures to assess functional outcome after surgery. Anatomic repair showed the highest post-operative scores [AOFAS 93.8 (SD ± 2.7; n = 119); Karlsson 95.1 (SD ± 3.6, n = 121)], compared to anatomic reconstruction [AOFAS 90.2 (SD ± 10.9, n = 128); Karlsson 90.1 (SD ± 7.8, n = 35)] and tenodesis [AOFAS 86.5 (SD ± 12.0, n = 10); Karlsson 85.3 (SD ± 2.5, n = 39)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SD ± 6.8, n = 128); Karlsson 51.6 (SD ± 5.5, n = 35) compared to anatomic repair [AOFAS 31.8 (SD ± 5.3, n = 119); Karlsson 40.9 (SD ± 2.9, n = 121)] and tenodesis [AOFAS 19.5 (SD ± 13.7, n = 10); Karlsson 29.4 (SD ± 6.3, n = 39)] (p < 0.005).

CONCLUSION

Anatomic reconstruction and anatomic repair provide better functional outcome after surgical treatment of patients with CAI compared to tenodesis reconstruction. These results further discourage the use of tenodesis reconstruction and other non-anatomic surgical techniques. Future studies may be required to indicate potential value of tenodesis reconstruction when used as a salvage procedure. Not optimal, but the latter still provides an increase in functional outcome post-operatively. Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. This has to be kept in mind when choosing between reconstruction and repair in the treatment of CAI.

LEVEL OF EVIDENCE

IV.

[Anatomic stabilization of chronic lateral instability of the ankle : Gold technique]

OBJECTIVES

Anatomical reconstruction of the lateral ligament complex in the ankle.

INDICATIONS

Chronic lateral ankle instability.

CONTRAINDICATIONS

Severe osteoarthritis, obesity, hindfoot varus, general contraindications (infection, circulatory disorders, diabetic foot syndrome).

SURGICAL TECHNIQUE

Anatomical V‑shaped reconstruction of the lateral ligament complex with half of the peroneus brevis tendon and additional retinaculum stabilization.

POSTOPERATIVE MANAGEMENT

Lower leg orthesis (e. g. protect.CAT Walker, medi GmbH, Bayreuth, Germany) for 6 weeks. Week 1-2, no weight bearing, no active pro- and supination. Starting in week 3-4, begin with partial weight bearing, pain adapted. Starting in week 7, free range of motion, begin with progressive training.

RESULTS

Between March 2014 and June 2016, 16 patients (6 female, 10 male) were treated with the above-named technique. Average age was 32.8 years (range 17.9-57.1 years). Ten patients completed the 6‑ and 12-month follow-ups. None of these 10 patients reported a feeling of instability. In the clinical examination, the lateral ligament complex was stable. Patients showed a free range of motion at the 12-month follow-up.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle

BACKGROUND

Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments.

HYPOTHESIS

Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated.

RESULTS

Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation.

CONCLUSION

MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.

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.

Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL

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.

Comparison of Broström technique, suture anchor repair, and tape augmentation for reconstruction of the anterior talofibular ligament

PURPOSE

Recently, tape augmentation for Broström repair has been introduced in order to improve the primary stability of the reconstructed anterior talofibular ligament (ATFL). The biomechanical effect of tape augmentation suture anchor (SA) repair is not known yet. The aim of the present study was to compare construct stability of the traditional Broström (TB) repair compared with a stand alone SA repair (SutureTak, Arthrex) and SA repair combined with tape augmentation (InternalBrace, Arthrex) internal brace (IB) of the ATFL.

METHODS

Eighteen fresh-frozen human anatomic lower leg specimens were randomly assigned to three different groups: TB group, SA group, and IB augmentation group. In vivo torsion conditions in ankle sprain were carried out quasi-statically (0.5°/s). Torque (Nm) required to resist as well as the rotary displacement (°) of the load frame was recorded. Intergroup differences for age, bone mineral density (BMD), angle at failure, and torque at failure were analysed using ANOVA.

RESULTS

In the TB group, ATFL reconstruction failed at an angle of 24.1°, in the SA group failure occurred at 35.5°, and in the IB group it failed at 46.9° (p = 0.02). Torque at failure reached 5.7 Nm for the TB repair, 8.0 Nm for the SA repair, and 11.2 Nm for the IB group (p = 0.04). There was no correlation between angle at ATFL failure, torque at failure, and BMD for the SA or IB groups.

CONCLUSION

The present biomechanical study reveals statistically superior performance in terms of angle at failure as well as failure torque for the IB group compared to the other reconstruction methods. BMD did not influence the construct stability in the SA repair groups.