Assessment of the feasibility of arthroscopic visualization of the lateral ligament of the ankle: a cadaveric study

The deltoid ligament complex is reliably visualised as four fascicles in two layers with 3D volumetric MRI in the ankles of 20 asymptomatic volunteers

PURPOSE

The anatomy of the deltoid ligament is complex. There is agreement on the presence of superficial and deep layers but the number and frequency of fascicles remains controversial. Identifying injuries to specific components of the deltoid ligament may inform decision-making on their management. The anatomy was reviewed to establish the number and dimension of fascicles visible with three-dimensional (3D) volumetric magnetic resonance images (MRI).

METHODS

Twenty ankles from asymptomatic healthy volunteers were imaged with 3D volumetric MRI. The presence of individual fascicles was recorded and measured in 3D.

RESULTS

The median age of participants was 26 years (range: 20-37) of which 13 (65%) were female. All 20 ankles had a deltoid ligament formed of four fascicles in two layers: three fascicles in the superficial layer; tibionavicular (mean dimensions 22.5 × 10.0 × 2.4 mm), tibiospring (16.6 × 6.7 × 1.9 mm) and tibiocalcaneal (23.8 × 4.6 × 1.8 mm) and a deep layer consisting of the tibiotalar fascicle, which could be divided into two parts: anterior tibiotalar (mean dimensions 10 × 5.6 × 4.1 mm) and the significantly larger posterior tibiotalar (14.2 × 13.8 × 17.5 mm, p < 0.01). There were no additional fascicles observed.

CONCLUSIONS

The deltoid ligament complex was consistently visualised as four fascicles (tibionavicular, tibiospring, tibiocalcaneal, tibiotalar) in two layers (superficial and deep) in all 20 ankles. The posterior part of the tibiotalar fascicle was the thickest of all the fascicles in the deltoid ligament. It is, therefore, possible to accurately identify the components of the deltoid ligament, and 3T MRI can be used to assess fascicle-specific injury, which will guide treatment and rehabilitation.

LEVEL OF EVIDENCE

Level III.

The calcaneofibular ligament groove at the inferior fibula, an ultrasonographic anatomical landmark

PURPOSE

Calcaneofibular ligament (CFL) injuries are harder to diagnose than anterior talofibular ligament (ATFL) ones. This study aimed to clarify the fibular attachment of the CFL and verify the bony landmark for evaluating the CFL on ultrasonography.

METHODS

Fifty-nine ankles were used in this anatomical study. To confirm the control function of the CFL, we performed passive movement manually using cadaveric ankles and observed the ankle positions where the CFLs were tense. Histological observation of CFL attachment of the fibula was performed using Masson's trichrome stain. The ATFL and CFL were removed, and the bone morphology of the CFL attachment and inferior fibular end was imaged using a stereomicroscope and a 3D scanner. Using ultrasonography, we evaluated the bone morphology of the fibular attachment of the CFL in short-axis images of 27 healthy adult ankles.

RESULTS

The CFL was tensed according to ankle motions: supination, maximum dorsi flexion, maximum plantar flexion, and mild plantar flexion-external rotation. Below the CFL attachment of the fibula was a slight groove between the inferior tip and the obscure tubercle of the fibula. This groove was observed in 81.5% of cases using short-axis ultrasonography.

CONCLUSION

The CFL was tensed in various ankle positions to control the movements of the talocrural and subtalar joints. There was a slight groove at the inferior end of the fibula where the CFL coursed downward. We called it the CFL groove and proposed that it could serve as a landmark for the short-axis image of ultrasonography.

A novel classification of lateral malleolus morphological characteristics based on three-dimensional computed tomography reconstruction

BACKGROUND

The study was to establish a novel classification of the morphological characteristics of fibula anterior-inferior margin (FAIM), which was reported in few studies.

METHODS

The 501 images with three-dimensional computed tomography (3D CT) reconstruction were reviewed retrospectively. The width, height, thickness, long axis, short axis, and lateral malleolus angle were measured.

RESULTS

The FAIM was divided into Angular, Flat, and Arc. The Flat has no distinct fibular obscure tubercles (FOT). The short axis of Angular and Arc were more significant than the Flat (P < 0. 05). The height of left was larger than the right, but short axis was less than it (P < 0.05). The height and short axis of males were larger than the females (P < 0.05).

CONCLUSIONS

A novel classification (the Angular, Flat and Arc) of FAIM was identified based on lateral malleolus morphology, and it suggested that not all have obvious FOT.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective study.

The Distal Fascicle of the Anterior Inferior Tibiofibular Ligament: A Potential Landmark for Lateral Ankle Ligament Reconstruction

BACKGROUND

A reliable landmark and precise distances from the ligament attachments are needed for lateral ankle stabilization surgery. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) has been used to locate the anterior talofibular ligament (ATFL) or calcaneofibular ligament (CFL) centers on the fibula. However, there is no anatomic study to validate the distal fascicle of the AITFL as a landmark of lateral ankle ligament stabilization, and more importantly, the exact distances from the ATFL or CFL attachments to the distal fascicle of the AITFL are unknown.

METHODS

Sixteen frozen cadaveric specimens (8 paired specimens) with no previous history of ankle injury were used in this study. Whether the distal fascicle of AITFL was present in each specimen was confirmed. Then, the distances from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL and CFL on the fibula were measured. All measurements were performed by 2 observers, and the intraobserver and interobserver reliabilities were analyzed by intraclass correlation coefficients (ICCs).

RESULTS

The distal fascicle of the AITFL was found in all specimens (100%). The mean distance from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL, CFL, and the intersection center of the 2 ligaments on the fibula was 6.0 to 7.1 mm, 11.5 to 13.2 mm, and 9.0 to 10.0 mm, respectively. Excellent interobserver and intraobserver agreement (all ICCs > 0.9, P < .01) was shown in the anatomic measurements of these distances.

CONCLUSION

In this cadaveric study, we found that the distal fascicle was a constant structure of the AITFL in the lateral ankle. The distances from the most distal insertion of the AITFL's distal fascicle to the ligamentous footprint centers were reliable and may be used to identify the origins of the ATFL and CFL for lateral ankle ligament reconstruction.

CLINICAL RELEVANCE

This anatomic study validates the AITFL's distal fascicle as a potential landmark and, more importantly, determines the range of distances from AITFL's distal fascicle to the attachment centers of lateral ankle ligaments by anatomic measurements. The data may be used to identify the ATFL and CFL for lateral ankle stabilization surgery and become particularly valuable for endoscopic or arthroscopic techniques.

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

DISCUSSION

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

LEVEL OF EVIDENCE

II.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safe Talar Tunnel Placement During Reconstruction of the Deep Layer of the Deltoid Ligament: A Comparison of 4 Different Anatomic Landmarks on the Lateral Malleolus

Background

Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair.

Purpose

To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL).

Study Design

Descriptive laboratory study.

Methods

A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels.

Results

For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm).

Conclusion

Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction.

Clinical Relevance

Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction.

Anatomical study of the bone morphology of the anterior talofibular ligament attachment

Anterior talofibular ligament (ATFL) injuries are the most common cause of ankle sprains. To ensure anatomically accurate surgery and ultrasound imaging of the ATFL, anatomical knowledge of the bony landmarks around the ATFL attachment to the distal fibula is required. The purpose of the present study was to anatomically investigate the ATFL attachment to the fibula with respect to bone morphology and attachment structures. First, we analyzed 36 feet using microcomputed tomography. After excluding 9 feet for deformities, the remaining 27 feet were used for chemically debrided bone analysis and macroscopic and histological observations. Ten feet of living specimens were observed using ultrasonography. We found that a bony ridge was present at the boundary between the attachments of the ATFL and calcaneofibular ligament (CFL) to the fibula. These two attachments could be distinguished based on a difference in fiber orientation. Histologically, the ATFL was attached to the anterodistal part of the fibula via fibrocartilage anterior to the bony ridge indicating the border with the CFL attachment. Using ultrasonography in living specimens, the bony ridge and hyperechoic fibrillar pattern of the ATFL could be visualized. We established that the bony ridge corresponded to the posterior margin of the ATFL attachment itself. The ridge was obvious, and the superior fibers of the ATFL have directly attached anteriorly to it. This bony ridge could become a valuable and easy-to-use landmark for ultrasound imaging of the ATFL attachment if combined with the identification of the fibrillar pattern of the ATFL.

The lowest point of fibula (LPF) could be used as a reliable bony landmark for arthroscopic anchor placement of lateral ankle ligaments ----compared with open Broström procedure

BACKGROUND

Arthroscopic technique procedures was wide accepted for the treatment of chronic ankle instability (CAI). But little acknowledge was involved to the bony landmarks and anatomic features of different bundles of lateral ligaments under arthroscopic view.

METHODS

Sixty patients with acute or chronic lateral ankle ligaments injury (LAI) were collected prospectively, and divided randomly into two groups. In arthroscopic group, the bone tunnels were made on the LPF arthroscopically. And in open group, the bone tunnels were made on the Fibular obscure tubercle (FOT) in open procedure. The inferior bundle of ATFL and Arcuate fibre was also identified reference to the LPF and labeled by a PDS II suture penetration. Following that, The distances of the bone tunnels to the different bony markers were measured and compare between two groups. The penetrating locations of PDS II on the inferior bundle of ATFL and Arcuate fibre were also confirmed intraoperatively. And the safe angle of anchor implantation on the axial view was measured on postoperative CT scan.

RESULTS

The distances of bone tunnel to the fibular tip, the fibular insertion of anterior-inferior tibiofibular ligament (AITFL), and the FOT in arthroscopic and open locating groups were 4.9 ± 2.2 and 6.3 ± 2.2 mm, 13.5 ± 2.7 and 12.4 ± 1.1 mm, 5.8 ± 2.2 and 5.6 ± 1.0 mm, respectively. The distances of bone tunnels to the FOT and fibular tip on 3d-CT view was 4.4 ± 1.5 and 4.6 ± 0.9 mm, 14.4 ± 3.2 and 13.2 ± 1.8 mm in arthroscopic and open group, and there were no significant differences between two groups. The safe angle of arthroscopic anchor placement on the axial plan was ranged from 24.9 ± 6.3o to 58.1 ± 8.0o. The PDS II sutures penetrating on the inferior bundles of ATFL and the arciform fibres were also comfirmed successfully by open visualizaion.The average distance of penetration point to the horizontal line cross the fibular tip was 2.3 ± 2.7 mm (ranged from - 3.1 to 6.0 mm), and to the vertical line cross the FOT was 2.7 ± 2.7 mm (ranged from - 2.5 to 7.5 mm).

CONCLUSION

Take the lowest point of fibula under arthroscopy (LPF) as a bony reference, we could identify the iATFL under arthroscopic visualization. By this way, we could place the suture anchors properly to the fibular footprint and suture the iATFL fibres successfully.

Both Open and Arthroscopic All-Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability

PURPOSE

To compare the return to sports and short-term clinical outcomes between the arthroscopic all-inside and the open anatomic reconstruction with gracilis tendon autograft for chronic lateral ankle instability (CLAI) patients.

METHODS

From March 2018 to January 2020, 57 CLAI patients were prospectively included with arthroscopic all-inside anatomic reconstruction (n = 31) or open anatomic reconstruction (n = 26) with gracilis tendon autograft. The patients were evaluated before operation and at 3 months, 6 months, 12 months, and 24 months after surgery. The American Orthopaedic Foot and Ankle Society score (AOFAS), visual analog scale (VAS), and Karlsson-Peterson score were evaluated at each time point, and stress radiography with a Telos device was performed before surgery and at final follow-up. The time to return to full weightbearing walking, jogging, sports, and work, Tegner activity score, and complications were recorded and compared.

RESULTS

All the subjective scores significantly improved after surgery from the preoperative level. Compared with the open group, the arthroscopic group demonstrated significantly earlier return to full weightbearing walking (8.9 vs 11.7 weeks, P < .001), jogging (17.9 vs 20.9 weeks, P = .012), and recreational sports (22.4 vs 26.5 weeks, P = .001) with significantly better AOFAS score and Karlsson score at 3 to 6 months, and better VAS score at 6 months after surgery. The 2 groups demonstrated no significant difference in the surgical duration or surgical complications. No significant difference was found in the clinical scores or stress radiographic measurements at 24 months after surgery (P > .05).

CONCLUSION

Compared with the open procedure, the arthroscopic all-inside anatomic lateral ankle ligament reconstruction with autologous gracilis tendon could achieve earlier return to full weightbearing, jogging, and recreational sports with less pain and better ankle functional scores at 3 to 6 months after surgery. Similar favorable short-term clinical outcomes were achieved for both techniques at 2 years after surgery.

STUDY DESIGN

Level I, randomized controlled trial.

Nonanatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair With a High-Position Anchor versus Anatomic Repair: An Analysis Based on 3D CT

BACKGROUND

In patients with chronic ankle instability, it is important to repair the anterior talofibular ligament (ATFL) at the anatomic origin site. However, there are limited reports on the clinical outcomes according to anatomic ATFL repair.

PURPOSE

To compare the clinical outcomes after arthroscopic ATFL repair according to whether the anchor is fixed at an anatomic position.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair for chronic ankle instability and were available for a minimum 2-year follow-up. The patients were divided into 3 groups according to the anchor position at the distal fibula on 3-dimensional computed tomography: anatomic arthroscopic ATFL repair (anatomic group), subanatomic arthroscopic ATFL repair (subanatomic group), and nonanatomic arthroscopic ATFL repair (nonanatomic group). The visual analog scale for pain, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score were measured as subjective outcomes. Posturographic analysis and radiologic evaluation using stress radiographs and axial view magnetic resonance imaging were performed as objective outcomes.

RESULTS

Of 96 patients, 16 were excluded per the exclusion criteria, and 80 were evaluated (anatomic group, n = 24; subanatomic group, n = 42; nonanatomic group, n = 14). The mean age of the patients was 34.5 years, and the mean follow-up period was 27.4 months. A between-group comparison revealed significant differences in FAOS, Karlsson score, and fall risk evaluated by posturography at the final follow-up. Post hoc analysis revealed that the anatomic group had better clinical scores on the FAOS than did the nonanatomic group in all 5 domains (all P < .017). Patients in the anatomic and subanatomic groups had better Karlsson scores and fall risk than those in the nonanatomic group (P = .004 and P = .013, respectively). In terms of objective outcomes, patients in the anatomic and subanatomic groups had better outcomes in fall risk than did those in the nonanatomic group (both P = .001). There were no differences in clinical scores and objective outcomes between the anatomic and subanatomic groups.

CONCLUSION

Nonanatomic ATFL repair showed inferior outcomes when compared with anatomic ATFL repair. When arthroscopic ATFL repair is performed, the anchor should be fixed in the anatomic position to improve prognosis.

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.

Ultrasound-Guided Ankle Lateral Ligament Stabilization

PURPOSE OF REVIEW

Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

RECENT FINDINGS

To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Independent Attachment of Lateral Ankle Ligaments: Anterior Talofibular and Calcaneofibular Ligaments - A Cadaveric Study

Anatomic knowledge of lateral ligaments around the lateral malleolus is important for repair or reconstruction of ankle instability. The detailed structure of the connective fibers between the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is unknown. To clarify the anatomic structure of ATFL and CFL and the connective fiber between the 2 ligaments, the lateral ligament was dissected in 60 ankles of formalin-fixed cadavers, and the distance was measured between bony landmarks and fibular attachment of ATFL and CFL using a digital caliper. All ankles had connective fibers between ATFL and CFL. The structure of connective fibers consisted of a thin fiber above the surface layer of ATFL and CFL; it comprised thin fibrils of the surface layer covering the lower part of ATFL and the front part of CFL. Both ATFL and CFL were independent fibers, and both attachments of the fibula were isolated. Single bands of ATFL were noted in 14 of 60 (23.3%) ankles, double bands that divided the superior and inferior bands were observed in 42 of 60 (70.0%) ankles, and multiple bands were observed in 4 of 60 (6.7%) ankles. A cord-like and a flat and fanning type of CFL was noted in 22 (36.7%) and 38 (63.3%) of the 60 ankles, respectively. Distances between ATFL/CFL and articular and inferior tips of the fibula were 4.3 ± 1.1 mm/7.6 ± 1.6 mm and 14.3 ± 1.9 mm/7.4 ± 1.7 mm, respectively (mean ± standard deviation). The results of this study suggest that knowledge of more anatomic structures of ATFL, CFL, and connective fiber will be beneficial for surgeons in the repair or reconstruction of the lateral ligament of the ankle.

No Difference between Percutaneous and Arthroscopic Techniques in Identifying the Calcaneal Insertion during Ankle Lateral Ligament Reconstruction: A Cadaveric Study

Background. Both percutaneous and arthroscopic techniques have been introduced in anatomic ankle lateral ligaments reconstruction. The purpose of this study was to compare these two techniques in identifying the calcaneal insertion of the calcaneofibular ligament (CFL). Methods. Fifteen fresh-frozen human ankle cadaver specimens were used in this study. Each specimen was tested in three stages. For stage 1, each specimen was evaluated under arthroscopy. After debridement was performed, the insertion of the CFL on the calcaneus was identified, and a 1.5mm Kirschner wire was drilled at the center of the insertion. For stage 2, a percutaneous technique was used to identify the center of the insertion of the CFL. A second 1.5 mm Kirschner wire was drilled through the skin marker. For stage 3, the ankle was dissected, the footprint of the CFL was identified under direct vision, and the distances between the center of the CFL insertion on the calcaneus and the two Kirschner wires were measured, respectively. Results. In the arthroscopic technique group, the mean distance from the Kirschner wire to the center of the CFL insertion in the calcaneus was 3.4 ± 1.3 mm. In the percutaneous technique group, the mean distance from the Kirschner wire to the center of the CFL insertion was 3.2 ± 1.4 mm. No significant difference was found between the two groups. Conclusion. No difference in identifying the calcaneal insertion of the CFL was found between the percutaneous and the arthroscopic ankle lateral ligaments reconstruction technique. Both techniques can be used during anatomic ligaments reconstruction in treatment of chronic ankle instability.

Kinematics and Laxity of the Ankle Joint in Anatomic and Nonanatomic Anterior Talofibular Ligament Repair: A Biomechanical Cadaveric Study

BACKGROUND

Although it is crucial to accurately identify the anterior talofibular ligament (ATFL) attachment site, it may not be feasible to fully observe the ATFL attachment site during arthroscopic surgery. As a result, the repair position might often be an unintentionally nonanatomic ATFL attachment site.

HYPOTHESIS

Anatomic ATFL repair restores kinematics and laxity to the ankle joint, while nonanatomic ATFL repair does not.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven normal fresh-frozen human cadaveric ankles were used. The ankles were tested with a 6 degrees of freedom robotic system. The following ankle states were evaluated: intact, ATFL injured, ATFL anatomic repair, and ATFL nonanatomic repair. The ATFL nonanatomic repair position was set 8 mm proximal from the center of the ATFL attachment site of the fibula. For each state, a passive plantarflexion (PF)-dorsiflexion (DF) kinematics test and a multidirectional loading test (anterior forces, inversion moment, and internal rotation moment) were performed.

RESULTS

The kinematics and laxity of the anatomic repair were not significantly different from those of the intact state. In nonanatomic repair, the inversion-eversion angle showed significant inversion (3.0°-3.4°) from 5° to 15° of DF, and the internal rotation-external rotation angle showed significant internal rotation (2.0°) at neutral PF-DF versus the intact state. In addition, internal rotation laxity was significantly increased (5.5°-5.8°) relative to the intact state in the nonanatomic repair at 30° and 15° of PF. There were no significant differences in anterior-posterior translation between the repairs.

CONCLUSION

Although the anatomic ATFL repair state did not show significant differences in kinematics and laxity relative to the intact state, the nonanatomic ATFL repair state demonstrated significant inversion and internal rotation kinematics and internal rotation laxity when compared with the intact state.

CLINICAL RELEVANCE

Nonanatomic repair alters kinematics and laxity from the intact condition.

Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability

BACKGROUND

The surgical treatment of chronic ankle instability (CAI) relies chiefly on anterior talo-fibular ligament (ATFL) repair (with or without augmentation) or anatomical reconstruction with a tendon graft. Arthroscopy enables not only a complete assessment and the same-stage treatment of concomitant articular lesions, but also an accurate assessment of ligament lesions. Pre-operative imaging studies (MRI, CT, US) may fail to provide sufficient detail about chronic ATFL lesions to guide the decision between repair and reconstruction. The aim of this study was to develop an arthroscopic classification of chronic ATFL lesions designed to assist in selecting the optimal surgical technique.

MATERIAL AND METHODS

Sixty-nine anterior ankle arthroscopy videos recorded before surgery for CAI were studied retrospectively. ATFL dissection was performed in all patients. Based on the video analysis, five ATFL grades were identified: 0, normal ATFL thickness and tension; 1, ATFL distension with normal thickness; 2, ATFL avulsion with normal thickness; 3, thin ATFL with no resistance during the hook test; and 4, no ATFL, with a bald malleolus. Intra- and interobserver reproducibility of the arthroscopic classification of chronic ATFL lesions was evaluated by computing the kappa coefficients (κ) after assessment by two independent observers.

RESULTS

All 69 ATFLs were classified as abnormal (none was grade 0). Each ATFL could be matched to a grade. Intra-observer agreement was good for both observers: κ was 0.67 with 75% of agreement for one observer and 0.68 with 76% of agreement for the other observer. Inter-observer agreement was fair to good, with κ values ranging from 0.59 to 0.88 and agreement from 70% to 91%.

DISCUSSION

Arthroscopic ATFL dissection is a simple procedure that provides a highly accurate assessment of ATFL lesions and mechanical resistance, focussing chiefly on the superior ATFL. Grade 1 and 2 lesions can be repaired using the Broström-Gould procedure, whereas grade 3 and 4 lesions require anatomic reconstruction with grafting.

CONCLUSION

This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI. It is helpful for determining the best surgical technique for stabilising the ankle. These results must be confirmed in a larger study.

Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries

BACKGROUND

Imaging studies done to evaluate chronic ankle instability (CAI) often fail to accurately detail injuries to the anterior talo-fibular ligament (ATFL) and may, therefore, also fail to provide guidance for selecting the most appropriate surgical procedure. Arthroscopy is now an indispensable tool for accurately diagnosing ATFL injuries. This study looked at agreement between arthroscopy and imaging study assessments of ATFL injuries. The primary objective was to adapt an arthroscopic classification of chronic ATFL lesions to the pre-operative imaging study findings in order to estimate the performance of computed tomography (CT)-arthrography, ultrasonography, and magnetic resonance imaging (MRI) in diagnosing ATFL lesions, using arthroscopy as the reference standard.

HYPOTHESIS

Agreement between arthroscopic and imaging findings of chronic ATFL injuries can be assessed by using a shared classification developed from the arthroscopic evaluation, used as the reference standard.

MATERIAL AND METHODS

A prospective multicentre study was conducted in 286 patients with arthroscopically-treated CAI. In each patient, the arthroscopic assessment of the ATFL was compared to the pre-operative findings by CT-arthrography, ultrasonography, and MRI. A classification of ATFL lesions based on the arthroscopic assessment was used to analyse the imaging studies. Using this classification, two independent observers compared the findings and evaluated the agreement between arthroscopy and imaging studies.

RESULTS

Of the 286 patients, 157 had complete information on the arthroscopic assessment and on pre-operative imaging studies and were included in the analysis. Imaging studies were CT-arthrography in 49 patients, ultrasonography in 63 patients, and MRI in 45 patients; both ultrasonography and MRI were performed in 3 patients. Agreement with arthroscopy was 82% and 88.5% for CT-arthrography, 66.7% and 76.2% for ultrasonography, 70.5% and 79.5% for MRI, and 73.4% and 81.2% for all imaging studies pooled.

DISCUSSION

Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with CAI, as it supplies far more accurate information than any of the current imaging studies and, in addition, provides a dynamic evaluation of the ligaments and assesses mechanical strength. In the study population, a simple arthroscopic evaluation consistently visualised ATFL lesions, thereby either correcting or confirming the pre-operative imaging study findings. Importantly, the arthroscopic assessment provided more accurate information on the lesions and quality of the ATFL compared to the imaging studies. Arthroscopy has improved our knowledge of chronic ATFL lesions and allowed the development of a simple but accurate four-grade classification of direct relevance to choosing the optimal therapeutic procedure. This classification must be disseminated among radiologists to improve the diagnostic performance of pre-operative imaging studies, assist surgeons in selecting the most appropriate ankle-stabilising procedure, and improve patient information. Further studies are needed to confirm the promising results reported here and the usefulness of this common arthroscopy and imaging-study classification for chronic ATFL lesions.

LEVEL OF EVIDENCE

II.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Arthroscopic Treatment of Ankle Instability - Allograft/Autograft Reconstruction

Inversion ankle sprains represent one of the most common traumatic injuries in the active sports population. Although most respond well to conservative treatment, some hide important lesions. Lateral ankle ligament injuries occur in more than 80% of all ankle sprains, with one-third of these developing chronic ankle instability (CAI). Lateral ankle ligament repair or reconstruction procedures aim to restore normal ankle anatomy and function in patients with CAI. Arthroscopic reconstruction techniques allow the surgeon to reach surgery objectives with minimal soft tissue injury. When the indications and surgical steps are respected, this arthroscopic technique seems to be safe and reproducible.

The distal margin of the lateral malleolus visible under ankle arthroscopy (articular tip) from the anteromedial portal, is separate from the ATFL attachment site of the fibula: A cadaver study

PURPOSE

The purpose of this study was to evaluate the relationship between the lateral malleolus view under ankle arthroscopy and the anterior talofibular ligament (ATFL) attachment site.

METHODS

Seven normal ankles from Thiel-embalmed cadavers were investigated. Ankle arthroscopy was performed using a 2.7 mm-diameter, 30-degree, oblique-viewing endoscope. An antero-medial portal (AM), a medial midline portal (MML), and an antero-central portal (AC) were created in order, and the ankle arthroscope was inserted. The lateral malleolus was visualized as distally as possible, and the site that appeared to be the distal margin was marked with a 1.5 mm-diameter K-wire. Visualization with arthroscopy was carried out from all portals to mark the distal margin, and the ankle was subsequently exposed to directly measure the distance from the center of the ATFL attachment site at the fibula to each marking.

RESULTS

The distances from the ATFL attachment site to the markings made under arthroscopy from the AM, MML, and AC portals were 10.4 ± 2.6 mm, 7.4 ± 1.9 mm, and 7.3 ± 1.9 mm, respectively. Compared to markings made from the MML or AC portal, the marking made from the AM portal was significantly further away from the ATFL attachment site.

CONCLUSIONS

A typical ankle arthroscopy portal may not allow complete visualization of the tip of the lateral malleolus, indicating that it may not be feasible to thoroughly observe the ATFL attachment site. It is necessary to perform arthroscopic surgeries with the understanding that the distal margin of the lateral malleolus that appears under ankle arthroscopy is 7-10 mm proximal to the ATFL attachment site.

Anatomic validation of the lateral malleolus as a cutaneous marker for the distal insertion of the calcaneofibular ligament

PURPOSE

An anatomic study was performed to confirm whether the lateral malleolus could serve as a simple and reproducible anatomic reference for the distal insertion of the calcaneofibular ligament (CFL).

METHODS

Dissection was performed after placement of a Kirschner wire to simulate the calcaneal tunnel for the distal insertion of the CFL. The skin was penetrated 1 cm distal and posterior to the tip of the lateral malleolus. The main information recorded was the distance from the Kirschner wire to the centre of the distal insertion of the CFL. Other elements were noted (characteristics of the CFL, distance between the distal insertion of the CFL-peroneal tubercle, nerve or tendon injuries).

RESULTS

Thirty ankles were dissected. The mean distance from the Kirschner wire to the centre of the distal insertion of the CFL was 2.4 ± 1.8 mm. Only one case of peroneal injury was noted. The sural nerve was usually located a mean 1.8 ± 1.1 mm from the Kirschner wire. The posterior tibial vascular pedicle was a mean 27.8 ± 3.5 mm from the point of exit of the Kirschner wire.

CONCLUSION

Using the lateral malleolus as the cutaneous reference for the distal insertion of the CFL seems to be more reliable than the pure arthroscopic technique. This study describes a percutaneous technique to obtain a calcaneal tunnel for distal insertion of the CFL. The sural nerve is at the greatest risk of injury with this technique and requires careful subcutaneous incision to prevent injury. This new percutaneous technique is less invasive than a purely arthroscopic technique and more accurately identifies the location of the tunnel. It can be used to do calcaneal tunnel in clinical practice during anatomic ligament reconstruction for chronic ankle instability.

Does antero-lateral ankle impingement exist?

Antero-lateral ankle impingement syndrome (ALAIS) is a well-established clinical entity that is a common consequence of ankle sprains. Injury to the anterior talo-fibular ligament plays a key role in the genesis of ALAIS. Arthroscopic antero-lateral synovectomy is the standard of care. However, this treatment approach may deserve to be challenged, as it does not include any procedure on the ligaments, despite the presence in some patients of lateral rotational micro-instability of the ankle, without objective laxity. Consequently, we reviewed current data on ALAIS and its links to ankle instability, from the dual perspective of diagnosis and treatment.

Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study

PURPOSE

The purpose of this study was to determine the clinical utility of three bony tubercles: fibular obscure tubercle, talar obscure tubercle and tuberculum ligamenti calcaneofibularis, to serve as anatomical landmarks for defining the precise location of the origins and insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL).

METHODS

Twelve lower extremity cadaveric specimens were procured. The detectability of the tubercles was tested using palpation and fluoroscopy with subsequent confirmation after dissection. If the tubercles were present, then distances from the identified tubercles to the footprint centres and the intersection of the ATFL and CFL were measured to allow precise localization of the ATFL and CFL origin and intersection sites. Further, if the tubercles were not detectable, then an attempt to provide an alternative means of localizing ATFL and CFL origin and insertion sites was made by measuring distances between alternative landmarks and other important structures. All the measurements were performed by two researchers, and the results were averaged.

RESULTS

The fibular obscure tubercle existed and was detectable in all specimens. It was located 1.3 mm proximal to the articular tip of the fibula, 2.7 mm to the intersection of the ATFL and CFL, 3.7 mm distal to the ATFL and 4.9 mm proximal to the CFL origins. The talar obscure tubercle existed 58 % of specimens and was detectable in 57 %. The talar obscure tubercle was located 1.4 mm to the ATFL. The ATFL insertion point was located 60 % of the distance from the inferolateral corner to the anterolateral corner of the of talar body along the anterior border of the talar lateral articular facet. The tuberculum ligamenti calcaneofibularis existed in 33 % of specimens and was detectable in 8 %. The CFL inserted 17 mm on a perpendicular projected line distal from the subtalar joint.

CONCLUSIONS

The fibular obscure tubercle was clinically relevant and reliable bony landmark of the ATFL and CFL origin location. However, the talar obscure tubercle was less reliable and the tuberculum ligamenti calcaneofibularis was rarely available and as such alternative landmarks for the ATFL and CFL insertion location should be utilized. The present study describes the utility of clinically relevant bony landmarks that may assist in identifying the origins and insertions of the ATFL and CFL to facilitate minimally invasive ankle stabilization surgery.

All Arthroscopic Remnant-Preserving Technique to Reconstruct the Lateral Ankle Ligament Complex

Arthroscopic lateral ankle ligament reconstruction has been recently advocated. But this technique has not been popularized because of the technical complexity and potential iatrogenic injury. Because the talocalcaneal and calcaneofibular ligaments are extra-articular structures, how to efficiently view and address them is a difficult task. Limited dissection outside the capsule to form a working space is required, but aggressive dissection is harmful for tissue healing although it is helpful for visualization and instrumentation. Because almost the entire talar body is covered by articular cartilage, it is very difficult to safely make a bone tunnel without damaging the cartilage. The remnants of the lateral ankle ligament have proprioceptive sensors that are important for functional stability, but it is difficult to perform anatomical reconstruction arthroscopically while preserving them because of the narrow working space. Furthermore, how to properly tension the reconstructed ligaments in such a narrow working space is also a very difficult task. We have designed a technique that preserves the remnants of lateral ankle ligaments, and all of the above-mentioned problems have been successfully addressed. We have used this technique clinically, and only minor complications occurred.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.