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

Broström ankle ligament repair augmented with suture tape : Results of magnetic resonance imaging evaluation

BACKGROUND

The Broström procedure is an established procedure in cases of primary lateral ankle ligament repair (LALR). To improve postoperative stability an augmentation device, InternalBrace™ (Arthrex, Naples, FL) has been introduced. This study evaluates remodelling of the anterior talofibular ligament (ATFL) in patients undergoing a tape augmented Broström technique as well as clinical outcomes.

METHODS

In this study 32 patients with chronic lateral ankle instability (CLAI) receiving augmented LALR were included. Clinical outcomes were evaluated at a one-time postoperative visit between 12 and 18 months. A 3 T magnetic resonance imaging (MRI) was done to evaluate the morphology of the ATFL. Statistical analysis was completed with the free software and environment R version 3.6.3 (Bell Laboratories, Murray Hill, NJ, USA) and P-values < 0.05 were considered statistically significant.

RESULTS

The mean follow-up time was 15.3 ± 1.8 months with a return to sport time of 4.0 ± 2.4 months. The average AOFAS (American Orthopaedic Foot and Ankle Society Score) score was 94.4 ± 7.2, the FAOS (Foot and Ankle Outcome Score) demonstrated 87.3 ± 10.4 points and the FFI (Foot Function Index - 2 scores (pain and function score)) was 22.9 ± 20.1 and 15.4 ± 10.4, respectively. The MRI findings demonstrated an average length of the ATFL of 18.6 ± 4.3 mm and the width was 3.6 ± 0.9 mm. A clear differentiation between the ATFL and the augmentation device could be shown in 28 cases. The Fisher's exact test could not depict a significant correlation between the presence of a bone marrow edema and the tension of the augmentation device with a level of significance of α = 0.05.

CONCLUSION

An anatomical healing tendency of the ligament repair and good integrity of the augmentation device could be shown based on MRI findings. The lateral ligament repair augmented with suture tape is an effective and safe procedure regarding surgical treatment in chronic lateral ankle instability producing good clinical outcome.

Successful Return to Sport and Daily Activities After Suture Augmentation of Both the Anterior Talofibular Ligament and Calcaneofibular Ligament

Purpose

To evaluate the return to sport and daily activities in addition to clinical outcomes after modification of the Brostöm repair, specifically using suture augmentation for concomitant fixation of both the anterior talofibular ligament and calcaneofibular ligament.

Methods

Patients who had grade III ankle sprains and lateral ankle instability, all of whom failed supervised conservative management, were included. Patients underwent a modified Broström procedure consisting of suture augmentation for both the anterior talofibular ligament and calcaneofibular ligament. For clinical outcome evaluation, Foot and Ankle Ability Measure (FAAM) and Karlsson-Peterson Scoring System for Ankle Function questionnaires coupled with questions regarding time of return to sport and level of sports activity were used.

Results

Thirty-one patients were included. The differences in preoperative and postoperative FAAM scores for both the Activities of Daily Living subscale and Sports subscale were significant (P < .001). The FAAM Activities of Daily Living score improved from an average of 46.06 preoperatively to 77.49 postoperatively (P < .001, 99% confidence interval, 26.4-36.4). The FAAM Sports score improved from an average of 4 preoperatively to 19.31 postoperatively (P < .001, 99% confidence interval, 11.6-19.0). For the Karlsson-Peterson Scoring System for Ankle Function, the surveyed population reported a mean of 82.74 points out of 100 post-op (standard deviation 20.14). The mean time to return to sport activity was 5.72 months. Mean follow-up time was 24.12 months.

Conclusions

This variant Broström procedure with suture anchors and augmentation of both the anterior talofibular ligament and calcaneofibular ligament was effective in helping patients return to their preinjury functionality level in both daily life and sports activity.

Level of Clinical Evidence

Level IV, therapeutic case series.

Anterior Talo-Fibular Ligament Reconstruction With InternalBrace™ for Chronic Lateral Ankle Instability in Pediatric Patients

INTRODUCTION

Ankle injuries and instability in a pediatric age group are common problems and often underreported. The injuries can range from a relatively benign ankle sprain to pain-limiting ankle instability that can inhibit the child from participating in sporting activities. However, conservative management and physiotherapy are the mainstay of treatment; a small group of patients present with persistent instability and benefit from surgical intervention in lateral ligament reconstruction. Our study looked at pediatric patients who had instability following failed conservative management.

METHODS

Retrospective analysis of 14 patients with Chronic lateral Ankle instability (CLAI) who underwent Modified Brostrom-Gould repair( MBG) with or without Internal brace augmentation between January 2015 and October 2020. Patients were evaluated for the visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), subjective satisfaction, and return to preinjury activity level.

RESULTS

Pain score improved from 8 (average 5-9) to 1 (average 0-3) following surgery. Functional assessment was made by assessing the Manchester Oxford questionnaire pre-and postoperatively. MOxFQ scores improved from 64 (8 SD) to 7 (15 SD). Thirteen of fourteen patients returned to normal sporting activities at the final follow-up.

CONCLUSION

Modified Brostrom-Gould with InternalBrace™ augmentation is an excellent procedure for chronic lateral ligament injuries in the Paediatric population. It can be safely performed if we respect the anatomy and the physeal growth plate. It allows faster rehabilitation and return to preinjury activity level.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years

BACKGROUND

An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation.

METHODS

Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used.

RESULTS

Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability.

CONCLUSION

At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone.

LEVEL OF EVIDENCE

Level II, retrospective cohort study.

Evaluation of Spin in the Clinical Literature of Suture Tape Augmentation for Ankle Instability

Background

Spin is defined as the use of specific reporting strategies to highlight the beneficial effect of a treatment despite nonsignificant results. The presence of spin in peer-reviewed literature can negatively impact clinical and research practices. The purpose of this study was to identify the quantity and types of spin present in primary studies and systematic reviews using suture tape augmentation for ankle instability as a model.

Methods

This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each abstract was assessed for the presence of the 15 most common types of spin. Extracted data included study title, authors, publication year, journal, level of evidence, study design, funding, reported adherence to PRISMA guidelines, and PROSPERO registration. Full texts of systematic reviews were used in the assessment of study quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

Results

Nineteen studies were included in the final sample. At least 1 type of spin was identified in each study except one (18 of 19, 94.7%). The most common type of spin observed was type 3 ("selective reporting or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention") (6 of 19, 31.6%), The second most reported category of spin was type 4 ("the conclusion claims safety based on non-statistically significant results with a wide confidence interval") (4 of 19, 21.1%). Among systematic reviews, we identified type 5 ("the conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") in 4 out of 6 (66.7%) of the articles that were included. No significant associations were found between study characteristics and type of spin.

Conclusion

In this exploration of the introduction of a new technology, we identified spin to be highly present in the abstracts of primary studies and systematic reviews concerning suture tape augmentation for ankle instability. Steps should be taken by scientific journals to ensure that spin is minimized in the abstract to accurately reflect the quality of the intervention.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults

BACKGROUND

Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability.

METHODS

A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine.

RESULTS

Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization.

CONCLUSION

Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Biomechanical Effect of Differential Tensioning on Suture-Augmented Ulnar Collateral Ligament Reconstruction of the Elbow

BACKGROUND

Medial ulnar collateral ligament (mUCL) reconstructions are becoming increasingly prevalent among the overhand throwing population. Suture tape augmentation has the potential to provide biomechanical advantages over standard docking reconstruction. However, the optimal tensioning of the suture augmentation technique has not yet been evaluated.

PURPOSE

To compare the subfailure biomechanical performance and graft strain of a standard docking mUCL reconstruction to an mUCL reconstruction using suture tape augmentation tensioned with 1 mm or 3 mm of laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 18 cadaveric elbows were dissected to the mUCL anterior band and biomechanically assessed via a valgus torque protocol to failure. Elbows were randomly assigned to be reconstructed via (1) a standard docking technique, (2) a suture-augmented reconstruction with 1-mm laxity, or (3) a suture-augmented reconstruction with 3-mm laxity. Reconstructed elbows were then subjected to the same loading protocol. Subfailure mechanical properties, failure mode, and mUCL/palmaris strain were assessed.

RESULTS

All reconstruction groups had decreased rotational stiffness, torque at 5° of angular rotation, and resilience compared with matched native controls. There were no differences in transition torque between groups. The failure mode of suture-augmented specimens was most often due to bone tunnel failure or reaching the maximum allowable angular displacement. In native controls or docking reconstructions, the primary failure mechanism was in the ligament or graft midsubstance. There were no significant differences in strain on the reconstructed or suture-augmented groups at any laxity compared with native controls.

CONCLUSION

Suture augmentation results in similar subfailure joint biomechanical properties as the standard docking reconstruction procedure at both laxity levels in a cadaveric model. There are improvements in the failure mode of suture-augmented specimens compared with standard docking. Graft strain may be modestly reduced in the 1-mm laxity group compared with other reconstruction groups.

CLINICAL RELEVANCE

Suture augmentation at both 1-mm and 3-mm laxity appears to offer similar advantages in subfailure biomechanics to standard docking reconstruction of the mUCL, with some improvements associated with failure mode. Strain data suggest a potential avoidance of graft stress shielding when tensioning the suture augmentation to 3-mm laxity, which is not as apparent with 1-mm laxity.

Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue

PURPOSE

Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants.

METHODS

64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test.

RESULT

Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found.

CONCLUSION

Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

The Influence of Suture-Tape Augmentation on Biological Healing of the Anterior Talofibular Ligament in Chronic Ankle Instability: A Quantitative Analysis Using MRI

While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL.

Comparison of Modified Broström Procedure with or without Suture Tape Augmentation Technique for the Chronic Lateral Ankle Instability

Purpose

To compare the clinical outcomes of the modified Broström repair (MBR) with or without suture tape augmentation (STA) for managing the chronic lateral ankle instability.

Methods

72 patients with chronic lateral ankle instability treated at our hospital from January 2018 to July 2019 were included, with 37 patients receiving the MBR and 35 treated by the MBR with STA. The clinical efficacy of the two techniques was assessed in terms of VAS, AOFAS, and Karlsson scores and by physical examination in follow-ups.

Results

In all 72 patients, operations were successful, and the patients were followed up for 29.3 months on average (range, 24-43 months). There were no significant differences in preoperative pain, AOFAS, and Karlsson scores between the two groups. Compared with preoperative findings, all the functional scores were significantly improved in both groups 3 months after the operation and at the last follow-up. Three months after the operation, the STA group had significantly lower VAS and higher AOFAS scores than the isolated MBR group, suggesting that patients in the STA group suffered less pain and achieved better functional improvement. However, the VAS and functional scores at the last follow-up and the Karlsson score at 3 months postoperatively showed no intragroup difference in both groups.

Conclusion

MBR with or without STA could achieve good results for the treatment of chronic lateral ankle instability. Compared with the widely used MBR, combining with STA may be more effective in promoting rehabilitation in early term.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review

Background:

There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle.

Purpose:

To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed.

Results:

There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I² = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, –3.73 to 6.21]; I² = 66%; P = .63), talar tilt angle improvement (MD, –0.07 [95% CI, –0.68 to 0.54]; I² = 0%; P = .42), or anterior talar translation improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I² = 0%; P = .77).

Conclusion:

Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

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.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study

INTRODUCTION

Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column.

METHODS

In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed.

RESULTS

A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001).

CONCLUSION

In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

INTRODUCTION

Modified Brostrom Gould (MBG) repair is widely accepted procedure for chronic lateral ankle instability (CLAI), but there are limitations with regards to strength of repair and risk of reinjury and complications. Internal brace has been recently used as augmentation of standard MBG repair. It provides stronger construct, facilitates early mobilisation and protects repaired ligament with minimal surgical morbidity. The aim of present study is to compare the outcome of MBG repair without and with Internal brace augmentation (IB) in CLAI.

METHODS

Retrospective analysis of 172 patients with CLAI who underwent MBG repair with or without IBA between November 2017 and October 2019. Patients were evaluated for Visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), Patients subjective satisfaction and return to preinjury activity level.

RESULTS

148 patients were included in the study with 87 in MBG group and 61 in IB group. The mean age, average injury-surgery interval and mean follow up duration was 40.6 ± 11.2 vs 37.5 ± 14.7 years, 13.1 ± 10.3 vs 14.1 ± 8 months and mean follow up duration of 24.2 ± 5.1 vs 20.7 ± 6.0 months respectively (p > 0.05). The mean time to return to preinjury activity level was significantly better in IB group compared to MBG group of 12.1 ± 2.3 vs 20.3 ± 3.9 weeks, p < 0.001. 55 (90.2%) patients in IB and 73 (83.7%) in MBG group return to preinjury activity level. Mean postoperative VAS score (1.9 ± 1.5 vs. 1.7 ± 1.4, p = 0.428), Mean MOxFQ score (19.7 ± 22.2 vs. 18.2 ± 15.4, p = 0.674) showed no significant difference between MBG and IB group respectively, at final follow up.

CONCLUSION

The use of IB augmentation with MBG repair showed significantly better outcome in terms of early rehabilitation and return to preinjury activity level compared to isolated MBG repair. The functional outcome and VAS score were better in IB group compared to MBG group with no significant difference.

LEVEL OF EVIDENCE

Level IV retrospective study.

Improved Outcome and Earlier Return to Activity After Suture Tape Augmentation Versus Broström Repair for Chronic Lateral Ankle Instability? A Systematic Review

PURPOSE

To determine whether the use of suture tape augmentation (ST) would lead to improved clinical outcomes, increased stability, shorter postoperative immobilization, and earlier return to activity and sports compared with Broström repair (BR) in surgical treatment of chronic lateral ankle instability (CLAI).

METHODS

A systematic literature search was performed using Pubmed and Embase according to PRISMA guidelines. The following search terms were used: ankle instability, suture tape, fiber tape, and internal brace. Full-text articles in English that directly compared BR and ST cohorts were included, with a minimum cohort size of 40 patients. Exclusion criteria were former systematic reviews, biomechanical studies, and case reports.

RESULTS

Ultimately, 7 clinical trials were included in this systematic review. Regarding the clinical and radiologic outcomes and complication rates, no major differences were detected between groups. Recurrence of instability and revision surgeries tended to occur more often after BR, whereas irritation of the peroneal nerve and tendons seemed to occur more frequently after ST. Postoperative rehabilitation protocols were either the same for both groups or more aggressive in the ST groups. When both techniques were performed with arthroscopic assistance, return to sports was significantly faster in the ST groups.

CONCLUSIONS

In conclusion, suture tape augmentation showed excellent results and is a safe technique comparable to traditional Broström repair. No major differences regarding clinical and radiologic outcomes or complications were found.

LEVEL OF EVIDENCE

III, systematic review of level I, II, and III studies.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Lateral Collateral Ligament Reconstruction Using Suture-tape for Chronic Varus Metatarsophalangeal Instability of The Hallux

Chronic varus instability or recurrent subluxation following isolated metatarsophalangeal dislocation of the hallux is a rare injury. A young Judo athlete with a history of repetitive sport injuries complained of recurrent medial dislocation of the hallux for 3 years. For prior injuries, he underwent manual reduction under local anesthesia and recovered with splint immobilization. Physical examination and fluoroscopic radiograph demonstrated the reducible but unstable first metatarsophalangeal joint to slight varus stress, and magnetic resonance imaging revealed an insufficient remnant of the lateral collateral ligament. For patients with the failed conservative treatment, no consensus has been reached regarding the best joint-salvage procedure to achieve a restoration of metatarsophalangeal stability and a fast return to sport activity. We report a case who achieved satisfactory clinical outcome through the collateral ligament reconstruction using a suture-tape.

Clinical and Functional Results of Broström-Gould Procedure With Suture Tape Augmentation: An Evaluation Using Three Scales

The mechanical superiority of suture tape augmentation associated with the Broström-Gould procedure for treating lateral ankle instability has been reported. This study aimed to describe functional results using the visual analog scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) scale, and Short Form of Quality of Life Survey (SF-36) in patients with ankle lateral instability who underwent the modified Broström-Gould repair and suture tape augmentation and to determine the recurrence of injury and the impact on the perception of its stability. This retrospective cohort study included patients with lateral ankle instability treated using the modified Broström-Gould procedure and suture tape augmentation from December 2015 to July 2018 with a 6- to 36-month follow-up. Clinical and functional results were evaluated using the 3 aforementioned scales. p ≤ 0.05 was considered statistically significant. Twenty-eight patients were included, 18 (64%) males and 10 (36%) females (mean ± standard deviation age of 33.25 ± 12.73). The mean pre- and postoperative VAS scores were 6 ± 1.18 and 0.53 ± 0.92, respectively. The average pre- and postoperative AOFAS scores were 65.89 ± 15.08 and 94.60 ± 6.88, respectively; results were excellent (91 to 100) in 18 (64%) patients and good (81 to 90) in 10 (36%). Three patients experienced recurrence of injury treated with physical therapy, and their progress was satisfactory; stability perception was maintained. Excellent clinical and functional results were demonstrated in our study using suture tape augmentation in the modified Broström-Gould procedure, which probably protects against the recurrence of lateral ankle instability.

Comparison of Open Anterior Syndesmotic Repair Augmented With Suture-Tape and Trans-syndesmotic Screw Fixation: A Biomechanical Study

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.

Is generalized ligamentous laxity a contraindication for a modified Broström operation to treat chronic lateral ankle instability? A systematic review

BACKGROUND

To investigate whether generalized ligamentous laxity (GLL) really is a contraindication for use of the modified Broström operation to treat chronic lateral ankle instability (CLAI).

METHODS

Case series and cohort studies of the clinical outcomes of the use of the modified Broström operation to treat patients with CLAI and GLL were systematically reviewed and a meta-analysis conducted.

RESULTS

A total of 447 patients (458 ankles) from 2 case series and 3 cohort studies were systematically analyzed, with mean follow-up times that ranged from 12 to 108 months. Postoperative foot and ankle values analyzed included foot and ankle outcome scores, foot and ankle ability measurements, Karlsson-Peterson ankle scores, American orthopedic foot and ankle society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, anterior talar translations (ATT), talar tilt angles (TTA) and adverse events. Reliable postoperative ankle stability was achieved in CLAI patients with GLL in the 2 case series without major complications. Suture-tape augmentation combined with a modified Broström operation was employed in 1 case series, and the modified Broström operation was only performed in CLAI patients with GLL if the contralateral uninjured ankle showed normal TTA and ATT in another case series. In the 3 cohort studies, 2 reported poorer outcomes and a significantly greater failure rate in patients with GLL compared with those without GLL, and 1 reported equivalent clinical results. In the further pooled data analysis, there was a significant difference in the postoperative TTA value between the GLL and non-GLL groups (SMD: 0.885, 95% CI [0.599-1.171], P = 0.000; I² = 98%, P = 0.000). The incidence of postoperative recurrent instability was significantly higher in the GLL group (RR: 6.265, 95% CI [2.563-15.309], P = 0.000; I² = 0%, P = 0.985). Two studies reported the preoperative Beighton score in 7 ankles with postoperative recurrent instability, 6 of which had a preoperative Beighton score ≥7.

CONCLUSIONS

GLL may not be a contraindication to the modified Broström operation being used to treat CLAI. However, some augmentation operations may be combined with the classic modified Broström operation, especially for those patients with preoperative Beighton scores ≥7, or with abnormal ATT and TTA in the contralateral ankle. This assertion should be further confirmed by a prospective, large-sample cohort and control study focused on this special population who are at a higher risk of developing postoperative instability.

LEVEL OF CLINICAL EVIDENCE

Level 3.

Arthroscopic Surgical Technique for Lateral Ankle Ligament Instability

In the past several years, arthroscopic repair of the lateral ankle ligaments has grown because it has shown comparable results with the traditional open Brostrom-Gould procedure. In addition, arthroscopic repair allows reduced swelling and cosmesis. This article discusses the authors' technique for lateral ankle instability, with published data supporting biomechanical equivalency to the standard open Brostrom-Gould procedure. An optional internal brace can provide further strength to the repair and lead to a quicker recovery. Arthroscopic repair both with and without the internal brace have shown positive clinical outcomes for patients as well as high satisfaction rates.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.

Knotless anchor repair produced similarly favourable outcomes as knot anchor repair for anterior talofibular ligament repair

PURPOSE

To compare clinical function after knot anchor versus knotless anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability.

METHODS

All patients who underwent arthroscopic surgical ATFL repair using knot or knotless suture anchors were included in this study. Functional scores (American Orthopedic Foot and Ankle Society (AOFAS), Karlsson score and Tegner activity scores) and magnetic resonance imaging (MRI) were used to evaluate the ankle with a follow-up of at least 2 years.

RESULTS

A total of 52 patients with chronic ankle instability were included in this study. Among these patients, 23 patients underwent one knot anchor repair procedure (Group A), and the other 29 patients underwent one knotless anchor repair procedure (Group B). At the final follow-up, there were no significant differences between Group A and Group B regarding the AOFAS score (89 ± 9 vs 84 ± 11; ns), Karlsson score (82 ± 14 vs 75 ± 18; ns), or Tegner activity score (4 ± 1 vs 4 ± 2; ns). There also were no significant differences in the mean ATFL signal-noise ratio (SNR) value (7.5 ± 4.4 vs 7.3 ± 2.9; ns) or ATFL angle (82° ± 7° vs 84° ± 9°; ns) between the groups.

CONCLUSION

When compared with knot repair, knotless repair of the lateral ankle ligament produced similar functional outcomes.

LEVEL OF EVIDENCE

III.

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability

Syndesmotic instability is a source of significant pain and disability. Both subtle instability and gross diastasis, whether acute or chronic, require stabilization and may benefit from reconstruction with ligamentous augmentation. The use of nonabsorbable suture-tape has emerged as a promising operative strategy, allowing surgeons to anatomically reconstruct the syndesmosis, in particular the anterior inferior tibiofibular ligament. The current work provides a detailed description of the technique and preliminary results of a patient cohort treated using nonabsorbable suture-tape for syndesmotic augmentation.Level of Evidence: Level V, expert opinion.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability

Background

Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.

Purpose

To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.

Results

A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.

Conclusion

No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

Return to Play in Athletes After Thumb Ulnar Collateral Ligament Repair With Suture Tape Augmentation

Background:

Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. These tears often occur as a result of a radially directed force on an extended thumb. To date, no literature exists on the use of suture tape augmentation for repair of the thumb UCL in a competitive athlete cohort.

Hypothesis:

Using suture tape augmentation for the thumb UCL will allow for a safe and expedient return to play in competitive athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective chart review was completed to identify all patients who underwent operative primary thumb UCL repair between 2014 and 2018. All procedures were performed at a single institution by the senior author. Inclusion criteria were acute complete tears of the thumb metacarpophalangeal joint UCL, treated with primary repair via suture tape augmentation in competitive high school, collegiate, or professional athletes. Exclusion criteria included recreational athletes, patients who underwent reconstruction (rather than repair), and patients with insufficient follow-up to establish return to play. Charts of patients identified through the retrospective review were further evaluated to determine patient- and injury-related variables. Return to play was defined as return to game competition and stratified as to whether this was at the same level of competition or any level of competition.

Results:

A total of 18 thumbs in 17 competitive high school, collegiate, and professional athletes were included in this study. One of the professional basketball players sustained injury to both thumbs approximately 10 months apart. The study group comprised 4 collegiate baseball players, 6 professional baseball players, 3 professional basketball players, 1 professional hockey player, 1 amateur-level hockey player, 1 high school basketball player, and 1 high school volleyball player. Mean follow-up was 27.9 months, and no complications were noted. Athletes who sustained an in-season injury (n = 13; 72.2%) returned to play at any level at a mean ± SD of 30.9 ± 10.1 days and at the same level at 36.3 ± 11.2 days. Athletes who sustained an out-of-season injury (n = 5; 27.8%) returned to play at any level at 101.4 ± 86.6 days and at the same level at 114.6 ± 87.0 days.

Conclusion:

The findings presented here offer evidence for return to play in competitive high school, collegiate, and professional athletes with a thumb UCL tear treated with repair and suture tape augmentation. All athletes returned to the same level of play. Those attempting to return in-season returned to the same level of play at a mean of just under 5 weeks. Augmenting the repair with anchored suture may prevent prolonged immobilization, expedite thumb motion, and improve postoperative recovery.

Arthroscopically Assisted Tape Augmentation for Anterior Talofibular Ligament Repair

In this Technical Note, we describe arthroscopically assisted tape augmentation of a modified Broström repair for chronic lateral ankle instability. Specifically, this technique involves talar anchor placement under direct arthroscopic visualization combined with a minimally invasive approach for anatomic anterior talofibular ligament repair and FiberTape (Arthrex, Naples, FL) augmentation. The primary advantage of our technique compared with open InternalBrace (Arthrex) techniques is that only a 2-cm incision is made and no subcutaneous suture passing and knot tying are required, which bear the danger of superficial peroneal nerve damage. In addition, the risk of nonanatomic anchor placement is diminished owing to direct arthroscopic visualization and preparation of the anterior talofibular ligament remnants.

Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability

PURPOSE

The aim of the study was to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. The hypothesis of the presented study is that suture-tape augmentation technique has comparable clinical and radiological outcomes with arthroscopic Broström repair technique.

METHODS

Sixty-one consecutive patients with chronic ankle instability were operated between 2012 and 2016 randomized to 2 groups. First group was composed of 31 patients whom were operated using an arthroscopic Broström repair technique (ABR) and second group was composed of 30 Patients whom were operated using arthroscopic lateral ligaments augmentation using suture-tape internal bracing (AST). At the end of total follow-up time, all patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiological evaluation was performed using anterior drawer and varus stress radiographs with standard Telos device in 150 N. Talar tilt angles and anterior talar translation were measured both preoperatively, 1 year postoperatively and at the final follow-up.

RESULTS

Preoperative total FAOS scores for ABR and AST groups were 66.2 ± 12 and 67.1 ± 11, respectively. Postoperative Total FAOS scores for ABR and AST groups were 90.6 ± 5.2 and 91.5 ± 7.7, respectively. There was no statistical difference in between 2 groups both pre- and postoperatively (n.s). According to FAAM, sports activity scores of ABR and AST groups were 84.9 ± 14 and 90.4 ± 12 at the final follow-up, which showed that AST group was significantly superior (p = 0.02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Mean operation time for AST and ABR groups were 35.2 min and 48.6 min, respectively, which shows statistically significantly difference (p < 0.05). There was no significant difference in recurrence rate of instability between to operation techniques (n.s).

CONCLUSIONS

Arthroscopic lateral ligament augmentation using suture tape shows comparable clinical outcomes to arthroscopic Broström repair in the treatment of chronic ankle instability at intermediate-term follow-up time. Arthroscopic lateral ligament augmentation using suture tape has a significant superiority in the terms of less operation time and no need for cast or brace immediate after surgery which allows early rehabilitation. It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life.

LEVEL OF EVIDENCE

II.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace

BACKGROUND

Current ulnar collateral ligament (UCL) reconstruction techniques are substantially less stiff and demonstrate lower load to failure compared with the native UCL. UCL repair with the addition of an internal brace has demonstrated superior biomechanical performance compared with docking UCL reconstruction, but internal bracing has not yet been used in UCL reconstruction.

HYPOTHESIS/PURPOSE

To evaluate the time-zero biomechanical performance of a UCL docking technique reconstruction with and without an internal brace compared with native UCL properties.

METHODS

Twelve matched pairs of cadaveric elbows were dissected and fixed at 90° for biomechanical testing. A cyclic valgus torque protocol was used to test the anterior band of the UCL in native specimens. After native specimens were failed, palmaris grafts were used for a docking reconstruction with or without internal brace and were subjected to the same valgus torque test protocol. Torsional stiffness, ultimate failure torque, and ulnohumeral gapping were determined.

RESULTS

Stiffness in UCL reconstructions using a standard docking technique (3.0 ± 0.4 N m/deg) were significantly less stiff (P < .001) than native UCL (4.0 ± 0.8 N m/deg), whereas reconstructions using an internal brace (3.6 ± 0.6 N m/deg) were not different (P = .120) compared with native. Ultimate failure torque for standard docking (18.3 ± 4.1 N m) was significantly lower (P < .001) than native UCL (36.9 ± 10.1 N m), whereas the internal brace samples (35.3 ± 9.8 N m) were not different (P = .772) than native.

CONCLUSION

UCL reconstruction with an internal brace augmentation provides superior stiffness and time-zero failure strength when compared with the standard docking technique.

In vivo assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study

AIMS

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

MATERIALS AND METHODS

A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).

RESULTS

At eight weeks, FiberTape alone or FiberTape-augmented autograft demonstrated increased biomechanical stability compared with autograft regarding ultimate load to failure (p = 0.035), elongation (p = 0.006), and energy absorption (p = 0.022). FiberTape-grafted samples also demonstrated increased bone mineral density in the bone tunnel (p = 0.039). Histological evaluation showed integration of all grafts in the bone tunnels by new bone formation, and limited signs of inflammation overall. A lack of prolonged inflammation in all samples was confirmed by quantification of inflammation biomarkers. However, no regeneration of ligament-like tissue was observed along the suture tape materials. Except for one autograft failure, no adverse events were detected.

CONCLUSION

Our results indicate that FiberTape increases the biomechanical performance of intra-articular ligament reconstructions in a verified rabbit model at eight weeks. Within this period, FiberTape did not adversely affect bone tunnel healing or invoke a prolonged elevation in inflammation. Cite this article: Bone Joint J 2019;101-B:1238-1247.

InternalBrace has biomechanical properties comparable to suture button but less rigid than screw in ligamentous lisfranc model

Purpose

The aim of this study was to investigate the biomechanical properties of the InternalBrace for lisfranc injuries.

Methods

A Sawbone model was developed comparing screw, suture button and InternalBrace.

Results

When loaded in axial tension at 0.5 mm/s, the screw was stiffest (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Cyclic loading with 10,000 cycles of 69 N, 138 N, and 207 N showed the InternalBrace maintained stiffness, but fatigued earlier than the suture button.

Conclusion

The mechanical properties of the InternalBrace support clinical use, but further studies are needed regarding early weight bearing.

Stabilizing lateral ankle instability by suture tape - a cadaver study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomechanical evaluation of different ankle orthoses in a simulated lateral ankle sprain in two different modes

Ankle orthoses are commonly used for prevention of recurrent ankle sprains. While there are some data on their functional performance or restriction of range of motion, there is little knowledge on the quantifiable passive mechanical effectiveness of various devices. This study aimed to determine the prophylactic stabilization effect for commonly prescribed ankle orthoses in a simulated recurrent ankle sprain. Eleven anatomic lower leg specimens were tested in plantar flexion and hindfoot inversion in a simulated ankle sprain in a quasi-static and dynamic test mode at 0.5°/s and 50°/s internal rotation, respectively. Tests included intact specimens, same specimens with the ruptured anterior talofibular ligament (ATFL), followed by stabilization with five different semi-rigid orthoses: AirGo Ankle Brace, Air Stirrup Ankle Brace, Dyna Ankle 50S1, MalleoLoc, and Aequi. Compared to the injured and unprotected state, two orthoses (AirGo and Air Stirrup) significantly reinforced the ankle. The Aequi ankle brace restored stability comparable to an intact joint. Dyna Ankle 50S1 and MalleoLoc provided insufficient resistance to applied internal rotation compared to the ankle with ruptured ATFL. Ankle orthoses varied significantly in their ability to stabilize the unstable ankle during an ankle sprain in both testing modes. Presented objective data on passive stabilization reveal a lack of supporting evidence for clinical application of ankle orthoses.

Effect of Lateral Ligament Augmentation Using Suture-Tape on Functional Ankle Instability

BACKGROUND:

Although lateral ligament augmentation using suture-tape has been effective for restoration of mechanical ankle stability, few data are available regarding changes of peroneal strength, proprioception, and postural control. The aim of this study was to determine effects of suture-tape augmentation on functional ankle instability (FAI).

METHODS:

Twenty-four patients who underwent suture-tape augmentation were eligible and were followed more than 2 years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test.

RESULTS:

CAIT and FAAM (average of daily and sports activity scores) significantly improved to average 27.2 points and 86.7 points, respectively, at final follow-up. Peak torque for eversion in 60 degrees/s angular velocity significantly improved to 10.6 Nm at final follow-up. Deficit ratio of peak torque for eversion significantly improved from mean 39.5% to 20.9%, and significant side-to-side difference was revealed ( P < .001). There were no significant differences in joint position sense. A significant improvement in balance retention time was revealed at final follow-up, and the relative deficit ratio compared to the unaffected side was 30.9%.

CONCLUSIONS:

Patient-reported functional outcomes significantly improved after lateral ligament augmentation using suture-tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were not significant at the intermediate-term follow-up. In addition, there was no positive effect on proprioception of the ankle.

LEVEL OF EVIDENCE:

Level IV, prospective case series.

A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability

BACKGROUND

Although various minimally invasive procedures for chronic ankle instability are increasingly being used, a question regarding whether these procedures can be a viable alternative of the modified Broström procedure remains controversial. This study was conducted to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients.

METHODS

Sixty female patients with chronic lateral ankle instability were randomly assigned and underwent surgical treatments by one surgeon. Twenty-eight patients with suture-tape augmentation and 27 modified Broström procedures were followed ≥2 years and analysed in this comparative study. The clinical evaluation included the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and stress radiographs. Medical expense related with operation was analysed to evaluate the cost-effectiveness.

RESULTS

There were no statistically significant differences in the clinical outcomes between two procedures based on FAOS, FAAM, recurrence rate of instability, and stress radiographs. Total medical expense was approximately 1.3 times more in the suture-tape group (P<0.001), despite shorter operation time.

CONCLUSIONS

Lateral ankle ligaments augmentation using suture-tape showed the similar clinical outcomes but low cost-effectiveness, as compared to modified Broström repair for young female patients with chronic ankle instability.

Revision of Surgical Lateral Ankle Ligament Stabilization

Ankle sprains continue to be among the most common musculoskeletal injuries, most of which never require surgical treatment. Surgical treatment has traditionally been successful for those patients whose symptoms do not improve with nonoperative care. However, recurrent instability, although rare, can occur early or late after a stabilization procedure, as the result of an acute traumatic event or chronic repetitive minor injury. A complete workup of patients with recurrent ankle instability should be completed before revision surgery and should include evaluation for generalized joint hypermobility as well as anatomic variations, such as hindfoot varus, first ray plantarflexion, and midfoot cavus.

Suture-button fixation and anterior inferior tibiofibular ligament augmentation with suture-tape for syndesmosis injury: A biomechanical cadaveric study

BACKGROUND

Suture-button (SB) fixation has been widely performed for syndesmosis injuries, but it has been reported unstable in some biomechanical studies. The purpose of this study was to evaluate the stability of the syndesmosis using SB fixation with anterior inferior tibiofibular ligament augmentation using suture-tape (ST).

METHODS

Eight normal fresh-frozen cadaveric legs were used. After initial tests of intact and injured models, SB fixation, SB fixation with ST augmentation, ST augmentation alone, and screw fixation were performed sequentially for each specimen. Loading tests stimulating dorsiflexion, inversion, and external rotation of the ankle joint were performed for each model. The tibiofibular diastasis (TFD) and the fibular rotational angle related to the tibia (FRA) were measured using a magnetic tracking system.

FINDINGS

In the injured model, both TFD and FRA increased significantly compared with the intact model in all directions (P < .05). In the SB fixation model, TFD and FRA generally showed significant increases (P < .05, except for TFD in external rotation). In the SB fixation with ST augmentation model and ST augmentation alone, TFD and FRA were not significantly different compared with the intact model (P > .05). In the screw fixation model, FRA with inversion force at the ankle was significantly decreased compared with the intact model (P = .027).

INTERPRETATION

SB fixation alone did not provide stability of the syndesmosis, and screw fixation became too rigid compared with the intact model. Using ST augmentation achieved dynamic stability similar to the intact model for syndesmotic injuries.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Surgical Procedures for Chronic Lateral Ankle Instability

Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.

Revision with suture-tape augmentation after failed collateral ligament reconstruction for chronic interphalangeal instability of the hallux

Chronic varus instability or recurrent subluxation following isolated interphalangeal dislocation of the hallux is a rare injury. No consensus has been reached regarding the best joint-salvage procedure for patients with the failed collateral ligament reconstruction using tendon graft. We report a case who achieved satisfactory clinical outcome through a modified surgical procedure (revision collateral ligament reconstruction augmented with suture-tape).

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

AIMS

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

PATIENTS AND METHODS

A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs.

RESULTS

The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon.

CONCLUSION

The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183-9.

Allograft tendon reconstruction of the anterior talofibular ligament and calcaneofibular Ligament in the treatment of chronic ankle instability

Background

The purpose was retrospectively to investigate functional and clinical outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) reconstruction using a single allograft.

Methods

Patients with severe chronic lateral instability of the ankle underwent surgery after conservative treatment failed. Ultrasounds of the ankle were performed, and if the AFTL and CFL were completely torn without enough soft tissue for repair, the ligaments were reconstructed using allograft tendon. Outcomes were assessed by clinical examination, stress radiography, ultrasound, the American Orthopaedic Foot and Ankle Society score (AOFAS), and Karlsson Ankle Functional score (KAFS) before surgery and at final follow-up.

Results

Nineteen patients, ten men and nine women with mean age of 27.9 years (range, 19–41 years), underwent reconstruction. Mean follow-up was 30 months (range, 24–40 months). At final follow-up, all patients had returned to activity without instability, pain, or limited range of motion. On stress radiography, mean talar tilt angle decreased from 17.32° ± 3.58° before surgery to 4.16° ± 1.12° at follow-up (p < 0.001). Mean anterior drawer test (ADT) distance decreased from 9.79 ± 1.01 mm before surgery to 3.97 ± 0.99 mm at follow-up (p < 0.05). Mean AOFAS improved from 64.00 ± 18.43 to 90.32 ± 5.17 points (p < 0.001), and mean KAFS improved from 50.84 ± 16.73 to 90.89 ± 5.08 points (p < 0.001). Ultrasound showed the reconstructed ligaments maintained good continuity and excellent tension. No case of infection and immunological rejection was reported.

Conclusion

This novel reconstruction technique takes into account the anatomical specialty of AFTL and CFL. This case series showed increased stability of the ankle in clinical and functional outcomes.

Trial registration

The trial registration number (TRN) and date of registration: ChiCTR-ORC-17010796, Mar 6th 2017. Retrospectively registered.

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

BACKGROUND

Although recent biomechanical studies have reported mechanical superiority of augmented anterior talofibular ligament reconstruction using suture-tape, clinical evidence regarding the efficacy of suture-tape augmentation is still insufficient. This prospective study was performed to evaluate the outcomes of the modified Broström procedure augmented with suture-tape for chronic ankle instability with generalized ligamentous laxity, which has been known to be a poor prognostic factor for anatomic ligament repair.

METHODS

Twenty-eight patients with generalized ligamentous laxity were followed for more than 2 years after the augmented modified Broström procedures for chronic ankle instability. Generalized ligamentous laxity was defined as a Beighton score ≥4 points. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) score. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate mechanical ankle stability.

RESULTS

FAOS and FAAM scores had significantly improved from preoperative average 63.2 and 54.3 points to 90.6 and 89.5 points at final follow-up, respectively ( P < .001). Talar tilt angle and anterior talar translation had significantly improved from preoperative average 16.2° and 12.1 mm to 3.6° and 4.2 mm at final follow-up, respectively ( P < .001). Preoperative side-to-side comparison with stress radiographs was significantly different, but this returned to within nonstatistical differences at final follow-up, respectively ( P = .105, .532). Although 6 patients sustained an ankle sprain after operation, only 1 patient (3.6%) showed a recurrence of subjective and mechanical instability.

CONCLUSIONS

Suture-tape augmentation for the modified Broström procedure appears to be an effective operative alternative for chronic ankle instability with generalized ligamentous laxity. As one of the methods to improve the clinical outcomes in patients with relative contraindications of the modified Broström repair, this procedure provided reliable stability with the advantages of anatomic ligament repair through the augmentation using suture-tape.

LEVEL OF EVIDENCE

Level IV, prospective case series.

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.

Generalized Ligamentous Laxity Is an Independent Predictor of Poor Outcomes After the Modified Broström Procedure for Chronic Lateral Ankle Instability

BACKGROUND

The modified Broström procedure for chronic lateral ankle instability (CLAI) has presented outstanding clinical results. However, after the procedure, some patients with generalized ligamentous laxity have experienced a recurrence of ankle instability.

PURPOSE

To understand the effect of generalized ligamentous laxity on prognosis and risk of recurrence in a cohort of patients with CLAI after the modified Broström procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 199 ankles from 188 patients underwent the modified Broström procedure for CLAI with a mean follow-up of 60.1 months (range, 48-108 months). Generalized ligamentous laxity was assessed in all patients. The Karlsson-Peterson ankle score (Karlsson score), talar tilt angle, and anterior displacement of the talus were used to evaluate clinical and radiological outcomes. Risk factors associated with clinical outcomes were evaluated using bivariate analysis and logistic regression analysis. Survival outcomes were compared using Kaplan-Meier analysis.

RESULTS

Generalized ligamentous laxity was evident in 42 cases (21.1%). The average Karlsson score improved from 54.6 ± 7.1 preoperatively to 87.9 ± 7.2 at last follow-up (P < .001). The presence of generalized ligamentous laxity was significantly associated with poor clinical and radiological outcomes. The rates of clinical failure were 10.8% and 45.2% in the nonlaxity group and the laxity group, respectively (P < .001). According to bivariate analysis, generalized ligamentous laxity, syndesmosis widening, osteochondral lesion of the talus, high preoperative talar tilt angle (>15°), and high preoperative anterior displacement of the talus (>10 mm) were significantly associated with clinical failure. Multivariate logistic regression analysis revealed that generalized ligamentous laxity was the most important independent predictor of clinical failure after the modified Broström procedure. The cumulative success rates for the nonlaxity group were significantly superior to those for the laxity group in Kaplan-Meier curves (P < .001).

CONCLUSION

Generalized ligamentous laxity is an independent predictor of poor outcomes and a risk factor of recurrent instability following the modified Broström procedure for CLAI.