Repair of only anterior talofibular ligament resulted in similar outcomes to those of repair of both anterior talofibular and calcaneofibular ligaments

[Injuries of the ankle ligaments]

Lateral ligament injuries are the most common injuries of the ankle joint and are usually treated with early weight bearing after a short period of immobilization. If the clinical presentation is suspicious, additional injuries to the deltoid ligament complex and the syndesmosis should be considered. The indications for additional diagnostics should be generously applied. Injuries to the deltoid ligament usually occur as part of a complex ankle injury and should also be addressed in the surgical treatment of accompanying injuries. Chronic instability in this area necessitates complex bony and soft tissue procedures. Syndesmotic injuries with insufficiency of the capsule-ligament apparatus are frequent in ankle fractures and are stabilized during fracture treatment. Isolated syndesmotic instability should also be surgically treated as chronic injuries are usually associated with poor clinical results and early osteoarthritis.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability

It is important to eliminate instability related to chronic lateral ankle instability (CLAI) to prevent osteoarthritis progression. We performed arthroscopic anterior talofibular ligament (ATFL) repair and performed calcaneofibular ligament (CFL) repair if instability remained. This study aimed to assess the clinical outcomes of our arthroscopic procedure compared to that of open surgery. Forty ankles underwent arthroscopic surgery and 23 ankles underwent open surgery to repair the lateral ankle ligaments for CLAI. In the arthroscopic surgery, varus stress was applied under fluoroscopy after ATFL repair, and CFL repair was performed if instability remained. Open surgery was performed using the Broström procedure with ATFL and CFL repair. To assess clinical outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) and Karlsson-Peterson (KP) scores were collected preoperatively and at the final follow-up. The talar tilt angle (TTA) was measured preoperatively and 1 year postoperatively. The arthroscopic group showed significantly higher AOFAS and KP scores at the final follow-up compared to the open surgery group. There was no significant difference in TTA at 1 year between the groups. In open surgery, 2 patients required revision surgery. There were no major complications, but scar-related pain in 2 cases of open surgery was reported. Arthroscopic ATFL repair with the CFL repair gave satisfactory clinical outcomes compared to open surgery in CLAI because of low invasive to soft tissue including the joint capsule. It is important to minimize soft tissue dissection in repairing the lateral ankle ligament in patients with CLAI.

Biomechanical improvement of anterior talofibular ligament by augmentation repair of ligament advance reinforcement system: a cadaver study

BACKGROUND

Ankle sprain are one of the most frequent sports injuries. Some individuals will develop chronic lateral ankle instability (CLAI) after ankle sprain and suffer from recurrent ankle sprain. Current surgical treatment of CAI with anterior talofibular ligament (ATFL) rupture fails to restore the stability of the native ATFL. Ligament Advance Reinforcement System (LARS) augmentation repair of ATFL was developed to improve its primary stability after repaired.

METHODS

This study was performed to evaluate whether LARS augmentation repair of ATFL had similar stability as the modified Broström repair and the intact ATFL to maintain ankle construct stability. Standardized surgical techniques were performed on eighteen fresh frozen cadaver ankle specimens. The intact ATFL group has just undergone an ATFL exploratory surgery. The modified Broström procedure is based on anatomical repair of the ATFL with a 2.9 mm suture anchor, and the LARS procedure is an augmentation procedure of the ATFL using LARS ligaments based on the modified Broström procedure. A dynamic tensile test machine was used to assess load-to-failure testing in the three groups. The ultimate failure load and stiffness were calculated and reported from the load-displacement curve. A one-way analysis of variance was used to detect significant differences (p < 0.05) between the LARS augmentation repair, the modified Broström repair and the intact ATFL, followed by least significant difference (LSD) post-hoc tests.

RESULTS

The LARS augmentation repair group showed an increased in ultimate failure to load and stiffness compared to the other two groups. There were no significant differences in ultimate failure to load and stiffness between the modified Broström and the intact ATFL, the LARS ligament for ATFL augmentation allows for improved primary stability after repair and reduced stress on the repaired ATFL, which facilitates healing of the remnant ligament.

CONCLUSIONS

The LARS augmentation repair of ATFL represents a stable technique that may allow for the ankle stability to be restored in patients with CAI after surgery.

Stepwise decision making for CFL repair in addition to arthroscopic ATFL repair yields good clinical outcomes in chronic lateral ankle instability regardless of the remnant quality

BACKGROUND

Although arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed, there are several issues such as the efficacy of the isolated ATFL repair for the ATFL and calcaneofibular ligament (CFL) injury and the influence of the poor remnant on the clinical outcomes to be discussed. This study aimed to evaluate clinical outcomes of the arthroscopic ATFL repair with the stepwise decision regarding the requirement of CFL repair and the influence of remnant qualities on clinical outcomes.

METHODS

Forty-four ankles underwent arthroscopic surgery to repair the lateral ankle ligament for CLAI. After arthroscopic ATFL repair, CFL repair was performed if instability remained. Clinical outcomes including the Karlsson-Peterson (KP) scores, Japanese Society for Surgery of the Foot (JSSF) scale, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were assessed at the final follow-up. ATFL remnants were classified into excellent, moderate, and poor according to the arthroscopic findings, and the clinical outcomes of each remnant group were compared.

RESULTS

Twenty-five ankles were required for CFL repair after ATFL repair. K-P score was significantly improved from 66.1 ± 5.3 to 94.8 ± 6.5 points (p < 0.01). JSSF scale was significantly improved from 70.5 ± 4.5 to 95.9 ± 6.0 points (p < 0.01). The SAFE-Q was also significantly improved on all subscales. There were no significant differences in clinical outcomes among excellent, moderate, and poor remnants.

CONCLUSIONS

Stepwise decision for CFL repair in addition to arthroscopic ATFL repair gave satisfactory clinical outcomes in CLAI regardless of the remnant quality.

Risk Factors for the Recurrence of Instability After Lateral Ankle Ligament Repair

BACKGROUND

Arthroscopic anterior talofibular ligament (ATFL) repair is widely performed for chronic lateral ankle instability (CLAI). Although many studies have reported excellent outcomes with this procedure, the recurrence of instability remains a common concern. Therefore, this study aimed to analyze the risk factors for the recurrence of instability after arthroscopic repair for CLAI.

METHODS

Fifty-six ankles of 53 patients with a mean age of 31.8 ± 14.7 years were retrospectively reviewed. All patients underwent arthroscopic ATFL repair. If instability remained immediately after ATFL repair, calcaneofibular ligament (CFL) repair was performed. The Ankle Activity Score (AAS) was assessed preoperatively, and clinical outcomes including the Japanese Society for Surgery of the Foot scale, Karlsson-Peterson scores, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were evaluated preoperatively and at the final follow-up. Talar tilt angle (TTA) was assessed preoperatively and 1 year postoperatively. Ankles were divided into 2 groups-nonrecurrence (postoperative TTA, <6 degrees) and recurrence (postoperative TTA, ≥6 degrees)-and clinical outcomes were compared.

RESULTS

Sixteen ankles showed recurrent instability, whereas 40 did not. AAS, TTA, and social functioning in the SAFE-Q were significantly higher in the recurrence group than those in the nonrecurrence group preoperatively. In addition, the rate of poor ATFL remnant quality and the number of CFLs not repaired despite the preoperative injury diagnosis were significantly higher in the recurrence group than in the nonrecurrence group.

CONCLUSION

Arthroscopic repair for ATFL and CFL deficiencies with preoperative high activity, poor remnant quality, and neglected CFL injury can result in the recurrence of instability. Appropriate surgical procedures to prevent the recurrence of instability should be selected for these ankles.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Lateral ankle instability - repair/ reconstruct what's new

Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.

Mid-term follow-up evaluation of a new arthroscopic Broström procedure for chronic lateral ankle instability

BACKGROUND

Chronic lateral ankle instability (CLAI) usually progresses from a previous lateral ankle sprain that was not treated properly. Several procedures have been introduced to address these patients, including open or arthroscopic techniques, the most common of which is the Broström procedure. Here, we describe a new outside-in arthroscopic Broström procedure and its results for treating patients with CLAI.

METHODS

Thirty-nine patients (16 male and 23 female; mean age, 35 years [range, 16-60 years]) with CLAI were treated arthroscopically after failing non-operative management. All patients were symptomatic with a combination of recurrent ankle sprains, "giving way," and avoidance of sports and presented with a positive anterior drawer test upon the physical examination. All patients underwent arthroscopic lateral ligament reconstruction using the new technique. Patient characteristics and pre- and postoperative visual analog scale (VAS), American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale system (AOFAS), and Karlsson scores were recorded.

RESULTS

The mean AOFAS score increased from 48 (mean 48, range 33-72) preoperatively to 91 (mean 91, range 75-98) at the final follow-up, Karlsson-Peterson and FAAM scores were also significantly improved. Two patients (5.13%) reported superficial peroneal nerve irritation symptoms postoperatively. Three patients (7.69%) complained of mild pain anteroinferior to the lateral ankle.

CONCLUSIONS

The arthroscopic outside-in Broström procedure with a single suture anchor was a safe, effective, and reproducible technique for CLAI. Ankle stability resumed with a high clinical success rate. The main complication was injury to the superficial peroneal nerve, which crossed the area of repair.

Clinical significance of the anteromedial talus osteophyte in anteromedial ankle impingement in chronic lateral ankle instability

PURPOSE

The aim of this study was to evaluate the relation between anteromedial ankle osteophytes (AMAO) and anteromedial ankle impingement (AMAI) in chronic lateral ankle instability (CLAI) through visualization and quantification.

METHODS

Forty-three patients with unilateral CLAI between September 2018 and March 2020 accepted arthroscopic repair of an anterior talofibular ligament (ATFL) and were split into two groups: AMAI (AMAI including intraoperative AMAO resection) and pure CLAI (with AMAO but without AMAI, no AMAO resection). The AMAO protrusion lengths in each direction were measured and compared after all of the ankles were reconstructed. All patients were assessed preoperatively and at 2-year follow-up with ankle dorsiflexion, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and visual analog scale (VAS) score.

RESULTS

Intelligent analysis showed that a large extent of osteophytes was found at the dorsomedial surface of the talar neck in AMAI group. The upper and inner bound protrusion distances of AMAO in AMAI group were greater than in the pure CLAI group. There was no significant difference in anterior bound protrusion distance of AMAO between the two groups. Preoperatively, the ankle dorsiflexion of AMAI group (7.6 ± 1.4°) was considerably lower than that of pure CLAI group (22.4 ± 1.9°) (p < 0.001). When compared to the pure CLAI group, the AMAI group had a substantially worse AOFAS score (62.2 ± 6.7 vs 71.1 ± 9.1; p < 0.001) and VAS score (6.0 ± 1.0 vs 4.9 ± 0.8; p < 0.05). However, there was no significant difference in postoperative ankle dorsiflexion, AOFAS score, or VAS score between the two groups.

CONCLUSION

AMAO is formed mostly on the dorsomedial surface of the talar neck in CLAI with AMAI, and the upper and inner bound protrusion lengths of AMAO were shown to be significantly correlated with the existence of AMAI in CLAI.

LEVEL OF EVIDENCE IV

Platelet-rich plasma, a biomaterial, for the treatment of anterior talofibular ligament in lateral ankle sprain

Background: Because of the rising prevalence of anterior talofibular ligament (ATFL) damage, there is a considerable interest in developing innovative techniques to improve the biological healing response of ATFL. Platelet-rich plasma (PRP) includes several growth factors linked to a favorable healing response, however none of the studies involved both quality evaluation and clinical results to evaluate this treatment. Purpose: To determine the clinical results of PRP injections into the ATFL in lateral ankle sprain (LAS) patients, as well as the quality of the ATFL based on radiographic outcomes. Methods: Patients with clinically confirmed grade II LAS for the first time (n = 83) were examined. The clinical outcomes of three types of injection methods were evaluated: none, once within 48 h after the sprain, and once more 4 weeks later after first injection. PRP was injected into the tear site of the ATFL using ultrasound guidance, and all ankles were immobilized for 2 weeks. The American Orthopedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) were used to assess the results at 2, 6, 8, 24, and 48 weeks of follow-up. The signal/noise ratio (SNR) value of Magnetic Resonance Imaging (MRI)-based ATFL signal intensity can disclose ATFL quality. The ATFL SNR results were then assessed 8, 24 and 48 weeks following the first injection to compare ATFL quality. Results: The PRP injection groups outperformed the control group in terms of clinical outcomes, and the two injections group outperformed other groups in terms of pain reduction and functional outcome at 8 weeks. The clinical results of all groups were comparable at 6 and 12 months follow-up. ATFL SNR findings improved significantly across all groups over time. At the same follow-up time, the PRP injection groups outperformed the control group, and the best SNR result showed in the two injections group at the final follow-up. Conclusion: PRP injection helped relieve early symptoms of LAS, although all patients saw a similar development after 6 months. The two PRP injections group produced considerably better clinical results and quality of the ATFL in short-term follow-up.

The ALR-RSI score is a valid and reproducible scale to assess psychological readiness before returning to sport after modified Broström-Gould procedure

PURPOSE

Psychological readiness scores have been developed to optimize the return to play in many sports-related injuries. The purpose of this study was to statistically validate the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale after modified Broström-Gould (MBG) procedure.

METHODS

A similar version of the ACL-RSI scale with 12 items was adapted to quantify the psychological readiness to RTS after MBG and to describe construct validity, discriminant validity, feasibility, reliability and internal consistency of the scale, according to the COSMIN methodology. The term "knee" was replaced by "ankle". The AOFAS and Karlsson scores were used as references patient-related outcome measurements (PROMs).

RESULTS

A total of 71 patients were included. The ALR-RSI score after MBG procedure was highly (r > 0.5) correlated to the AOFAS and Karlsson scores, with a Pearson coefficient r = 0.69 [0.54-0.80] and 0.72 [0.53-0.82], respectively. The mean ALR-RSI score was significantly greater in the subgroup of 55 patients who resumed sports activity compared to those that no longer practiced sport: 61.9 (43.8-79.6) vs 43.4 (25.0-55.6), (p = 0.01). The test-retest showed an "excellent" reproducibility with a ρ intraclass correlation coefficient of 0.93 [0.86-0.96]. The Cronbach's alpha statistic was 0.95, attesting an "excellent" internal consistency between the 12 ALR-RSI items.

CONCLUSION

The ALR-RSI score is a valid and reproducible tool for the assessment of psychological readiness to RTS after an MBG procedure for the management of CLAI, in a young and active population. The ALR-RSI score may help to identify and counsel athletes on their ability to return to sport.

LEVEL OF EVIDENCE

III.

One in Three Patients With Chronic Lateral Ankle Instability Has a Cartilage Lesion

BACKGROUND

Chronic lateral ankle instability (CLAI) is associated with the presence or development of intra-articular pathologies such as chondral or osteochondral lesions, or (O)CLs. Currently, the incidence of (O)CLs in patients with CLAI is unknown.

PURPOSE

To determine the incidence of (O)CLs in patients with CLAI.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature search was conducted in the PubMed (MEDLINE), Embase (Ovid), and Cochrane databases for articles published from January 2000 until December 2020. Two authors independently screened the search results and conducted the quality assessment using the methodological index for non-randomized studies (MINORS) criteria. Clinical studies were included that reported findings on the presence of ankle (O)CLs based on pre- or intraoperative diagnostic measures in patients with CLAI (>6 months of symptoms). Patient and lesion characteristics were pooled using a simplified method. Lesion characteristics included localization and chondral and osteochondral involvement. The primary outcome was the incidence of (O)CLs in ankles with CLAI. A random-effects model with 95% CIs was used to analyze the primary outcome. The distribution of (O)CLs in the ankle joint was reported according to talar or tibial involvement, with medial and lateral divisions for talar involvement.

RESULTS

Twelve studies were included with 2145 patients and 2170 ankles with CLAI. The pooled incidence of (O)CLs in ankles with CLAI was 32.2% (95% CI, 22.7%-41.7%). Among all lesions, 43% were chondral and 57% were osteochondral. Among all (O)CLs, 85% were located on the talus and 17% on the distal tibia. Of the talar (O)CLs, 68% were located medially and 32% laterally.

CONCLUSION

(O)CLs were found in up to 32% of ankles with CLAI. The most common location was the talus (85%). Furthermore, most lesions were located on the medial talar dome (68%). These findings will aid physicians in the early recognition and treatment of ankle (O)CLs in the context of CLAI.

Fully Intra-articular Lasso-Loop Stitch Technique for Arthroscopic Anterior Talofibular Ligament Repair

BACKGROUND

Arthroscopic techniques have gradually become popular for anterior talofibular ligament (ATFL) repair. However, the reliability of the repair and the risk of nerve injuries are of concern. The aim of this study was to evaluate the fully intra-articular lasso-loop stitch technique for arthroscopic ATFL repair.

METHODS

From October 2018 to December 2019, 43 cases with chronic lateral ankle instability were treated with this fully intra-articular lasso-loop stitch technique using the Arthro-Pierce instrument. The Karlsson-Peterson score, Cumberland Ankle Instability Tool (CAIT) score, visual analog scale (VAS) score, anterior drawer and talar tilt stress fluoroscopy were evaluated at the preoperative and final follow-up appointments, respectively. All surgical complications were also recorded.

RESULTS

A total of 39 cases were followed up for a mean of 28.23 ± 3.64 months (range, 23-34 months). At the final follow-up, the averages of the Karlsson-Peterson, CAIT and VAS scores were 90.26 ± 6.58, 88.56 ± 7.21 and 0.79 ± 1.06, respectively. During surgery, 2 cases were modified with augmentation of the inferior extensor retinaculum. No nerve injuries were encountered. Only 1 female complained about mild knot irritation. A 25-year-old solider required revision surgery due to an accidental injury.

CONCLUSION

We found the fully intra-articular lasso-loop stitch technique for ATFL repair using the Arthro-Pierce instrument to be reliable and safe with a sufficient and good-quality ligament remnant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ankle instability – review and new trends

Ankle instability is an old topic with increasing importance in Orthopaedics’ world, as we start now realising how underdiagnosed this pathology has been. A lot of effort has been made in recent years to better understand the pathomechanics of this injury, with new surgical techniques being tried and even new anatomic structures being described. The objective of this paper is to review and compile the most important and recent literature on this matter, in an academic way, but oriented to clinical practice, so it can help surgeons keep updated in this so important subject.

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Connecting fibers between ATFL's inferior fascicle and CFL transmit tension between both ligaments

PURPOSE

The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis.

METHODS

An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL.

RESULTS

A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD ± 0.34).

CONCLUSION

Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.

Comparison of Function- and Activity-Related Outcomes After Anterior Talofibular Ligament Repair With 1 Versus 2 Suture Anchors

Background:

Few studies have compared the clinical outcomes of using 1 versus 2 suture anchors for anterior talofibular ligament (ATFL) repair.

Purpose:

To compare the function and activity-related outcomes of arthroscopic ATFL repair using 1 versus 2 suture anchors.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study involved 46 patients (22 patients in the 1-anchor group, 24 patients in the 2-anchor group) who underwent ATFL repair between January 2015 and December 2017. American Orthopaedic Foot & Ankle Society score, Karlsson and Peterson score, and Tegner activity level were evaluated preoperatively and ≥2.5 years postoperatively. At follow-up, patients were also asked about time to return to sport as well as level and intensity of physical fitness. Satisfaction was evaluated with the Sefton grading system.

Results:

After ≥2.5 years of follow-up (30 months in the 1-anchor group, 33 months in the 2-anchor group), patients in the 2-anchor group had a higher Tegner activity level than those in the 1-anchor group (mean ± SD, 4.75 ± 1.07 vs 4.05 ± 1.17; P = .039). As compared with patients in the 2-anchor group, fewer patients in the 1-anchor group returned to their preoperative activity level (54.2% vs 22.9%; P = .029); the rate of activity at the same or higher intensity as preinjury was also lower in the 1-anchor group (50% vs 79.2%; P = .038). However, there were no differences between the groups in terms of American Orthopaedic Foot & Ankle Society and Karlsson and Peterson scores, time to return to work/sport, duration of activity participation, level of physical fitness, or satisfaction according to Sefton grading.

Conclusion:

Arthroscopic ATFL repair appears to be an effective treatment regardless of whether 1 or 2 suture anchors are used. The techniques had similar functional outcome scores, but 1-anchor repair produced inferior activity-related outcomes.

The arthroscopic all-inside ankle lateral collateral ligament repair is a safe and reproducible technique

PURPOSE

Neurovascular structures around the ankle are at risk of injury during arthroscopic all-inside lateral collateral ligament repair for the treatment of chronic ankle instability. This study aimed to evaluate the risk of damage to anatomical structures and reproducibility of the technique amongst surgeons with different levels of expertise in the arthroscopic all-inside ligament repair.

METHODS

Twelve fresh-frozen ankle specimens were used for the study. Two foot and ankle surgeons with different level of experience in the technique performed the procedure on 6 specimens each. The repair was performed following a standardized procedure as originally described. Then, an experienced anatomist dissected all the specimens to evaluate the outcome of the ligament repair, any injuries to anatomical structures and the distance between arthroscopic portals and the superficial peroneal nerve (SPN) and sural nerve.

RESULTS

Dissections revealed no injury to the nerves assessed. Mean distance from the anterolateral portal and the SPN was of 4.8 (range 0.0-10.4) mm. The mean distance from the accessory anterolateral portal to the SPN and sural nerve was of 14.2 (range 7.1-32.9) mm and 28.1 (range 2.8-39.6) mm, respectively. The difference between the 2 surgeons' groups was non-statistically significant for any measurement (mm). In all specimens both fascicles of the anterior talofibular ligament were reattached onto its original fibular footprint. The calcaneofibular ligament was not penetrated in any specimen.

CONCLUSIONS

The all-inside arthroscopic lateral collateral ligament repair is a safe and reproducible technique. The clinical relevance of this study is that this technique provides a safe and anatomic reattachment of the anterior talofibular ligament, with minimal risk of injury to surrounding anatomical structures regardless of the level of experience with the technique.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Arthroscopic all-inside ATFL and CFL repair is feasible and provides excellent results in patients with chronic ankle instability

PURPOSE

Chronic ankle instability has been described as presenting with complete tears of both the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in 20% of cases. Arthroscopic techniques to treat chronic ankle instability are increasingly being reported and in some instances they can be technically demanding. The aim of this study was to describe an arthroscopic all-inside repair of both the ATFL and CFL, and to report the outcomes of a group of patients with chronic ankle instability that underwent the technique.

METHODS

Twenty-four patients [22 male and 2 female, median age 41 (range 22-56) years] with chronic ankle instability and torn ATFL and CFL were treated arthroscopically after failing non-operative management. Median follow-up was 35 (mean 34.7, and range 18-55) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, both fascicles of the ATFL and the CFL were repaired.

RESULTS

Arthroscopic examination demonstrated ATFL and CFL injuries in all patients. Subjective improvement in their ankle instability was observed postoperatively. The anterior drawer and the talar tilt tests were negative at follow-up. The median AOFAS score increased from 65 (mean 65, range 52-85) preoperatively to 97 (mean 97, range 85-100) at final follow-up.

CONCLUSION

Chronic ankle instability with concomitant injury of both the ATFL and CFL, can be successfully treated by an arthroscopic all-inside repair. The clinical relevance of the study is the description of the first arthroscopic all-inside ATFL and CFL anatomic repair technique, which offers excellent clinical results and the inherent benefits from minimally invasive surgery.

LEVEL OF EVIDENCE

IV, retrospective case series.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.