Hemi-Castaing ligamentoplasty for the treatment of chronic lateral ankle instability: a retrospective assessment of outcome

Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.

Anatomical Tenodesis Reconstruction Using Free Split Peroneal Brevis Tendon for Severe Chronic Lateral Ankle Instability

Many operative procedures have been reported for the management of chronic lateral ankle instability, and anatomical reconstructions are an excellent option. However, if the remnants of the ligaments are considerably damaged, anatomical reconstructions using such remnants can be difficult. In cases such as these, tenodesis stabilization may be required. However, tenodesis stabilization often restricts the range of ankle movement. The purpose of this study was to determine the effectiveness of a new procedure that we developed to mitigate the problems associated with tenodesis stabilization procedures. We installed grafts in the original anatomical position by devising a system for positioning the drill holes in the bones so that our procedure did not restrict the range of ankle movement. A retrospective review of 37 patients (13 men, 24 women) with a mean age of 30.2 (range, 16-66) years was performed at an average of 69 (range, 47-77) months after the surgery. The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved significantly from 65.6 (range, 47-77) points preoperatively to 98.0 (range, 87-100) points postoperatively (P < 0.001). With the number of subjects available, no significant differences were detected between the postoperative mean ranges of movement of the ankle and subtalar joints and those of the preoperative ankle. Patients who underwent anatomical tenodesis reconstructions with a free split peroneal brevis tendon showed good outcomes after a 69-month follow-up period.

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

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

Functional Results of All-Inside Arthroscopic Broström-Gould Surgery With 2 Anchors Versus Single Anchor

BACKGROUND

The all-inside arthroscopic Broström-Gould technique gained particular attention among clinicians and researchers due to its high rate of satisfactory results. Thus far, there is a lack of evidence regarding the differences in clinical outcomes between the use of 1 anchor and 2 anchors. The purpose of this study was to compare the differences in clinical function and activity levels in patients treated with 1 or 2 anchors in all-inside arthroscopic Broström-Gould surgery for chronic lateral ankle instability (CLAI).

METHODS

The data of 75 patients with CLAI (unilateral) admitted from May 2013 to July 2016 were retrospectively analyzed. All patients were treated with all-inside arthroscopic Broström-Gould surgery. The patients were divided into a single-anchor group (n = 36) and double-anchor group (n = 39) according to the number of anchors used. There was no statistical difference in general characteristics between the 2 groups before surgery. After 36 to 72 months of follow-up, the pain visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Foot and Ankle Outcome Score (FAOS) were used to evaluate and compare the clinical function results between the 2 groups.

RESULTS

The incidence of wound complications; reaction to the suture; injury to the nerve, blood vessel, or tendon; and length of postoperative hospitalization were similar between the 2 groups. At the last follow-up, there was no significant difference in the VAS and AOFAS scores between single- and double-anchor groups, but the KAFS and FAOS in the double-anchor group were significantly higher than in the single-anchor group. Additionally, more patients in the double-anchor group returned to preinjury sports activities.

CONCLUSION

All-inside arthroscopic Broström-Gould surgery for the treatment of CLAI yielded a better functional effect and better recovery to preinjury mobility when 2 anchors were used instead of a single anchor.

LEVEL OF EVIDENCE

Level III, comparative study.

Endoscopic anatomic ligament reconstruction is a reliable option to treat chronic lateral ankle instability

PURPOSE

Anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament is a valid treatment of chronic hindfoot instability. The purpose of this study was to investigate the outcomes of this procedure performed by an all-inside endoscopic technique.

METHODS

This study is a retrospective evaluation of a prospective database. Subjects were all patients who underwent an endoscopic lateral ligament reconstruction between 2013 and 2016. All patients had symptoms of ankle instability with positive manual stress testing and failed nonoperative treatment during at least 6 months. At final follow-up the outcome was assessed using the visual analogue score (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and Karlsson-Peterson scores.

RESULTS

After an average follow-up of 31.5 ± 6.9 months, all patients reported significant improvement compared to their preoperative status. The preoperative AOFAS score improved from 76.4 ± 15 to 94.7 ± 11.7 postoperatively (p = 0.0001). The preoperative Karlsson-Peterson score increased from 73.0 ± 16.0 to 93.7 ± 10.6 postoperatively (p = 0.0001). The VAS score improved from 1.9 ± 2.5 to 0.8 ± 1.7 (p < 0.001). Two patients had complaints of recurrent instability.

CONCLUSION

Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure and produces good clinical results with minimal complications. In addition, the endoscopic approach allows an assessment of the ankle joint and treatment of associated intra-articular lesions.

LEVEL OF EVIDENCE

II.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Comparative case series, Level III.

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.

Hemi-Castaing ligamentoplasty for the surgical treatment of chronic lateral ankle instability in young athletes: our 7 years experience

Background and aim of the work: in this study we report our 7-years experience (from January 2011 to December 2017) of 35 patients with chronic lateral ankle instability treated with the Hemi-Castaing reconstruction procedure, all performed in our clinic. Methods: thirty-five patients (F12-M23; median age around 31 yrs, range 18-52 yrs). All patients used to practice amateur sports at competitive level. The procedures were performed in 19 cases on the right ankle whereas in 16 cases on the left ankle. The average follow-up was 54.2 months. Results: of the 35 patients included in our study, all of them were able to practice sport as the same level as before from 80 to 100 days after intervention. Optimal functional results were achieved in all patients and no further episodes of ankle sprain occurred. All patients rated their outcome as good/excellent. No intra-operative complications were observed, whereas we noticed a case of surgical wound dehiscence after surgery. The Hemi-Castaing procedure provided a high lateral ankle stability, with excellent clinical and functional results. In our study, no significant difference in evertor strength was found according to side, and there was no significant change in E/I ratio. Moreover, joint position sense was not impaired. Conclusion. According to us, this surgical technique is efficient and safe, providing remarkable outcomes in the treatment of chronic lateral ankle instability. (www.actabiomedica.it)

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up

INTRODUCTION

A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ.

HYPOTHESIS

The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair.

MATERIALS AND METHODS

A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected.

RESULTS

Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair.

CONCLUSION

Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair.

STUDY DESIGN

Review of the literature; level of proof IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Lateral ligament reconstruction procedures for the ankle

Capsule/ligament lesions of the lateral compartment of the ankle lead to lateral laxity, which is a prime contributor to chronic ankle instability. Lateral ligament reconstruction stabilizes the joint. Exhaustive preoperative clinical and paraclinical work-up is essential. The present article classifies, presents and criticizes the main techniques in terms of long-term stabilization and reduction of osteoarthritis risk. Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligament reconstruction are the two recommended options. Non-anatomic reconstructions using the peroneus brevis should be abandoned. Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available. Postoperative neuromuscular reprogramming is fundamental to optimal recovery. Finally, the concept of complex ankle instability is discussed from the diagnostic and therapeutic points of view. The various forms of ligament reconstruction failure and corresponding treatments are reported.

Outcome of Arthroscopic Treatment of Posterior Impingement of the Ankle

BACKGROUND

Open and arthroscopic techniques have been utilized in the treatment of posterior impingement of the ankle and hindfoot. Because posterior impingement occurs more frequently in patients who repetitively plantarflex the ankle, this population may especially benefit from a procedure that reduces pain and results in maximal range of motion (ROM). The purpose of this study was to assess the outcome of hindfoot endoscopy in patients with posterior ankle impingement through a higher level of function outcome measures and physical examination parameters, focused on analysis of ROM.

METHODS

Twenty patients were followed prospectively at a minimum 1-year follow-up (mean 38.2 months). Nineteen of 20 patients were competitive athletes. Patients completed a minimum of 3 months of nonoperative treatment. Diagnoses included os trigonum, tibial exostosis, talar exostosis, loose body or fracture nonunion, and ganglion cyst removal. Patients underwent arthroscopic treatment utilizing a posterior approach; all relevant pathology was addressed.

RESULTS

At the most recent follow-up, visual analog scale pain and American Orthopaedic Foot & Ankle Society hindfoot scores showed significant improvement (P < .01) pre- to postoperatively; Tegner score remained unchanged (P = .888). Three patients were professional athletes; all returned to their previous level of professional activity. ROM variables between affected and unaffected sides reached statistical similarity at the most recent follow-up. Only ankle plantarflexion reached statistical significance when compared pre- to postoperatively. Fifteen percent of patients reported postoperative neuritis.

CONCLUSIONS

Posterior ankle arthroscopy allowed for maintenance or restoration of anatomic ROM of the ankle and hindfoot, ability to return to at least previous level of activity, and improvement in objective assessment of pain relief and higher level of function parameters. Complications associated with this procedure were minimal.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Hemi-Castaing ligamentoplasty for chronic lateral ankle instability does not modify proprioceptive, muscular and posturographic parameters

PURPOSE

The Hemi-Castaing ligamentoplasty uses a powerful dynamic stabilizer of the ankle which is the peroneus brevis tendon. To our knowledge, there is no study available evaluating the effects of this type of surgery on proprioceptive, muscular and posturographic parameters.

METHODS

This case-control study included 39 subjects divided into two groups: the operated (n = 24) and the control group (n = 15). All subjects underwent a clinical, proprioceptive and isokinetic assessment using a CON-TREX dynamometer, and a postural evaluation using the Win-Posturo force platform.

RESULTS

At a mean period of 23 (SD 5.4) post-operative months, the Karlsson ankle functional score was 84.2 (SD 23.8) and the AOFAS score was 88.1 (SD 16.2). The mean ankle joint position error for operated ankles was from 1.9° (SD 0.9) at 10° of inversion range of motion to 2.5° (SD 1.7) at 20°. It was similar to that achieved in the control group ranging from 2.2° (SD 1) at 10° to 2.3° (SD 1.3) at 20°. No significant loss of ankle eversion strength could be observed after ligamentoplasty. Ankle eversion/inversion ratio when tested under all velocities and contraction modes failed to reveal any statistical difference between the operated and healthy ankles in the patient group, neither between the patient and control groups.

CONCLUSIONS

This surgical technique achieved excellent functional outcomes. It did not impair the agonist/antagonist balance of ankle muscles, and use of half the peroneus brevis tendon did not lessen the eversion strength.

LEVEL OF EVIDENCE

Case-control study, Level III.

The role of activity level in orthopaedics: an important prognostic and outcome variable

A patient's activity level is increasingly recognized as an important factor that can influence orthopaedic outcomes. Validated, reliable activity measurement tools now exist for the shoulder, hip, knee, and ankle. These tools can be directly applied as outcome measures that determine whether interventions restored function. It is now evident that activity level is a powerful prognostic factor for outcomes in orthopaedic procedures such as anterior cruciate ligament reconstruction, articular cartilage repair, and total joint arthroplasty. Yet despite the recent increase in studies that have made use of quantitative, joint-specific activity scales, much room remains for further understanding of the exact role of activity level in the progression, treatment, and patient perception of musculoskeletal disorders, particularly in the shoulder and ankle, as well as in pediatric patients.

Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability

INTRODUCTION

Chronic ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. In case of severe joint laxity, surgical treatment with reconstruction of the lateral ligamental complex is recommended. The aim of this study was to evaluate the functional outcome of patients treated with lateral ligament reconstruction with allograft for severe chronic lateral ankle instability.

MATERIALS AND METHODS

We performed a retrospective cohort study of ten patients who underwent allograft external non-anatomic ligamentoplasty for severe chronic lateral ankle instability between 2009 and 2011, with an average follow-up of 16.3 months (SD 8.2). Median age at surgery was 29 years (range 25-35). All patients presented both ATFL and CFL lesion. Patients were evaluated using American Orthopaedic Foot and Ankle Society score, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending range of motion, anterior drawer sign and talar tilt test. Telos stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

Follow-up examination at an average of 16.3 months (SD 8.2) after surgery showed significant improvement of all variables compared to pre-operative values (p < 0.001). Most patients rated their outcome as good/excellent. Telos stress radiographs documented improvement in joint stability.

CONCLUSIONS

Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability.

Chronic ankle instability: diagnosis and treatment

BACKGROUND

Chronic ankle instability (CAI) is a very common injury but still remains an area of debate.

QUESTIONS

This review aims to define the current diagnosis and treatment of persons with CAI.

METHODS

A PubMed (MEDLINE) search of the years 2010 and 2011 (1 January 2010 to 15 July 2011) was performed using three keywords: ankle and chronic and instability. The number of articles in English language that was identified was 57.

RESULTS

Low reliability has been found in effectively testing CAI in a clinical setting. No single force-plate measure is very effective in predicting if an individual had CAI or not. Availability of a nonradiographic device (ankle arthrometer) to measure ankle instability could improve diagnostic accuracy and facilitate decision making in patients with CAI. The sensitivity of magnetic resonance imaging (MRI) may not be adequate to detect lesions in these patients before surgery. In a symptomatic patient, negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. Conservative treatment (rehabilitation, taping, brace) may reduce the occurrence of recurrent ankle sprains and may be effective in managing CAI. In patients with CAI, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helped the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability. There is no consensus regarding optimum surgical treatment for CAI, but all of them often have good results.

CONCLUSIONS

Conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails.