Clinical and magnetic resonance imaging assessment of anatomical lateral ankle ligament reconstruction: comparison of tendon allograft and autograft

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.

Incidence of Septic Arthritis After Vancomycin Soaking of the Graft During Arthroscopic Anatomic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction

Background

Vancomycin soaking of the graft during arthroscopic anterior cruciate ligament reconstruction has been shown to be effective in reducing the rate of postoperative infection.

Purpose/Hypothesis

The present study aimed to (1) analyze the effect of vancomycin-soaked grafts during arthroscopic anatomic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the incidence of infection and (2) evaluate the influence of infection on functional outcomes and identify the risk factors of infection. It was hypothesized that vancomycin soaking of the graft would reduce the postoperative infection rate.

Study Design

Cohort study; Level of evidence, 3.

Methods

Consecutive patients at 2 centers who underwent ATFL/CFL reconstruction between December 2011 and July 2022 were included. All patients had undergone anterolateral arthroscopic debridement of the ankle and anatomic ATFL/CFL reconstruction with a gracilis tendon autograft. Vancomycin soaking of the graft was begun in both centers in January 2021. Complications, functional scores, return to sports (RTS) rates, and the level of return were compared between patients with and without vancomycin-soaked grafts and between patients with and without infection.

Results

Overall, 182 patients (48% men; mean age, 34 ± 11.9 years) were included, with a mean follow-up of 23 ± 16.1 months. The rate of postoperative infection was significantly lower in the group with vancomycin soaking versus without (0/92 [0%] vs 8/90 [8.9%]; P = .001). At the final follow-up, there were 26 complications (14.3%): 8 infections, 6 recurrent tears, and 12 peripheral neuropathies. The infections developed after a mean of 17 ± 11 days. The functional scores were excellent at the final follow-up (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Score, 86.5 ± 18.7; Karlsson score, 85 ± 18.3). Patients with infection had significantly decreased AOFAS scores (52.8 ± 27.6 vs 83.3 ± 21.5; P = .003), Karlsson scores (57 ± 27.7 vs 83.6 ± 20; P = .006), and RTS rates (25% vs 77%; P = .005) versus patients without infection.

Conclusion

Vancomycin-soaked grafts for arthroscopic anatomic ATFL/CFL reconstruction decreased the rate of postoperative infection. Infection led to a deterioration in results. Vancomycin-soaking of the graft did not have a negative effect on functional results.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level of evidence II.

Ankle Sprains in Athletes: Current Epidemiological, Clinical and Imaging Trends

Purpose

Ankle injuries are frequent sports injuries. Despite optimizing treatment strategies during recent years, the percentage of chronification following an ankle sprain remains high. The purpose of this review article is, to highlight current epidemiological, clinical and novel advanced cross-sectional imaging trends that may help to evaluate ankle sprain injuries.

Methods

Systematic PubMed literature research. Identification and review of studies (i) analyzing and describing ankle sprain and (ii) focusing on advanced cross-sectional imaging techniques at the ankle.

Results

The ankle is one of the most frequently injured body parts in sports. During the COVID-19 pandemic, there was a change in sporting behavior and sports injuries. Ankle sprains account for about 16-40% of the sports-related injuries. Novel cross-sectional imaging techniques, including Compressed Sensing MRI, 3D MRI, ankle MRI with traction or plantarflexion-supination, quantitative MRI, CT-like MRI, CT arthrography, weight-bearing cone beam CT, dual-energy CT, photon-counting CT, and projection-based metal artifact reduction CT may be introduced for detection and evaluation of specific pathologies after ankle injury. While simple ankle sprains are generally treated conservatively, unstable syndesmotic injuries may undergo stabilization using suture-button-fixation. Minced cartilage implantation is a novel cartilage repair technique for osteochondral defects at the ankle.

Conclusion

Applications and advantages of different cross-sectional imaging techniques at the ankle are highlighted. In a personalized approach, optimal imaging techniques may be chosen that best detect and delineate structural ankle injuries in athletes.

Revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedure

PURPOSE

The Brostrom-Gould procedure has been considered as a gold standard operative technique for chronic lateral ankle instability. Despite the popularity and excellent outcomes of the modified Brostrom procedure, some patients still experience recurrence of ankle instability. Few studies reported outcomes of revision reconstruction for patients with a failed modified Brostrom procedure. This study aimed to evaluate the outcomes of a percutaneous anatomic revision lateral ankle ligament reconstruction for patients with a failed modified Brostrom procedure.

METHODS

From March 2017 to April 2020, 21 patients with persistent ankle instability after a modified Brostrom procedure underwent revision lateral ankle ligament reconstruction. The operation was performed through minimally invasive incisions. Functional assessment was performed using the Karlsson-Peterson ankle scoring system (KP) and the Visual Analogue Scale (VAS). The questionnaires of KP and VAS were completed before surgery and at the last follow-up. Patients' subjective satisfaction level was graded as excellent, good, fair, and poor. Preoperative and postoperative anterior talar displacement and varus talus tilt angle in stress radiographs were recorded.

RESULTS

The average age at the revision surgery time was 39.6years. The mean follow-up was 39.2months. The VAS score improved from 4.1 ± 1.5 preoperatively to 1.3 ± 1.3 at the final follow-up (p < .05). The KP score improved from 59.0 ± 20.2 preoperatively to 88.2 ± 9.6 at the last follow-up (p < .05). The mean varus talar tilt angle was 14.1 ± 3.9 mm preoperatively versus 4.9 ± 4.7 mm at the final follow-up (p < .05). The mean anterior talar displacement was 12.8 ± 2.2 mm versus 5.6 ± 3.7 mm at the last follow-up (p < .05).

CONCLUSIONS

The revision anatomic reconstruction of the lateral ligaments of the ankle is effective for patients with recurrent instability after a failed modified Broström procedure.

High return to sports and return to work rates after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability

PURPOSE

To evaluate clinical outcomes as well as return to sports (RTS) and return to work (RTW) rates following anatomic lateral ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability (CLAI) in a high-risk population, and to compare these outcome parameters between patients having received a gracilis tendon autograft (GT) and free split peroneus brevis tendon (PBT) autograft.

METHODS

Twenty-eight consecutive patients, who were diagnosed with CLAI, presenting with ≥ 1 risk factor (ligamentous hyperlaxity, insufficient substance of native ligament and/or high-demand athlete), who underwent ankle ligament reconstruction with a tendon autograft between January 2011 and December 2018, were included in this retrospective study. At 63.7 ± 28.0 months (24-112), 23 patients with a mean age of 29.7 ± 10.9 years were available for follow-up. The Karlsson Score, the Foot and Ankle Outcome Score (FAOS), the Tegner Activity Scale and the visual analog scale (VAS) for pain were collected at a minimum follow-up of 24 months. RTS and RTW were evaluated by questionnaire. A subgroup analysis with regard to the graft used for ankle ligament reconstruction (GT versus PBT) was performed.

RESULTS

Patients reported a Karlsson score of 82.1 ± 17.5 (37-100), a FAOS score of 87.8 ± 8.4 (73-99), a median Tegner activity scale of 5.0 (IQR 4-6) and a VAS for pain of 0.5 ± 0.9 (0-4) at rest and of 2.0 ± 2.1 (0-7) during activities at final follow-up. Postoperatively, 96% of patients had returned to sports after 8.3 ± 6.2 months. All patients (100%) had returned to work at 3.5 ± 5.7 (0-24) months, with 87% reporting an equal or improved working ability compared to that preoperatively. Postoperatively, exercise hours per week were significantly reduced compared to preoperatively in patients with a split PBT (n = 12; 13.0 ± 12.9 to 5.6 ± 6.4 h, p = 0.038) autograft as opposed to patients with a GT autograft (n = 11; 13.1 ± 8.7 to 12.4 ± 7.1 h, n.s.). No other group differences were observed.

CONCLUSION

Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory.

LEVEL OF EVIDENCE

IV.

Anatomic reconstruction of lateral ankle ligaments: is there an optimal graft option?

PURPOSE

Different graft options are available for the reconstruction of lateral ankle ligaments to treat chronic ankle instability (CAI), which fall in two categories: allografts and autografts. This study aims to provide an updated comparison of the clinical outcomes after stabilisation procedures using allografts and autografts, to correctly advise the clinician during the choice of the best material to be used for the reconstruction of the lateral ligamentous complex of the ankle.

METHODS

A systematic review was performed to analyse the use of autografts and allografts for anatomic reconstruction of the lateral ligamentous complex of the ankle in CAI patients. The presence of a postoperative assessment through outcome measures with proofs of validation in the CAI population or patient's subjective evaluation on the treatment were necessary for inclusion. The quality of the included studies was assessed through the modified Coleman Methodology Score (mCMS). Relevant clinical outcome data were pooled to provide a synthetic description of the results in different groups or after different procedures.

RESULTS

Twenty-nine studies (autograft: 19; allograft: 9; both procedures: 1) accounting for 930 procedures (autograft: 616; allograft: 314) were included. The average mCMS was 55.9 ± 10.5 points. The Karlsson-Peterson scale was the most frequently reported outcome scale, showing a cumulative average post- to preoperative difference of 31.9 points in the autograft group (n = 379, 33.8 months follow-up) and of 35.7 points in the allograft group (n = 227, 25.8 months follow-up). Patient satisfaction was good or excellent in 92.8% of autograft (n = 333, 65.2 months follow-up) and in 92.3% of allograft procedures (n = 153, 25.0 months follow-up). Return to activity after surgery and recurrence of instability were variably reported across the studies with no clear differences between allograft and autograft highlighted by these outcomes.

CONCLUSIONS

The systematic analysis of validated CAI outcome measures and the patient's subjective satisfaction does not support a specific choice between autograft and allograft for the reconstruction of the ankle lateral ligamentous complex in CAI patients. Both types of grafts were associated to a postoperative Karlsson-Peterson score superior to 80 points and to a similar rate of patient's subjective satisfaction.

LEVEL OF EVIDENCE

Level IV.

[Anatomical reconstruction of anterior talofibular ligament by partial peroneal brevis tendon combined with double intra-fix screws]

Objective

To investigate the effectiveness of anatomical reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon combined with double intra-fix screws.

Methods

A clinical data of 46 patients with the anterior talofibular ligament rupture admitted between September 2015 and October 2019 and met the selection criteria were retrospectively analyzed. All anterior talofibular ligaments were reconstructed with partial peroneal brevis tendon and fixed with double intra-fix screws. There were 22 males and 24 females, with an average age of 28.1 years (range, 16-52 years). Forty cases had a history of ankle sprain, 1 case was injured by a heavy object, and 5 cases were suffered from falls. There were 17 cases on the left side and 29 cases on the right side. The disease duration ranged from 3 months to 10 years (median, 20.3 months). The visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, varus angle of ankle, and the difference of the anterior talar translation between healthy and affected sides (looseness, similarity, tightness) were recorded before and after operation; 23 patients were evaluated by Patient-Reported Outcomes Measurement Information System (PROMIS) score, including pain interference (PI) and physical function (PF) scores.

Results

The operation time was 39-179 minutes, with an average of 65.8 minutes. All incisions healed by first intention. All patients were followed up 12-30 months (mean, 23 months). The VAS score, AOFAS ankle-hindfoot score, varus angle of ankle, difference of the anterior talar translation between healthy and affected sides, and PI and PF scores of PROMIS at 6 months and last follow-up significantly improved when compared with those before operation ( P<0.05). There was no significant difference in VAS score, PI score of PROMIS, and AOFAS ankle-hindfoot score between at 6 months and at last follow-up ( P>0.05). However, the PF score of PROMIS, the difference of the anterior talar translation between healthy and affected sides, and the varus angle of ankle were significant ( P<0.05).

Conclusion

Anatomical reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon and double intra-fix screws has the advantages of small incision, convenient tendon removal, and firm graft fixation. The postoperative patients recover quickly and the effectiveness is satisfactory.

All-inside arthroscopic modified Broström-Gould procedure for chronic lateral ankle instability with and without anterior talofibular ligament remnant repair produced similar functional results

PURPOSE

The Broström-Gould procedure, with the repair of the anterior talofibular ligament (ATFL) combined with the transfer of the extensor retinaculum, is considered the gold standard procedure for the management of chronic lateral ankle instability (CLAI). Lateral ligament reconstruction is considered if the ATFL remnant quality is poor or the ATFL has been damaged beyond the ability to suture it. It remains unclear whether not repairing the ATFL remnant produces comparable functional outcomes to the classical Broström-Gould procedure.

METHODS

This retrospective cohort study included 84 patients with CLAI undergoing either repair or non-repair of the ATFL remnant using an all-inside arthroscopic Broström-Gould procedure from 2015 to 2018. The Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Functional Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports were compared in both groups.

RESULTS

All the functional scores (VAS, AOFAS, KAFS, ATT, AJPS) significantly improved in both groups at 1 and 2 years after surgery. At all the follow-up time points, the VAS, AOFAS, KAFS, ATT, AJPS, and the rate of return to sport scores were comparable between the repair and non-repair group.

CONCLUSION

There are no statistically significant differences in postoperative outcomes between ATFL remnant repair and non-repair for the management of CLAI using the all-inside arthroscopic Broström-Gould procedure. From the clinical viewpoint, the present study shows that the potential differences in clinical outcomes between ATFL remnant repair and non-repair are likely not relevant when performing an all-inside arthroscopic Broström-Gould procedure for CLAI.

LEVEL OF EVIDENCE

III.

Anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up

PURPOSE

The aim of this study was to compare long-term outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) repair and reconstruction at 5-10 years after surgery.

METHODS

Forty-five patients who underwent surgical repair or reconstruction of both ATFL and CFL were retrospectively investigated in this study. American Orthopedic Foot and Ankle Society (AOFAS), Karlsson Score, and Tegner activity scale were used to evaluate the ankle function at a follow-up of 5-10 years. Ultrasound examination was used to evaluate the ATFL and CFL, and MRI was used to evaluate the cartilage.

RESULTS

At final follow-up, no patient had recurrent ankle instability. There were no significant differences in AOFAS (92.6 ± 6.5 vs 89.6 ± 3.4; n.s.) or Karlsson Score (93 ± 8.2 vs 90.6 ± 5.0; n.s.) between the reconstruction group (twenty patients) and the repair group (twenty-five patients) postoperatively. There were also no significant differences in activity level as measured by the Tegner activity score (6 (range 4 to 8) vs 6 (range 5 to 7); n.s.). Five patients in the reconstruction group complained of some tightness of the ankles. Ultrasound showed the reconstructed ligaments maintained good continuity and were thicker than the repaired ligaments.

CONCLUSION

Patients in both the repair and the reconstruction cohort had high patient satisfaction with the outcomes and high function and activity levels that indicated recreational sports participation over a long period.

LEVEL OF EVIDENCE

III.

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.

Quantitative Magnetic Resonance Imaging UTE-T2* Mapping of Tendon Healing After Arthroscopic Rotator Cuff Repair: A Longitudinal Study

BACKGROUND

Quantitative ultrashort echo time-T2* (UTE-T2*) mapping shows promise for the detection of potential tendon biochemical conditions, while validation against established clinical studies in the shoulder is needed.

PURPOSE

To evaluate and characterize the healing process of the repaired rotator cuff based on longitudinal changes in UTE-T2* values, clinical outcomes, and repair status in patients after arthroscopic rotator cuff repair (ARCR).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients with ARCR (n = 25) underwent quantitative MRI and clinical examinations at serial follow-up time points: 3, 6, 12, and 24 months postoperatively. Age-matched healthy controls (n = 15) were evaluated at 3 and 12 months after enrollment. Clinical scores included the Constant, American Shoulder and Elbow Surgeons, and Fudan University Shoulder score, and visual analog scale for pain. The MRI examination included UTE-T2*mapping. UTE-T2* maps were generated for T2* values at the healing site. Sugaya classification was adopted to evaluate the repair status. Longitudinal analyses of clinical outcomes, UTE-T2* changes, and Sugaya classification were conducted.

RESULTS

The overall retear rate was 8% (2/25, all Sugaya type IV). All patients (including the ones with retear) achieved satisfactory outcomes at 12 months that lasted to 24 months on the basis of clinical scores. The mean UTE-T2* values at the healing site showed an increase from 3 to 6 months (P = .03) and then decreased to a level similar to that observed in age-matched healthy tendons at 12 months (P = .1). No significant differences were found between UTE-T2* values at 12 and 24 months (P = .6). UTE-T2* values at the healing site significantly varied with the repair status according to Sugaya classification (P < .05). Moreover, significant correlations were noted between clinical scores and UTE-T2* values at 6 months (r = -0.6 to -0.3; all P < .05) and 12 months (r = -0.6 to -0.2; all P < .05).

CONCLUSION

This study indicated a healing-related relationship between clinical outcomes and quantitative UTE-T2* values, which highlights the potential of using UTE-T2* mapping to track the tendon-healing process noninvasively. Moreover, the repaired tendon was comparable to age-matched healthy controls at 12-month follow-up based on UTE-T2* values.

A modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction: medium-term clinical and radiologic results comparable with open reconstruction

BACKGROUND

The aim of this study was to compare clinical and radiologic outcomes of a modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction with traditional open reconstruction.

METHODS

From January 2012 and March 2016, 60 eligible patients with chronic lateral ankle instability (CLAI) received all arthroscopic remnant-preserving reconstruction or open reconstruction of the anterior talofibular ligament and calcaneofibular ligament using semitendinosus autograft. They were divided into the arthroscopic group (n = 28) and the open group (n = 32). The American Orthopaedic Foot and Ankle Society (AOFAS),visual analog scale (VAS), and Karlsson scores and ankle range of motion (ROM) were used to evaluate clinical outcomes pre-operatively and at six and 12 months and the final follow-up of at least 24 months post-operatively, with SF-36 physical component summary (PCS) and mental component summary (MCS) scores evaluated for quality of life, and the anterior talar translation and talar tilt measurements for radiologic outcomes.

RESULTS

There was no difference in pre-operative demographics between two groups (P > 0.05). At the final follow-up, the AOFAS, VAS, Karlsson, SF-36 PCS, and MCS scores improved significantly in both groups (P < 0.05). However, no significant difference was found in AOFAS (91.9 ± 6.8 vs 91.1 ± 5.5), VAS (2.7 ± 1.7 vs 2.5 ± 1.6), Karlsson (95.3 ± 6.7 vs 94.8 ± 6.5), SF-36 PCS (53.2 ± 6.1 vs 52.9 ± 5.7), and MCS scores (55.7 ± 5.8 vs 54.2 ± 5.4) between the two groups (P > 0.05). There was no significant difference in post-operative operated/non-operated ankle ROM between two groups (P > 0.05). No significant difference was observed in talar tilt angle (7.6 ± 4.1° vs 6.8 ± 3.6°) and anterior talar translation (5.8 ± 1.7 mm vs 5.7 ± 1.5 mm) between the two groups at the final follow-up (P > 0.05), although these two variables improved significantly in both groups (P < 0.05). No severe complications were encountered in both groups during the follow-up period.

CONCLUSIONS

The modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction could produce excellent clinical and radiologic outcomes comparable with open reconstruction.

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for Chronic Ankle Instability: A Systematic Review and Meta-analysis

The purpose of this study was to systematically review the current evidence in the literature to ascertain whether the anatomic ankle ligament reconstruction procedure with allograft resulted in improved patient outcomes after ≥2 years of follow-up. A literature search of Medline, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Clinical studies investigating anatomic lateral ankle ligament reconstruction procedures for chronic ankle instability with a mean of >2 years' follow-up were included. Means were calculated for population size, age, follow-up duration, and postoperative Tegner scores. Pooled estimates were calculated for postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion, return to sports, risk of postoperative instability, and complications. Six clinical trials with 153 patients were included. The pooled estimated mean for the postoperative AOFAS score was 89.4 points (95% confidence interval [CI], 86.0 to 92.9; I² = 88.7%). The pooled proportion of patients who returned to sports after surgery was 80% (95% CI 57.0% to 100%; I² = 88.7%). The pooled total risk of recurrent instability after surgery was 6% (95% CI 1% to 12%; I² = 0%). No rejection was reported. Anatomic lateral ankle ligament reconstruction procedure results in significant improvements in patient function and outcome scores, with low rates of recurrent instability.

Hamstring Autograft for Lateral Ligament Stabilization

PURPOSE OF REVIEW

This paper seeks to review the current literature and trends regarding use of hamstring autograft for lateral ankle instability.

RECENT FINDINGS

Reconstruction of the lateral ankle ligaments using hamstring autograft has been found to be an effective method to treat ankle instability in terms of patient-reported outcomes and objective measures. Biomechanically, reconstruction has been shown to be stronger (load to failure) when compared with the Broström procedure. Clinical studies have demonstrated non-inferiority when compared with the Broström procedure, with one synthetic reconstruction technique demonstrating superior outcomes. Reconstruction of the lateral ankle ligaments using hamstring autograft is especially useful in patients who are at high risk of failure (insufficient soft tissue available for repair, ligamentous laxity, previous failed ligament repair, ossicle > 1 cm, or in the heavier, high-demand athletes).

Good outcomes at mid-term following the reconstruction of chronic Achilles tendon rupture with semitendinosus allograft

PURPOSE

Chronic Achilles tendon rupture is commonly treated surgically, yet there are limited available data on tendon allografts for Achilles tendon reconstruction. The purpose of this study was to evaluate the patient-reported outcomes of chronic Achilles tendon rupture reconstructed with semitendinosus allograft.

METHODS

A total of 34 patients (30 males and 4 females, average age 36.1 ± 6.8 years ranging from 25 to 50 years) who underwent Achilles tendon reconstruction with semitendinosus allograft from 2011 to 2015 were identified for this retrospective study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Achilles tendon total rupture score (ATRS), and Tegner score were evaluated preoperatively and at final follow-up.

RESULTS

A total of 33 patients (97.1%) were followed up for a median time of 53 (range 24-80) months. The median AOFAS score increased from 50 (5-75) to 100 (86-100), the median VISA-A score increased from 23 (5-59) to 94 (52-100), the median ATRS score increased from 22.5 (6-67) to 99 (84-100), and the median Tegner score increased from 1 (0-3) to 4 (3-9).

CONCLUSIONS

Reconstruction of chronic-ruptured Achilles tendon with semitendinosus allograft offers satisfactory patient-reported results with low risk of re-rupture and complications. This technique could be considered an effective alternative for chronic ruptures of the Achilles tendon.

LEVEL OF EVIDENCE

Case series, Level IV.

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.

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.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.