Simultaneous surgery for chronic lateral ankle instability accompanied by only subchondral bone lesion of talus

Ankle Instability: Facts and Myths to Protect Your Cartilage Repairing

The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review

BACKGROUND

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT.

DESIGN

A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated.

RESULTS

Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported.

CONCLUSIONS

This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Retrograde drilling for ankle joint osteochondral lesions: a systematic review

BACKGROUND

Extensive literature exists about the treatment of ankle osteochondral lesions, but there is no specific review of retrograde drilling, despite its common application. Indications for retrograde drilling are still few and are far from clear, and some evolutions of the technique have recently occurred. The aim of this review is to provide an update on actual applications and techniques of retrograde drilling for ankle osteochondral lesions.

METHODS

A systematic review was carried out according to the 2020 PRISMA guidelines. The PubMed and Embase databases were searched in June 2023. The search string focused on studies related to retrograde drilling in the treatment of ankle osteochondral lesions.

RESULTS

Twenty-one articles for a total of 271 ankles were included in this review. The mean length of the treated lesions was 11.4 mm. Different navigation systems were used, with fluoroscopy the most commonly used. Various adjuvants were employed after drilling, with bone graft the most commonly applied. In most cases, postoperative patient satisfaction and symptom relief were reported, and no complications occurred. Retrograde drilling was found to be suitable for the treatment of subchondral cysts with intact cartilage or small lesions. Some modifications to the original technique may allow surgical indications to be extended to more complex cases.

CONCLUSIONS

Middle-term results of retrograde drilling showed postoperative satisfaction and symptom relief with both original and modified techniques. Additional research is required to investigate the long-term results.

LEVEL OF EVIDENCE

IV.

TRIAL REGISTRATION

This systematic review was registered on PROSPERO (id number: CRD42022371128).

A Systematic Review of the Retrograde Drilling Approach for Osteochondral Lesion of the Talus: Questioning Surgical Approaches, Outcome Evaluation and Gender-Related Differences

BACKGROUND

Retrograde drilling (RD) is a minimally invasive surgical procedure mainly used for non-displaced osteochondral lesions (OCL) of the talus, dealing with subchondral necrotic sclerotic lesions or subchondral cysts without inducing iatrogenic articular cartilage injury, allowing the revascularization of the subchondral bone and new bone formation.

METHODS

This systematic review collected and analyzed the clinical studies of the last 10 years of literature, focusing not only on the clinical results but also on patients' related factors (gender, BMI, age and complications).

RESULTS

Sixteen clinical studies were retrieved, and differences in the type of study, follow-up, number and age of patients, lesion type, dimensions, grades and comparison groups were observed, making it difficult to draw conclusions. Nevertheless, lesions on which RD showed the best results were those of I-III grades and not exceeding 150 mm² in size, showing overall positive results, a good rate of patient satisfaction, improvements in clinical scores, pain reduction and return to daily activities and sports.

CONCLUSIONS

There are still few studies dealing with the issue of post-surgical complications and gender-related responses. Further clinical or preclinical studies are thus mandatory to underline the success of this technique, also in light of gender differences.

Acute Ankle Sprains

Understanding the types of ankle sprains is essential in determining the most appropriate treatment and preventing substantial missed time from sports. Commonly known and recognized is an acute lateral ankle sprain, however, a differentiation should also be made to understand high (syndesmotic) ankle sprains as the mechanism of injury and recovery periods differ between these two types.

Preexisting and treated concomitant ankle instability does not compromise patient-reported outcomes of solitary osteochondral lesions of the talus treated with matrix-induced bone marrow stimulation in the first postoperative year: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum)).

RESULTS

From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively.

CONCLUSION

Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year.

LEVEL OF EVIDENCE

Level IV.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

Outcomes of Single-Stage Versus Staged Treatment of Osteochondral Lesions in Patients With Chronic Lateral Ankle Instability: A Prospective Randomized Study

Background:

There is controversy about whether treatment of chronic lateral ankle instability (CLAI) with osteochondral lesions of the talus (OLT) can be performed concurrently.

Purpose:

To investigate the midterm results of arthroscopic treatment of CLAI combined with OLT in different surgical settings. It was hypothesized that the outcomes of treating both injuries at the same time would not be inferior to those of staged surgery.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Included were 103 patients with both CLAI and OLT who underwent arthroscopic microfracture surgery and an open, modified Broström-Gould procedure for ligament repair from January 2015 to December 2016. The patients were assigned randomly to a staged group (51 patients) and a single-stage group (52 patients). The staged group underwent arthroscopic debridement of the OLT and microfracture, then rehabilitation for 4 to 6 months before undergoing modified Broström-Gould ligament repair. The single-stage group underwent both procedures simultaneously. Clinical evaluations were performed on the day before surgery and at 12-month, 24-month, and final follow-up periods using the Karlsson-Peterson score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and pain visual analog scale. The Karlsson-Peterson score at 24 months postoperatively was considered the primary outcome. The predefined noninferiority margin for the primary outcome was −5 points.

Results:

At the final follow-up, 50 patients in the single-stage group and 48 patients in the staged group completed the study. The median lesion size was 0.72 cm² (interquartile range [IQR], 0.5-1.12 cm²) in the single-stage group and 0.84 cm² (IQR, 0.7-1.05 cm²) in the staged group. At 12-month follow-up, the single-stage group had a significantly higher median Karlsson-Peterson score (79 [IQR, 70-85] vs 75 [IQR 65-80] for staged; P = .024) and median AOFAS score (85 [IQR, 76-89] vs 79.5 [IQR, 70-87] for staged; P = .045). At 24-month follow-up, the median difference in the Karlsson-Peterson score for single-stage versus staged surgery was 2 points (95% CI, −2 to 5 points), and the confidence interval was greater than the predefined value.

Conclusion:

At midterm follow-up, there was no clinical difference between single-stage versus staged surgery to treat CLAI with OLT. Single-stage surgery achieved better clinical outcomes than staged surgery at short-term follow-up.

Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Broström ligament repair

Background

The arthroscopic modified Broström procedure, with repair of the anterior talofibular ligament and extensor retinaculum, produces good functional outcomes in patients with chronic lateral ankle instability (CLAI). CLAI can be associated with osteochondral lesions of the talus (OLTs). It remains unclear whether associated limited OLTs affect clinical outcomes in such patients.

Methods

This retrospective cohort study included 92 CLAI patients with and without OLTs undergoing an all-inside arthroscopic modified Broström procedure from June 2016 to May 2019. The patients were divided into non-lesion group (n = 32) and lesion group (n = 60) according to whether CLAI was associated or not with OLTs. All the osteochondral lesions less than 15 mm in diameter were managed with bone marrow stimulation techniques (arthroscopic microfracture) at the time of the arthroscopic modified Broström procedure. The Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports were compared in both groups.

Results

Increase in all the functional scores (VAS, AOFAS, KAFS, ATT, and AJPS) in both groups was, respectively, recorded 1 year and 2 years after surgery. At the 1-year and 2-year follow-up, there was no significant difference in the VAS, AOFAS, KAFS, ATT, and AJPS scores between the non-lesion and lesion groups.

Conclusion

In patients with CLAI who underwent an arthroscopic modified Broström procedure, the presence of limited OLTs (less than 15 mm in diameter), which required arthroscopic microfracture, did not exert any influence on outcome.

Level of Evidence

Level III, a retrospective comparative study.

Autologous Matrix-Induced Chondrogenesis With Lateral Ligament Stabilization for Osteochondral Lesions of the Talus in Patients With Ankle Instability

Background:

Autologous matrix-induced chondrogenesis (AMIC) has been shown to result in favorable clinical outcomes in patients with osteochondral lesions of the talus (OLTs). Though, the influence of ankle instability on cartilage repair of the ankle has yet to be determined.

Purpose/Hypothesis:

To compare the clinical and radiographic outcomes in patients with and without concomitant lateral ligament stabilization (LLS) undergoing AMIC for the treatment of OLT. It was hypothesized that the outcomes would be comparable between these patient groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Twenty-six patients (13 with and 13 without concomitant ankle instability) who underwent AMIC with a mean follow-up of 4.2 ± 1.5 years were enrolled in this study. Patients were matched 1:1 according to age, body mass index (BMI), lesion size, and follow-up. Postoperative magnetic resonance imaging and Tegner, American Orthopaedic Foot & Ankle Society (AOFAS), and Cumberland Ankle Instability Tool (CAIT) scores were obtained at a minimum follow-up of 2 years. A musculoskeletal radiologist scored all grafts according to the MOCART (magnetic resonance observation of cartilage repair tissue) 1 and MOCART 2.0 scores.

Results:

The patients’ mean age was 33.4 ± 12.7 years, with a mean BMI of 26.2 ± 3.7. Patients with concomitant LLS showed worse clinical outcome measured by the AOFAS (85.1 ± 14.4 vs 96.3 ± 5.8; P = .034) and Tegner (3.8 ± 1.1 vs 4.4 ± 2.3; P = .012) scores. Postoperative CAIT and AOFAS scores were significantly correlated in patients with concomitant LLS (r = 0.766; P = .002). A CAIT score >24 (no functional ankle instability) resulted in AOFAS scores comparable with scores in patients with isolated AMIC (90.1 ± 11.6 vs 95.3 ± 6.6; P = .442). No difference was seen between groups regarding MOCART 1 and 2.0 scores (P = .714 and P = .371, respectively).

Conclusion:

Concurrently performed AMIC and LLS in patients with OLT and ankle instability resulted in clinical outcomes comparable with isolated AMIC if postoperative ankle stability was achieved. However, residual ankle instability was associated with worse postoperative outcomes, highlighting the need for adequate stabilization of ankle instability in patients with OLT.

Re-operation rate after surgical treatment of osteochondral lesions of the talus in paediatric and adolescent patients

BACKGROUND

The aim of this study is to analyse the re-operation rate after surgical treatment of osteochondral lesions of the talus (OCLTs) in children and adolescents.

METHODS

Between 2009 and 2019, 27 consecutive patients with a solitary OCLT (10 male, 17 female; mean age 16.9 ± 2.2 years; 8 idiopathic vs. 19 traumatic) received primary operative treatment (arthroscopy + bone marrow stimulation [BMS], n = 8; arthroscopy + retrograde drilling, n = 8; autologous chondrocyte implantation [ACI]/autologous bone grafting, n = 9; arthroscopy + BMS + retrograde drilling; n = 1; flake fixation, n = 1). Seventeen OCLTs were located at the medial and ten at the lateral talus. 'Re-operation' as the outcome measure was evaluated after a median follow-up of 42 months (range 6-117 months). Patients were further subdivided into groups A (re-operation, n = 7) and B (no re-operation, n = 20). Groups A and B were compared with respect to epidemiological, lesion- and therapy-related variables.

RESULTS

Seven of 27 patients needed a re-operation (re-operation rate 25.9% after a median interval of 31 months [range 13-61 months]). The following operative techniques were initially used in these seven patients: arthroscopy + BMS n = 2, arthroscopy + retrograde drilling n = 4, ACI + autologous bone grafting n = 1. A comparison of group A with group B revealed different OCLT characteristics between both groups. The intraoperative findings according to the International Cartilage Repair Society (ICRS) classification revealed significantly more advanced cartilage damage in group B than in group A (p = 0.001).

CONCLUSIONS

We detected a re-operation rate of 25.9% after primary surgical OCLT treatment. Patients with re-operation had significantly lower ICRS classification stages compared to patients without re-operation.

Does the Association of Microfractures for the Treatment of Osteochondral Lesions of the Talus Affect the Outcome Following Arthroscopic Treatment for Chronic Ankle Instability?

BACKGROUND

The purpose of the present study was to retrospectively compare the outcomes of patients who underwent arthroscopic thermal capsular shrinkage with those who underwent both arthroscopic thermal capsular shrinkage and arthroscopic osteochondral lesion (OCL) treatment with microfractures. Our hypothesis was that the simultaneous treatment does not negatively affect the outcome of the combined surgical procedure by influencing the postoperative rehabilitation protocol and does not significantly differ from capsular shrinkage alone in terms of subjective and objective outcomes.

METHODS

Seventy-six patients with chronic ankle instability were treated at our department from 2004 to 2012 and reviewed retrospectively. Forty-two patients underwent arthroscopic thermal-assisted capsular shrinkage (group A), and 34 patients underwent combined arthroscopic capsular shrinkage and microfractures for OCL lesions of the talus (group B). All patients underwent a four-step surgical procedure including synovectomy, debridement, capsular shrinkage, and bracing and nonweightbearing for 21 days. In patients with OCL lesions, microfractures of the OCL were associated. Clinical assessment included objective examination, the American Orthopaedic Foot and Ankle Society ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale.

RESULTS

The median follow-up was 6 years (range, 2-9 years). The median postoperative visual analogue scale score, American Orthopaedic Foot and Ankle Society score, and Tegner score were improved from the preoperative level for both groups (P < .001). No significant difference was found between the two groups for the subjective scores and satisfaction rate (P = not significant). Similarly, no significant difference regarding the incidence of range-of-motion restriction was reported between the two groups (P = not significant).

CONCLUSIONS

The association of microfractures for the treatment of osteochondral lesions does not affect the outcome following arthroscopic treatment for chronic ankle instability up to 6 years from surgery.

Demographic Predictors of Concomitant Osteochondral Lesion of the Talus in Patients With Chronic Lateral Ankle Instability

Background:

Osteochondral lesion of the talus (OLT) is commonly found as a concomitant pathologic lesion in a large proportion of patients with chronic lateral ankle instability (CLAI). This study investigated which characteristics in a patient with CLAI increase the risk for OLT.

Methods:

Three hundred sixty-four patients who underwent a modified Broström operation for their CLAI were reviewed retrospectively. The characteristics of each patient and variables associated with OLTs were investigated. Statistical analyses were performed to determine the effect of each potential predictor on the incidence of OLT, and to evaluate the associations between the patient characteristics and variables associated with OLTs.

Results:

Patients with OLTs were more frequently female (female vs male: 63.1% vs 43.9%, P = .003). In addition, the lesion sizes were larger in female patients (female vs male: 113.9 ± 24.9 mm² vs 100.7 ± 18.0 mm², P = .002), and medial lesions were more common in female patients (female vs male; 93.3% vs 81.8%, P = .036). The lesion sizes were larger in patients with a wider talar tilt angle (P < .001), and patients with a medial OLT showed a wider talar tilt angle (12.0 ± 2.0 degrees vs 10.3 ± 2.2 degrees, P = .002).

Conclusion:

In this CLAI patient cohort, we found female patients to be at greater risk for OLTs than male patients. Furthermore, CLAI female patients with concomitant OLT had on average a larger lesion size, more frequent OLT medial position, and were associated with wider talar tilt angles, suggesting that females had more intrinsic ankle instability than males.

Level of Evidence:

Level IV, retrospective case series.

Concomitant ankle instability has a negative impact on the quality of life in patients with osteochondral lesions of the talus: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare patients with osteochondral lesions of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 63 patients with a solitary OCLT were used. All patients received autologous matrix-induced chondrogenesis (AMIC) for OCLT treatment. Patients in group A received an additional ankle stabilisation, while patients in group B received AMIC alone. Both groups were compared according to demographic, lesion-related, and therapy-related factors as well as baseline clinical outcome scores at the time of surgery. The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used.

RESULTS

Patients in group A were older compared to group B [median 34 years (range 20-65 years) vs. 28.5 years (range 18-72 years)]; the rate of trauma-associated OCLTs was higher (89.7% vs. 38.3%); more patients in group A had a previous non-surgical treatment (74.1% vs. 41.4%); and their OCLT lesion size was smaller [median 100 mm² (range 15-600 mm²) vs. 150 mm² (range 25-448 mm²)]. Most OCLTs were located medially in the coronary plane and centrally in the sagittal plane in both groups. Patients in group A had worse scores on the FAOS quality-of-life subscale compared to patients in group B.

CONCLUSION

Patients with OCLT with concomitant CAI differ from those without concomitant CAI according to demographic and lesion-related factors. The additional presence of CAI worsens the quality of life of patients with OCLT. Patients with OCLT should be examined for concomitant CAI, so that if CAI is present, it can be integrated into the treatment concept.

LEVEL OF EVIDENCE

IV.

Retrograde Drilling for Osteochondral Lesions of the Talus in Skeletally Immature Children

BACKGROUND

Osteochondral lesions of the talus (OLTs) involve damage to the cartilage and subchondral bone and are infrequent in children. Clinicians usually attempt nonsurgical treatment of OLTs first, and subsequently progress to surgical treatments, including retrograde drilling (RD), if the initial outcomes are insufficient. Good clinical outcomes of RD have been reported. However, the clinical outcomes of RD in skeletally immature children remain unclear, and the associated preoperative and postoperative computed tomography (CT) findings have not been reported. The purpose of this study was to evaluate the clinical outcomes and CT findings and clarify the efficacy of RD for OLTs.

METHODS

From January 2015 to April 2018, RD was performed on 8 ankles in 6 skeletally immature children. The patients comprised 4 boys and 2 girls with a mean age at surgery of 11.1 years. The mean follow-up was 22.8 months. The clinical outcomes were evaluated according to the Japanese Society for Surgery of the Foot (JSSF) scale. Preoperative and final follow-up CT findings were used to determine the degree of healing.

RESULTS

The mean JSSF scale in all ankles improved from 79.4 (range, 69-90) points preoperatively to 98.4 (range, 87-100) points at final follow-up (P < .05). In the preoperative CT findings, 3 ankles had no bone fragmentation, 4 had partial bone fragmentation, and 1 had whole fragmentation. In the final follow-up CT findings, 4 ankles demonstrated good healing, 3 were fair, and 1 was poor.

CONCLUSION

The present findings suggest that RD is an effective surgical treatment for OLTs in skeletally immature children.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A comparison between arthroscopic and open surgery for treatment outcomes of chronic lateral ankle instability accompanied by osteochondral lesions of the talus

BACKGROUND

This study aimed to examine the efficacy and safety of the arthroscopic treatment of osteochondral lesion of talus (OLT) and lateral ankle instability. It was hypothesized that the outcome of all-arthroscopic surgery was no worse than that of the combined open and arthroscopic surgery for treating chronic lateral ankle instability accompanied by OLT.

METHODS

The patients diagnosed of chronic lateral ankle instability accompanied by OLT, who were surgically treated between May 2015 and May2017, were targeted for inclusion. Specifically, patients who received the arthroscopic treatment of OLT and lateral ankle instability were enrolled in the all-arthroscopic group, while patients who received the arthroscopic treatment of OLT and open lateral ankle stabilization were enrolled in the combined open and arthroscopic group. All the patients were followed up in terms of the Karlsson Ankle Functional Score, visual analog scale (VAS) score, Tegner activity score, and American Orthopaedic Foot & Ankle Society (AOFAS) score. Meanwhile, the satisfaction and complication rates were evaluated and compared.

RESULTS

This retrospective study included a total of 67 patients, including 32 patients in the all-arthroscopic group and 35 patients in the combined group. At a minimum of 24-month follow-up, the functional outcomes were significantly improved in both groups in relation to the preoperative condition. However, the two groups did not differ significantly from each other in terms of the Karlsson score (83.1 ± 8.2 vs 81.7 ± 9.1; P = 0.89), the VAS score (1.8 ± 1.6 vs 2.1 ± 1.7; P = 0.73), the Tegner score (5.5 ± 2.3 vs 5.0 ± 2.1; P = 0.72), and the AOFAS score (87.7 ± 7.6 vs 86.9 ± 7.3; P = 0.77). In addition, the satisfaction and complication rates exhibited no significant differences between the two groups.

CONCLUSION

In comparison with the open lateral ankle stabilization and arthroscopic treatment of OLT, the all-arthroscopic procedure showed no difference in clinical outcomes at a minimum of 24-month follow-up. Despite the benefits of minimally invasive arthroscopic procedure combined with a relatively aggressive postoperative rehabilitation protocol, the clinical outcomes for patients with chronic lateral ankle instability accompanied by OLT did not yield significant improvement.

TRIAL REGISTRATION

The present study was carried out with the approval issued by the Institutional Review Board of Xiangya Hospital (no. 202002010).

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.

Inverse Relationship Between Radiographic Lateral Ankle Instability and Osteochondral Lesions of the Talus in Patients With Ankle Inversion Injuries

BACKGROUND

Insufficient or excessive bony constraint surrounding the talus might contribute to the occurrence of ligamentous injury or bone contusion, respectively, at the time of ankle inversion injuries. This study aimed to investigate the relationship between radiographic lateral ankle instability and osteochondral lesions of the talus (OLT) following ankle inversion injuries.

METHODS

A total of 195 patients (113 men and 83 women; mean age, 38.7 years) with a history of ankle inversion injuries were included in this study. All patients underwent ankle magnetic resonance imaging (MRI) and stress radiography. The tibiotalar tilt angle on varus stress radiograph, anterior translation of the talus on anterior-drawer lateral radiographs, bimalleolar tilt angle, and fibular position were radiographically determined. The radiographic lateral ankle instability was defined as tibiotalar tilt angle ≥10 degrees, and the presence of OLT was confirmed on MR images. The relationship between the radiographic lateral ankle instability and the presence of OLT was statistically analyzed.

RESULTS

The presence of radiographic lateral ankle instability (tibiotalar tilt angle ≥10 degrees) showed an inverse relationship with that of OLT in the chi-squared test (P = .003). An increased tibiotalar tilt angle was associated with lower incidence of OLT (P = .011) in the multiple regression analysis, and the presence of OLT was associated with a decreased tibiotalar tilt angle (P = .016) in the binary logistic regression analysis.

CONCLUSIONS

This study showed an inverse relationship between lateral ankle instability and the development of OLT following ankle inversion injury. The role of bony constraint in the development of sports injuries in the ankle should be considered with these injuries.

LEVEL OF EVIDENCE

Level III, diagnostic, comparative study.

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.

Concurrent arthroscopic osteochondral lesion treatment and lateral ankle ligament repair has no substantial effect on the outcome of chronic lateral ankle instability

PURPOSE

The purpose of the study was to evaluate the effect of concurrent arthroscopic osteochondral lesion (OCL) treatment and lateral ankle ligament repair on the outcome of chronic lateral ankle instability. It was hypothesized that the arthroscopic OCL treatment might have some negative effect on the outcome of chronic lateral ankle instability (CLAI) by compromising the rehabilitation program.

METHODS

Ankle arthroscopy and anatomic lateral ankle ligament repair with suture anchors were performed for 70 patients with CLAI between 2010 and 2012. Thirty-four patients (group A), 20 males and 14 females with a median age of 30(14-54) years, received arthroscopic abrasion, curettage, drilling, or microfracture for OCLs. The splint was removed daily for joint motion exercises beginning at post-operative 2 weeks and full weight bearing was allowed between post-operative week 8 and 12. The other 36 patients (group B) with no combined OCL were followed up as controls. Pre-operative and post-operative visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores, sprain recurrence, ankle stability, and range of motion (ROM) were evaluated and compared.

RESULTS

The median follow-up was 46.5 (38-55) months and 44.5 (38-56) months for group A and group B, respectively. The median post-operative VAS score, AOFAS score, and Tegner score were improved from the pre-operative level for both groups with good-to-excellent results for more than 90% patients. No significant difference was found between the two groups for the subjective scores and satisfaction rate (n.s.). Recurrent sprain was found among nine patients(26.5%) of the group A and five patients (13.9%) of the group B (n.s.). The incidence of the ROM restriction of group A was significantly higher than in group B (23.5 vs 5.6%, P = 0.043).

CONCLUSIONS

The concurrent arthroscopic treatment of OCL with lateral ankle ligament repair demonstrated no substantial negative effect on the overall mid-term outcome of the patients with CLAI except for a potential risk of ROM restriction.

LEVEL OF EVIDENCE

III.

Treatment of talus osteochondral defects in chronic lateral unstable ankles: small-sized lateral chondral lesions had good clinical outcomes

PURPOSE

To assess and compare the clinical and MRI outcomes of patients with talus osteochondral defect (OCD) and patients without OCD in a cohort with chronic lateral ankle instability.

METHODS

All patients who underwent open or arthroscopic anterior talofibular ligament repair of the lateral ligament complex by a single surgeon were included in this study. Ankle arthroscopic surgery was initially performed to manage any intra-articular OCD, including debridement and microfracture. Functional scores (AOFAS, Karlsson score) and Tegner activity level scores were determined. An MRI scan was performed at follow-up to assess talus OCD after treatment. Spearman's correlation coefficients were calculated between functional scores and various factors.

RESULTS

A total of 104 patients with chronic ankle instability were included in this study. Among them, 33 patients had cartilage injury on the talus (OCD group), and the other 71 patients had no cartilage injury (control group). After surgery, there was a significant increase in the AOFAS scores (p < 0.001), the Karlsson scores (p < 0.001), and the Tegner activity scores (p < 0.001) in both the OCD group and the control group. However, there was no significant difference in the AOFAS scores (90.7 ± 6.6 vs. 92.5 ± 8.5; n.s.), the Karlsson scores (89.7 ± 9.3 vs. 91.2 ± 9.1; n.s.), or the Tegner activity scores (5 vs. 6; n.s.) between the OCD group and the control group postoperatively. In the OCD group, there was a significant negative association between the functional scores (AOFAS, Karlsson score, or Tegner score) and the number of intra-articular lesions. For the lateral OCD, the mean lesion area significantly decreased from 49.0 ± 10.7 mm² preoperatively to 18.3 ± 13.1 mm² at the final follow-up (p < 0.001).

CONCLUSION

No significant difference in functional outcomes was found between the OCD group and the control group postoperatively. Arthroscopic microfracture is a good option for the long-term treatment of lateral talus OCD.

LEVEL OF EVIDENCE

III.