Arthroscopic ankle lateral ligament repair alone versus arthroscopic ankle lateral ligament repair with reinforcement by inferior extensor retinaculum

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability

PURPOSE

Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique.

METHODS

All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared.

RESULTS

A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference.

CONCLUSION

Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients.

LEVEL OF EVIDENCE

Level III.

Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability

PURPOSE

Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair.

MATERIALS AND METHODS

Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed.

RESULTS

The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05).

CONCLUSIONS

Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

LEVEL OF EVIDENCE: 4

Advancement of Periosteal and Capsular Complexes With or Without Augmentation Using a Free Graft From Lower Extensor Retinaculum: A Comparative Study With Propensity Score Matching

Background

This study compared the outcome of the L-shaped (L-AD) advancement of the periosteal and capsular complexes with or without augmentation using a free graft of the lower extensor retinaculum (AUG) in patients with chronic lateral ankle instability.

Methods

A matched pair analysis was performed of retrospectively collected medical records of patients undergoing lateral ankle ligament repair who had completed at least 2 years of follow-up. Patients who underwent L-AD with AUG and patients undergoing L-AD alone were matched for age, sex, stress radiography findings, and body mass index. Patients with general joint laxity, osteoarthritic changes in the ankle, and subtalar symptoms and who underwent simultaneous surgical treatment for conditions other than that for lateral ankle ligament were excluded. A total of 46 patients were included in the study (23 patients in each group). Clinical outcome scores and postoperative mechanical instability were compared.

Results

The median American Orthopaedic Foot & Ankle Society (AOFAS) score improved significantly (P < .001) from 72 to 97 in the L-AD alone group and from 77 to 100 in the L-AD with AUG group. The mean (±SD) talar tilt angles improved significantly from 11.1 to 4.7 degrees postoperatively (P < .001) in the L-AD alone group vs 9.7 to 5.2 degrees (P < .001) in the L-AD with AUG group. The mean anterior drawer distances were improved significantly postoperatively from 6.4 to 4.7 mm (P < .001) in the L-AD alone group, and from 6.5 to 4.5 mm (P < .001) in the L-AD with AUG group.

Conclusion

The L-AD technique significantly improved AOFAS scores and mechanical instability of ankles with chronic lateral instability with a very low complication rate. Additional augmentation using a free graft showed no advantages in the ankle with a talar tilt of <20 degrees.

Level of Evidence

Level III, retrospective case-control series.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair

PURPOSE

To compare the clinical outcomes of the lasso-loop and simple suture techniques in arthroscopic anterior talofibular ligament (ATFL) repair for the treatment of chronic lateral ankle instability (CLAI).

METHODS

From 2018 to 2020, patients with CLAI who underwent arthroscopic ATFL repair using the lasso-loop or simple suture technique were matched 1:1 (arthroscopic lasso-loop [AL] group, n = 29; simple arthroscopic suture [AS] group, n = 29) based on age, sex, affected side, body mass index, and follow-up duration using propensity score matching and retrospectively evaluated. Karlsson score, visual analogue scale (VAS) score, Tegner score, anterior drawer test (ADT) results, complications, patient-reported satisfaction, and magnetic resonance (MR) re-evaluation findings of ATFL quality were used to describe the outcomes.

RESULTS

The patient characteristics or follow-up durations did not significantly differ between the two groups. The Karlsson score, VAS score, and Tegner score improved significantly in both groups after a mean follow-up duration of 29.6 ± 2.8 months. The postoperative clinical scores, ADT results, satisfaction rates, complication rates and MR re-evaluation findings were not significantly different between the two groups at the latest follow-up.

CONCLUSION

The lasso-loop technique was equivalent to the simple suture technique in arthroscopic ATFL repair for the treatment of CLAI after a minimum follow-up of 2 years, suggesting that the simple suture technique is sufficient for arthroscopic ATFL repair in most patients without the need to add a lasso loop.

LEVEL OF EVIDENCE

Level III.

Arthroscopic modified Broström operation versus open reconstruction with local periosteal flap in chronic ankle instability

INTRODUCTION

The modified Broström operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure. Comparative studies on the surgical therapy of CAI are limited and generally refer to similar surgical procedures. Aim of this study was to compare the arthroscopic MBO and the RPF.

MATERIALS AND METHODS

We retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. We compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

RESULTS

Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively. Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out. Also in terms of complications and follow-up operations, no significant difference was found between the two procedures.

CONCLUSIONS

Both surgical procedures give very good results one year postoperatively in terms of pain, instability, function and complication rate. With significantly better results regarding pain and instability three months postoperatively, the MBO allows a faster recovery in patients operated with this technique.

Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair

PURPOSE

The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair.

METHODS

A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores.

RESULTS

Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy.

CONCLUSION

Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality.

LEVEL OF EVIDENCE

IV.

Anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation for chronic lateral ankle instability with poor remnant quality: results and complications

PURPOSE

Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients.

METHODS

One hundred and eight patients with CLAI, who were treated surgically using anatomic reconstruction with allograft tendon and suspensory fixation between April 2016 and January 2018 at our hospital, were retrospectively analysed. None of the patients had sufficient ligament remnants for the modified Broström procedure during the intraoperative evaluation. Eighteen patients were excluded. Seventeen patients were lost to follow-up and 73 patients completed the study. The mean duration of instability symptoms was 39.1 months (range, 6-480 months). The mean follow-up time was 57.5 months (range, 48-69 months). Clinical results were evaluated using the Karlsson scoring scale, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score, visual analogue scale (VAS), patients' subjective satisfaction, and incidence of complications. Mechanical stability was evaluated using the varus talar tilt angle (TTA) and anterior talar displacement (ATD).

RESULTS

The AOFAS-AH scores significantly improved from 67.7 ± 8.5 points to 89.8 ± 9.5 (p < 0.001). The Karlsson scoring scales evolved from 58.8 ± 16.5 to 88.4 ± 11.2 (p < 0.001). VAS scores significantly decreased from 2.9 ± 1.3 to 1.1 ± 1.0 (p < 0.001). On stress radiographs, TTA decreased from 15.1 ± 2.5 degrees to 5.8 ± 2.1 degrees (p < 0.001), whereas ATD reduced from 13.4 ± 2.9 mm to 5.7 ± 1.5 mm (p < 0.001). Patients' subjective satisfaction indicated 46 excellent, 20 good, 5 fair, and 2 bad results. Postoperatively, 15 cases (20.5%) did not achieve complete relief of discomfort or swelling, 9 cases (12.3%) experienced joint stiffness or decreased range of motion, and 6 cases (8.2%) had soft tissue irritation. Residual instability and reoperation are rare. Allograft rejection or wound infection was not observed.

CONCLUSION

For the CLAI patients with poor remnant quality, anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation is an effective procedure, while the top three complications in incidence were residual discomfort, joint stiffness, and soft tissue irritation.

LEVELS OF EVIDENCE

Level IV, retrospective case series.

Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques

Background

There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability.

Methods

Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24—36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded.

Results

At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77—100), 90.17 ± 4.64 (range, 85—100) and 0.53 ± 0.63 (range, 0—2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered.

Conclusions

The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization.

High-stress distribution in the lateral region of the subtalar joint in the patient with chronic lateral ankle instability

PURPOSE

Chronic lateral ankle instability (CLAI) is associated with osteoarthritis (OA). However, the characteristics of patients with CLAI who progress to OA are not clear. Measurement of Hounsfield Unit (HU) value on computed tomography (CT) is reported to be useful to evaluate the stress distribution. We aimed to evaluate the stress distribution in the ankle and subtalar joints and factors enhancing it in patients with CLAI.

MATERIALS AND METHODS

Thirty-three ankles with CLAI (CLAI group) and 26 ankles without CLAI (control group) were included. A mean age of CLAI was 35.2 years and control was 30.3 years. Color map was created in the ankle and subtalar joint according to the HU values using three-dimensional CT to identify the region with high HU values, and HU values in those regions were measured using two-dimensional CT and compared between control and CLAI groups. In CLAI group, the relationships between HU values and ankle activity score (AAS), OA, talar tilting angle (TTA), cartilage injury were assessed.

RESULTS

The HU values in the anteromedial region of the talus and lateral region in the subtalar joint were higher than those in the control. In CLAI, patients with an AAS of ≧ 6, over 10° of TTA, cartilage injury, and OA changes in the medial gutter had significantly higher HU values in the lateral region of the subtalar joint than those with an AAS of ≦5, less than 10° of TTA without cartilage injury and OA change.

CONCLUSIONS

CLAI patients, especially in the patients with high activity level, large TTA, cartilage injury, and OA changes at the medial gutter, have high HU values in the lateral region of the subtalar joint, which suggests that disruption of the subtalar compensation toward OA will occur. For these patients, instability should be completely eliminated to prevent ankle OA.

LEVEL OF EVIDENCE

Level III, comparative series.

Clinical outcomes of anterior tibiofibular ligament's distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients

PURPOSE

Treatment of chronic ankle instability (CAI) for ankle sprain patients remains a challenge. If initial treatments fail, surgical stabilization techniques including ligament reconstruction should be performed. Anterior tibiofibular ligament (ATiFL) distal fascicle transfer for CAI was recently introduced. The goal of the study is to assess the 1-year clinical effectiveness of ATiFL's distal fascicle transfer versus ligament reconstruction with InternalBrace™ (Fa. Arthrex, Naples).

METHODS

Between October 2019 and February 2021, 25 patients (14 males and 11 females) scheduled for ligament reconstruction treatment of CAI were enrolled after propensity score matching. Twelve underwent ligament reconstruction with InternalBrace™ (InternalBrace™ group) and thirteen underwent ATiFL's distal fascicle transfer (ATiFL's distal fascicle transfer group). We recorded the American Orthopedic Foot & Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), anterior drawer test grade, patient satisfaction and complications. All results of this study were retrospectively analyzed.

RESULTS

Statistically significant (p = 0.0251, independent-samples t test) differences in the AOFAS can be found between the ATiFL's distal fascicle transfer group and the InternalBrace™ group. No substantial changes in the VAS (p = 0.1778, independent-samples t test), patient satisfaction (p = 0.1800, independent-samples t test) and anterior drawer test grade (p = 0.9600, independent-samples t test) were found between the two groups. There was one patient with superficial wound infection and one patient with sural nerve injury in the InternalBrace™ group and ATiFL's distal fascicle transfer group, respectively.

CONCLUSION

This is the first study that assessed a cohort of CAI patients and suggests that the ATiFL's distal fascicle transfer operation has the potential to attain good-to-excellent clinical outcomes after 1-year recovery. The AOFAS scores were significantly higher for patients with ATiFL's distal fascicle transfer, indicating that this technique may be considered a viable option for both patients and their surgeon, while long-term outcomes should be investigated in the future.