Lateral ankle triad: the triple injury of ankle synovitis, lateral ankle instability, and peroneal tendon tear

Ankle Instability and Peroneal Disorders in Cavovarus Feet: Do I Need a Calcaneal Osteotomy?

In order to understand the relation among ankle instability, peroneal disorders, and cavovarus deformity, it is mandatory to clarify the different stages of those disorders and also to put them into relation to each other. Finally, we need to take the patients compliance and expectations into consideration to define the individually right way of treatment.

Clinical Manifestations, Diagnosis and Management of Synovial Fistula Associated Lateral Ankle Sprain or Instability: A Retrospective Study of 19 Surgically Confirmed Patients

We aimed to investigate the preoperative history, clinical manifestations, imaging findings, and postoperative clinical outcomes for patients with surgically confirmed synovial fistula around the ankle joint. 19 consecutive patients who were confirmed to have synovial fistula in the surgical field were enrolled in this study. Medical records of all patients in terms of preoperative details, operative findings, and postoperative outcomes at 1 year after the surgery were retrieved. As a diagnostic modality, the normal saline test or MRI was used. Intraoperatively, the synovial fistula was repaired with the capsuloligamentous repair or additional periosteal augmentation. All patients had a history of ankle sprain prior to symptoms and showed positive results in the saline load test. One patient had recurred symptom after the surgery, so needed a revisional periosteal augmentation. At 1 year follow-up period, the average Foot ankle outcome score was 87.65 and no surgery-related complication was detected. Synovial fistula of the ankle joint needs to be taken into consideration as a possible complication in patients with ankle sprain history and recurrent joint swelling. The saline load test would be useful for its diagnosis, and treatment should be focused on the complete closure of capsular opening along with restoration of its surrounding pathologic conditions.

Clinical Outcomes of Peroneal Tendon Tears: A Systematic Review

The purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane. Criteria for inclusion were clinical studies reporting outcomes after treatment for peroneal tendon tear within the last 10 years. Nine studies evaluating 336 patients (146 males/190 females) and 336 ankles were included in this review. The mean age of included patients was 46.3 years (range, 46-56.9 years). The weighted mean follow-up was 23.82 months (range 9.2-78 months. Five surgical interventions were reported: primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction. Four studies recorded the AOFAS score, with a weighted mean preoperative score of 69.58 and a weighted mean postoperative score of 88.82. Six studies measured the VAS score showing an improvement from a mean weighted preoperative score of 4.68 to a mean weighted postoperative score of 1.2. FAAM score was measured in 3 studies, which showed an improvement from 41.1 preoperatively to 84.4 postoperatively. The average overall complication rate was 38.7% (130/336) with the most commonly reported minor complication being ankle pain, which made up 46.2% of all minor complications (56/121). Primary repair without tenodesis was associated with a higher complication rate compared to any other surgical intervention (p=.001176). The current systematic review showed that overall clinical outcomes were positive in lieu of the different modalities of surgical intervention for peroneal tendon tears.

Preoperative Assessment of the Peroneal Tendons in Lateral Ankle Instability: Examining Clinical Factors, Magnetic Resonance Imaging Sensitivity, and Their Relationship

The purpose of our study was to examine the preoperative clinical factors and magnetic resonance imaging (MRI) findings associated with peroneal pathology in chronic lateral ankle instability patients, as well as the clinical factors associated with peroneal lesions being detected on MRI. Peroneal pathology was determined from intraoperative findings. Patients with/without peroneal pathology were compared regarding their preoperative clinical findings. MRI reports were examined to determine the sensitivity of detecting peroneal pathologies. Clinical factors were compared between patients (N = 238) with undetected and detected peroneal lesions on MRI. Conservative treatment, preoperative physical therapy, and lack of a traumatic inciting event were associated with peroneal pathology. MRI had a sensitivity of 61.11% for detecting peroneal pathology. No clinical factors were significantly different between "detected" and "undetected" cases. Certain historical factors were associated with peroneal pathology in patients with chronic lateral ankle instability, and MRI had a high false-negative rate. Surgeons should exercise caution when ruling out peroneal pathology based on preoperative physical examination or MRI.

High-resolution US and MR imaging of peroneal tendon injuries

Injuries of the peroneal tendon complex are common and should be considered in every patient who presents with chronic lateral ankle pain. These injuries occur as a result of trauma (including ankle sprains), in tendons with preexisting tendonopathy, and with repetitive microtrauma due to instability. The peroneus brevis and peroneus longus tendons are rarely torn simultaneously. Several anatomic variants, including a flat or convex fibular retromalleolar groove, hypertrophy of the peroneal tubercle at the lateral aspect of the calcaneus, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, and an os peroneum, may predispose to peroneal tendon injuries. High-resolution 1.5-T and 3-T magnetic resonance (MR) imaging with use of dedicated extremity coils and high-resolution ultrasonography (US) with high-frequency linear transducers and dynamic imaging are proved to adequately depict the peroneal tendons for evaluation and can aid the orthopedic surgeon in injury management. An understanding of current treatment approaches for partial- and full-thickness peroneal tendon tears, subluxation and dislocation of these tendons with superior peroneal retinaculum (SPR) injuries, intrasheath subluxations, and peroneal tendonopathy and tenosynovitis can help physicians achieve a favorable outcome. Patients with low functional demands do well with conservative treatment, while those with high functional demands may benefit from surgery if nonsurgical treatment is unsuccessful. Radiologists should recognize the normal anatomy and specific pathologic conditions of the peroneal tendons at US and MR imaging and understand the various treatment options for peroneal tendon and SPR superior peroneal retinaculum injuries. Online supplemental material is available for this article.

Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study

PURPOSE

This study aimed to investigate current trends in ankle arthroscopy across time, sex, age, and region of the United States as well as the use of ankle arthroscopy in the management of lateral ankle instability.

METHODS

Patients who underwent ankle arthroscopy and those who underwent ankle arthroscopy and lateral ankle ligament repair or peroneal retinacular repair from 2007 through 2011 were identified using the PearlDiver national database. These searches yielded volumes of unique patients, sex and age distribution, and regional volumes of patients. Χ-square linear-by-linear association analysis was used for comparisons, with P < .05 considered significant.

RESULTS

We identified 15,366 ankle arthroscopy procedures in the database from 2007 to 2011. Over the 5-year study period, there was a significant increase in the overall number of ankle arthroscopies being performed, from 2,814 in 2007 to 3,314 in 2011 (P < .0001). Female patients had ankle arthroscopy more frequently than did male patients (P = .027). The majority of patients who had ankle arthroscopy were between the ages of 30 and 49 years. The use of ankle arthroscopy during lateral ligament repair procedures increased from 37.2% in 2007 to 43.7% in 2011 (P < .0001). The incidence of combined ankle arthroscopy and peroneal tendon retinacular repair increased 50%, from 2.8/100 ankle arthroscopies in 2007 to 4.2/100 ankle arthroscopies in 2011 (P < .0001).

CONCLUSIONS

The incidence of ankle arthroscopy increased significantly from 2007 to 2011, outpacing shoulder, knee, and elbow arthroscopy. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years. The use of ankle arthroscopy in the surgical management of lateral ankle instability also increased significantly. The incidence of concomitant ankle arthroscopy and lateral ligament repair increased significantly, as did the incidence of concomitant ankle arthroscopy and repair of peroneal tendon subluxation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Predictors of peroneal pathology in Broström-Gould ankle ligament reconstruction for lateral ankle instability

BACKGROUND

Chronic ankle instability has a well-known association with intra- and extraarticular ankle pathologies, including peroneal tendonitis and subluxation. Patients with peroneal pathology are at risk for failure of conservative treatment for their ankle instability, thus identifying these patients is important and helps to guide management. There has been no literature looking at, in patients with chronic ankle instability, which associated ankle pathologies and patient characteristics are predictive of peroneal pathology.

METHODS

A retrospective chart review was performed on all patients (N = 136) who underwent a Broström-Gould ankle ligament reconstruction at a single institution from 2010 to 2014. Preoperative clinical examinations and MRIs as well as operative procedures were documented. Patients with and without peroneal pathology were divided into 2 cohorts, and their preoperative characteristics underwent a univariate analysis with P < .05 defined as showing a significant difference.

RESULTS

Of patients undergoing lateral ankle ligament reconstruction, 53.3% required operative intervention for symptomatic peroneal tendon pathology. Female gender was the only significant predictor of peroneal pathology (P = .008). The presence of an osteochondral lesion of the talus (OLT) was a significant negative predictor of peroneal pathology (P < .001). The remainder of the variables (age, BMI, duration of symptoms, tobacco, traumatic etiology, worker's compensation, global hyperlaxity, contralateral ankle instability, sport participation, ankle tilt, and deltoid tear) did not show a significant difference between cohorts.

CONCLUSION

In patients who underwent Broström-Gould ankle ligament reconstruction for chronic lateral ankle instability, female gender was significantly associated with concomitant peroneal tendon pathology. Conversely, preoperative MRI findings of an OLT showed a significant negative association with peroneal pathology. All of the other variables did not show a positive or negative association.

Predicting functional recovery after acute ankle sprain

Introduction

Ankle sprains are among the most common acute musculoskeletal conditions presenting to primary care. Their clinical course is variable but there are limited recommendations on prognostic factors. Our primary aim was to identify clinical predictors of short and medium term functional recovery after ankle sprain.

Methods

A secondary analysis of data from adult participants (N = 85) with an acute ankle sprain, enrolled in a randomized controlled trial was undertaken. The predictive value of variables (age, BMI, gender, injury mechanism, previous injury, weight-bearing status, medial joint line pain, pain during weight-bearing dorsiflexion and lateral hop test) recorded at baseline and at 4 weeks post injury were investigated for their prognostic ability. Recovery was determined from measures of subjective ankle function at short (4 weeks) and medium term (4 months) follow ups. Multivariate stepwise linear regression analyses were undertaken to evaluate the association between the aforementioned variables and functional recovery.

Results

Greater age, greater injury grade and weight-bearing status at baseline were associated with lower function at 4 weeks post injury (p<0.01; adjusted R square=0.34). Greater age, weight-bearing status at baseline and non-inversion injury mechanisms were associated with lower function at 4 months (p<0.01; adjusted R square=0.20). Pain on medial palpation and pain on dorsiflexion at 4 weeks were the most valuable prognostic indicators of function at 4 months (p< 0.01; adjusted R square=0.49).

Conclusion

The results of the present study provide further evidence that ankle sprains have a variable clinical course. Age, injury grade, mechanism and weight-bearing status at baseline provide some prognostic information for short and medium term recovery. Clinical assessment variables at 4 weeks were the strongest predictors of recovery, explaining 50% of the variance in ankle function at 4 months. Further prospective research is required to highlight the factors that best inform the expected convalescent period, and risk of recurrence.

Fatigue of the hip abductors results in increased medial-lateral center of pressure excursion and altered peroneus longus activation during a unipedal landing task

BACKGROUND

Previous studies have reported that diminished hip abductor muscle strength is associated with a loss of frontal plane postural stability and increased risk for ankle sprain. The purpose of this study was to determine whether hip abductor fatigue results in compensatory changes in neuromuscular activation of the peroneus longus (an important lateral stabilizer of the ankle) during a unipedal landing task.

METHODS

Thirty healthy females performed a unipedal landing task before and after completing a hip abductor fatigue protocol. Paired t-tests were used to assess changes in medial-lateral center of pressure displacement, and EMG (electromyographic) amplitude of the peroneus longus following hip abductor fatigue. Changes in peroneus longus onset timing also were assessed.

FINDINGS

Following the hip abductor fatigue protocol, participants exhibited increased mean center of pressure displacement (7.7 (1.5) vs. 9.2 (2.0) cm, P<0.01), and increased EMG amplitude of peroneus longus (0.75 (0.18) vs. 0.86 (0.21), P<0.01) during the deceleration phase of landing. Post-fatigue, significantly earlier peroneus longus onset timing prior to landing was observed (88.9 (24.9) vs. 121.9 (25.7) ms, P<0.01).

INTERPRETATION

The increased EMG amplitude and earlier onset of the peroneus longus appears to be a protective compensatory adaptation to stabilize the ankle in response to frontal plane postural instability induced by hip abductor fatigue.