Management of chronic lateral ankle instability in military service members

Outcomes Following Modified Broström for Chronic Lateral Ankle Instability With and Without Peroneal Tendon Exploration

BACKGROUND

It is not known how peroneal tendon exploration influences results after modified Broström for lateral ankle instability. We propose peroneal exploration at the time of modified Broström will have similar outcomes as no peroneal exploration.

METHODS

A retrospective analysis was performed of patients undergoing modified Broström with and without peroneal exploration. Foot and Ankle Outcome scores and data regarding military retention were gathered and compared.

RESULTS

Seventeen patients were identified in the modified Broström only cohort and 24 in the peroneal exploration cohort. Patients had mean follow-up of 5 years in both cohorts. The mean FAOS in the modified Broström only cohort was 68 and 72 in the cohort with peroneal exploration (P = .541). When each FAOS subcategory was analyzed, no difference was identified in any subcategory. Eight of 17 patients (47%) in the modified Broström only cohort remained active duty compared with 8 of 24 patients (33%) in the modified Broström with peroneal exploration cohort (P = .518). One patient medically discharged in the modified Broström only cohort versus 6 in peroneal exploration cohort (P = .109). Overall satisfaction with the procedure was 12 of 17 (71%) in the modified Broström only cohort and 19 of 24 (79%) in the peroneal exploration cohort (P = .529).

CONCLUSIONS

No significant difference was identified between patients undergoing modified Broström alone or modified Broström with peroneal exploration. There was no significant difference in return to duty, medical discharge or patient satisfaction.

LEVELS OF EVIDENCE

Level III: retrospective case-control study with prospectively collected data.

Treatment of Chronic Ankle Instability in the Military Population: A Systematic Review

BACKGROUND

The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare and evaluate chronic ankle instability treatment strategies in the military population.

METHODS

Electronic databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews guidelines for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports.

RESULTS

Eight studies met the inclusion criteria, representing 695 military service members-625 males (89.9%) and 70 females (10.1%)-and 4 treatment strategies: Broström-related procedures, modified Watson-Jones procedure, Colville's technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of satisfactory outcomes was 100% for Colville's technique, and ranged from 73.2% to 94.7% for Broström-related procedures and 72% to 80% for the modified Watson-Jones procedure. Mean American Orthopaedic Foot and Ankle Society scores, anterior drawer displacement, talar tilt, and visual analogue scale scores were also reported.

CONCLUSION

This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville's technique is another promising option for this patient population but would require additional studies to support this claim.

LEVELS OF EVIDENCE

Level IV.

Current concepts in the surgical management of chronic ankle lateral ligament instability

Background/aims

Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI).

Methods

The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI.

Results

Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes.

Conclusion

Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Postoperative Ankle Imaging, 2022

Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography.

Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System

OBJECTIVE

To investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and ankle-related medical care use at 1 year after ankle sprain.

DESIGN

Retrospective cohort study of all beneficiaries of the US Military Health System seeking care for an ankle sprain over a 4-year period.

METHODS

Individuals were classified according to whether they did or did not receive physical rehabilitation. For those who received rehabilitation (n = 6150), linear relationships (with appropriate covariate controls) were analyzed with generalized linear models and generalized additive models to measure the effects of rehabilitation timing on injury recurrence and injury-related medical care use (costs and visits) at 1 year after injury. The nonlinear effect of rehabilitation timing on the probability of recurrence was assessed.

RESULTS

Approximately 1 in 4 people received rehabilitation. The probability of ankle sprain recurrence increased for each day that rehabilitation was not provided during the first week. The probability of ankle sprain recurrence plateaued until about 2 months after initial injury, then increased again, with 2 times greater odds of recurrence compared to those who received physical rehabilitation within the first month. When rehabilitation care was delayed, recurrence (odds ratio [OR] = 1.28), number of foot/ankle-related visits (OR = 1.22), and foot/ankle-related costs increased (OR = 1.13; up to $1400 per episode).

CONCLUSION

The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred. J Orthop Sports Phys Ther 2021;51(12):619-627. doi:10.2519/jospt.2021.10730.

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BACKGROUND

Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.

METHODS

This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.

RESULTS

Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.

CONCLUSION

Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.

LEVEL OF EVIDENCE

3b.

Postoperative Rehabilitation of Chronic Lateral Ankle Instability: A Systematic Review

Chronic lateral ankle instability often causes adults to require a surgical intervention with subsequent physical therapy to assist with returning to their prior level of function. This systematic review is hoping to provide an up to date understanding of surgical procedures performed to correct chronic lateral ankle instability and establish a protocol for others to follow when treating adults who are status-post chronic lateral ankle instability surgery. This review looked at level I to III research studies that included surgical interventions to correct chronic lateral ankle instability as well as a rehabilitation protocol. This study found implementation of a rehabilitation protocol after surgical intervention could improve balance and subjective functional outcomes. It also determined that early weight-bearing may allow for early strengthening as range of motion returns faster. Further research is required utilizing larger randomized studies to better evaluate the outcomes of specific rehabilitation protocols in this patient population.

Do Mid-term Outcomes of Lateral Ankle Stabilization Procedures Differ Between Military and Civilian Populations?

BACKGROUND

Ankle instability is common and previous studies have documented greater than 85% good-to-excellent outcomes based upon both patient-reported outcome measures and subjective evaluation of ability to return to previous activity levels after lateral ankle stabilization in the civilian population. However, patient-reported outcomes and performance may differ in the military population. The military oftentimes requires servicemembers to navigate uneven terrain and ladderwells, which can stress ankles differently than in their civilian counterparts. There has been limited evidence regarding patient outcomes after lateral ankle stabilization within a military population and its elucidation is important in optimizing outcomes for our servicemembers. Furthermore, the potential benefit of fibular periosteum augmentation with lateral ankle stabilization procedures in a military population has not been described. The results of using this extra tissue to reinforce the repair are important in determining whether its routine incorporation is indicated in the military.

QUESTIONS/PURPOSES

In an active-duty military population, we asked: (1) What proportion of patients who underwent lateral ankle stabilization using anatomic repair techniques with or without fibular periosteum augmentation achieved good-to-excellent outcomes based on the Foot and Ankle Disability Index (FADI) score at a minimum follow-up interval of 2 years? (2) Was the proportion of patients who achieved a good-to-excellent FADI score higher among those treated with fibular periosteum augmentation than those treated without? (3) Did the likelihood of achieving a good-to-excellent outcome after lateral ankle stabilization vary based on whether the procedure was performed by a fellowship-trained sports or foot and ankle orthopaedic surgeon versus a podiatrist?

METHODS

Between 2007 and 2017, 15 surgeons (six orthopaedic surgeons and nine podiatrists) performed 502 lateral ankle stabilizations. We excluded 4% (18 of 502) of patients because they were not active-duty at the time of surgery, and we excluded 12% (56 of 502) of lateral ankle stabilizations because they were performed as part of other potentially confounding foot or ankle procedures. We considered 60% (303 of 502) as lost to follow-up because the patients could not be contacted at least 2 years after surgery, they declined to participate, or they did not fully answer the questionnaires. This left 125 patients for analysis. Of those, 79% (99 of 125) had a procedure with fibular periosteum augmentation and 21% (26 of 125) had a procedure without augmentation. During the study period, five fellowship-trained orthopaedic foot and ankle surgeons and two podiatrists always used fibular periosteum augmentation. Orthopaedic surgeons performed 75% (94 of 125) of the procedures, and the other 25% (31 of 125) were performed by podiatrists. Whether a servicemember was treated by one specialty or the other was simply based upon whom they were referred to for care. Orthopaedic surgeons tended to perform procedures with augmentation (five with versus one without) and podiatrists tended to perform procedures without augmentation (two with versus seven without). To help account for this confounding factor, we performed separate analyses for procedures performed with versus without augmentation in addition to procedures performed by orthopaedic surgeons versus podiatrists. We retrospectively contacted each patient to obtain their self-reported overall result, FADI outcome score, and postoperative military capabilities. The minimum follow-up duration was 2 years; overall mean follow-up duration was 7 years. The fibular periosteum augmentation group mean follow-up was 7 ± 4 years and without augmentation was 6 ± 3 years. The orthopaedic surgeons group mean follow-up was 7 ± 3 years and the podiatrists group was 7 ± 3 years. We obtained postoperative FADI scores via phone interview along with data regarding the patients' postoperative military capabilities, but did not have preoperative FADI scores.

RESULTS

Pooling both surgical treatments, 67% (84 of 125) of the patients reported good-to-excellent results and 33% (41 of 125) reported very poor-to-fair results. We found no difference in the proportion of patients treated with fibular periosteal augmentation who achieved a good or excellent score on the FADI than was observed among the patients treated without periosteal augmentation (68% [67 of 99] versus 65% [17 of 26]; odds ratio 1 [95% CI 0 to 2]; p = 0.81). The proportion of patients who achieved a good or excellent score on the FADI did not differ depending on whether the procedure was performed by an orthopaedic surgeon or a podiatric surgeon (66% [62 of 94] versus 71% [22 of 31]; OR 1 [95% CI 1 to 2]; p = 0.66).

CONCLUSION

The patient-reported outcome scores after lateral ankle stabilization in our study of military servicemembers at a minimum of 2 years and a mean of 7 years were far lower than have been reported in studies on civilians. Indeed, our findings may represent a best-case scenario because more patients were lost to follow-up than were accounted for, and in general, surgical results among missing patients are poorer than among those who return for follow-up. Variability in the addition of fibular periosteum augmentation and whether an orthopaedic surgeon or podiatrist performed the procedure did not account for these findings. With one third of patients reporting very-poor-to-fair results after these reconstructions, and many patients lost to follow-up, we recommend surgeons counsel their servicemember patients accordingly before surgery. Specifically, that there is a one third chance they will need permanent restrictions or have to leave the military postoperatively; analogously, we believe that our findings may apply to similarly active patients outside the military, and we question whether these procedures may not be serving such patients as well as previously believed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Prevalence of Chronic Ankle Instability in French Paratroopers

Introduction

Ankle sprain is the most common musculoskeletal injury in the physically active population (up to 50% of sports injuries) and is common in the general population with about one ankle sprain per 10 000 person-days worldwide. It is an even more frequent pathology in the military population with a prevalence of five to eight times higher than in the civilian population. In the general population, 20 to 74% of sprains are complicated by chronic ankle instability. No studies estimate this prevalence in a French military population. The main objective of our study was, therefore, to estimate the prevalence of chronic ankle instability in French paratroopers.

Materials and Methods

The study was carried out in a French parachute regiment over a period of 1 year during periodic medical examinations. To diagnose chronic ankle instability, we used the criteria defined by the International Ankle Consortium in 2013 and two questionnaires that this consortium recommended (FAAM and IdFAI).

Results

Chronic ankle instability has a prevalence of 43.1% after an ankle sprain with a total of 2.3% among paratroopers, which is comparable to data in the literature. After their first sprain, 23.1% of subjects did not consult a health professional and 47.6% of subjects did not receive physiotherapy.

Conclusions

Physiotherapy is the basis of care, both for prevention and treatment of chronic ankle instability. It is necessary to raise awareness of this injury among the military and to encourage their adherence to treatment in order to preserve the operational capabilities of combat units. Subsequently, further studies are needed to expand the study population to provide a more comprehensive view of the impact of this injury on the military. Studies concerning the management of chronic ankle instability adapted to the military population would also be relevant.

Postoperative Outcome of the Modified Broström Procedure in the Active Duty Military Population: A Retrospective Cohort Study

Ankle sprains are common injuries and typically treated conservatively. Chronic ankle instability, however, can require surgery when nonoperative measures fail. We evaluated the clinical outcomes of an active duty population in a retrospective study of patients who had undergone a modified Broström procedure at our facility from January 2010 through April 2014 by a single surgeon. The electronic medical records and Army E-profile database were reviewed to determine whether the patients had returned to active duty and whether they had any permanent postoperative lower extremity activity restrictions. A total of 127 patients met the inclusion criteria and had undergone the modified Broström procedure during the study period; 34 (26.8%) separated from the military postoperatively. Of these 34 patients, 23 (18.1%) were unfit for reasons related to their ankle and 11 (8.7%) required military separation for reasons unrelated to their ankle. Thus, 93 patients (73.2%) were able to remain on active duty after undergoing the Broström procedure. Of the 93 patients able to remain on active duty, 38 (40.9%) required activity modifications and 55 (59.1%) were able to return to full duty. Chronic ankle instability in active duty patients can be severely limiting. The modified Broström procedure can provide significant improvement in symptoms and allow patients to remain on active duty. In our high-demand population, ~73% of patients were able to remain on active duty after their injury and subsequent surgery, 60% of whom returned to their previous level of duty without any physical restrictions.

Comparison of Magnetic Resonance Imaging and Stress Radiographs in the Evaluation of Chronic Lateral Ankle Instability

BACKGROUND

In patients who develop chronic ankle instability, clinicians often obtain magnetic resonance imaging (MRI) as part of the evaluation prior to operative referral. The purpose of this study was to analyze the diagnostic efficacy of MRI in the diagnosis of chronic lateral ankle instability. Our hypothesis was that magnetic resonance imaging would not be a specific diagnostic tool in the evaluation of chronic lateral ankle instability.

MATERIALS AND METHODS

A retrospective chart review of 187 consecutive patients (190 ankles) was performed. Inclusion criteria for the study group required a primary complaint of instability that required operative repair or reconstruction, a documented clinical evaluation consistent with instability, stress radiographs, and MRI. Stress radiographs and clinical examinations for the study group and a control group were reviewed independently by both a musculoskeletal radiologist and a board-certified orthopaedic foot and ankle surgeon. Predictive values in terms of sensitivity, specificity, and prevalence were performed. In total, 112 patients (115 ankles) were identified who underwent an operative reconstruction of their lateral ligaments with a history, physical examination, and stress radiographs consistent with lateral ankle instability. A control group was selected consisting of 75 patients seen in the foot and ankle clinic with a diagnosis other than lateral ankle instability. Thirty-seven of the patients in the control group had stress radiographs performed in the clinic to rule out instability as part of their evaluation, and this allowed for an evaluation of the efficacy of stress radiographs in addition to MRI. Statistical analysis was performed using predictive values from sensitivity, specificity, and prevalence.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in regards to MRI in the evaluation of patients found to have clinical lateral ankle instability and those who did not had statistical significance. Sensitivity of MRI was 82.6%, specificity was 53.3%, NPV was 66.7%, and PPV was 73%. Since 37 patients in the control group also had stress radiographs, a subanalysis was performed to identify the same values with stress radiographs. Sensitivity, specificity, NPV, and PPV were 66%, 97%, 48%, and 98.7%, respectively. The overall accuracy within this study was 71% for MRI and 74% for stress radiographs.

CONCLUSION

This study demonstrated that MRI has high sensitivity but low specificity in the evaluation of clinical ankle instability. While MRI has value as a screening tool for concomitant ankle pathology, it should not be considered diagnostic in terms of lateral ankle instability.

LEVEL OF EVIDENCE

Level III, retrospective cohort, comparative series.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.