All Arthroscopic Remnant-Preserving Technique to Reconstruct the Lateral Ankle Ligament Complex

Accuracy of Cutaneous Landmarks Compared to Ultrasound to Locate the Calcaneal Footprint of the CFL

The purpose was to determine the accuracy of the techniques of Lopes et al. and Michels et al., compared to ultrasound, to locate the center of the calcaneal footprint of the CFL in healthy volunteers. The authors recruited 17 healthy adult volunteers at 1 center with no current ankle pathologies and no previous surgical antecedents on either ankle. The authors recorded the age, sex, height, BMI, and ankle side for each volunteer. Measurements were made on both ankles of the 17 volunteers to increase the sample size and ensure less dispersion of data, independently by 2 surgeons: 1 senior surgeon with 15 years' experience and 1 junior with 3 years' experience. The location of the center of the calcaneal footprint of the CFL was determined by each surgeon using 3 methods: (1) the cutaneous technique of Lopes et al., (2) the cutaneous technique of Michels et al., and (3) ultrasound imaging. The 17 volunteers (34 feet) had a mean age of 26.3 ± 8.7 and a BMI of 21.7 ± 2.9. The Michels point was significantly closer (4.6 ± 3.7 mm) than the Lopes point (11.1 ± 5.4 mm) to the true center of the calcaneal footprint of the CFL determined by ultrasound, notably in the vertical direction. The Michels point was located significantly closer to the true center of the calcaneal footprint of the CFL and demonstrated less dispersion than the Lopes point, indicated by significantly lower absolute mean deviation from the true center of the calcaneal footprint of the CFL, and that ultrasound is therefore preferred to locate the footprint the CFL.

Efficacy of arthroscopic internal fixation with countersunk screw in the treatment of talus fracture

Objective

To explore clinical effects of arthroscopic internal fixation with countersunk screw in the treatment of talus fracture.

Methods

Forty-eight patients with talus fracture treated in hospital of Chengde Medical University from February 2015 to December 2019 were enrolled for present investigation. The patients with talus fracture were randomly assigned into two groups, with twenty-four patients per group. The patients with talus fracture in the observation group were treated with arthroscopic internal fixation with countersunk screw, while the traditional open reduction and internal fixation were applied for the ones in control group. The clinical efficacy of the patients was evaluated three months after the operation, and the preoperative and postoperative ankle joint functions, fracture-healing time, hospital stay, and complications were carefully compared between observation and control group.

Results

A total efficiency as high as 91.67% was showed in observation group, which is distinctly better than the effective rate of control group (66.67%, P<0.05). Before operation, ankle function scores (AOFAS) of control group and observation group is 42.08 ± 4.29 and 41.75±5.31 with no significantly difference (P>0.05); while after the surgery, AOFAS scores of control group is significantly lower than that of observation group: (66.28±7.51 vs. 53.0 ±6.79, P<0.05). Moreover, healing time and hospitalized duration of observation group are 3.19±1.04 months and 3.57±0.97 days, which are also significantly shorter than 4.18±1.25 months and 8.28±2.54 days in control group, respectively, (P < 0.05). And the total complication rate in control group is 20.83%, which is higher than 8.33% in observation group (P >0.05).

Conclusion

Arthroscopic internal fixation with countersunk screw can significantly improve the efficacy and ankle joint functions, shorten the fracture-healing time and hospital stays without increasing the incidence of complications.

Arthroscopic anatomical reconstruction of lateral collateral ligaments with ligament advanced reinforcement system artificial ligament for chronic ankle instability

BACKGROUND

Recently, the use of ligament advanced reinforcement system (LARS) artificial ligament, a new graft which has several unique advantages such as no donor-site morbidity, early recovery and no risk of disease transmission which has been a significant breakthrough for anatomical ligament reconstruction. Growing studies suggested that the special design of the LARS ligament with open fibers in its intra-articular part was believed to be more resistant to torsional fatigue and wearing. However, the safety and efficacy of LARS artificial ligament for ankle joint lateral collateral ankle ligament reconstruction has not been defined to date.

AIM

To evaluate the clinical results of all-arthroscopic anatomical reconstruction of ankle joint lateral collateral ligaments with the LARS artificial ligament for chronic ankle instability.

METHODS

Twenty-two patients with chronic lateral instability underwent anatomical reconstruction of the lateral collateral ligaments of ankle with LARS artificial ligament. The visual analogue score (VAS), American Orthopaedic Foot and Ankle Society score (AOFAS score) and Karlsson score were used to evaluate the clinical results before and after surgery.

RESULTS

A total of 22 patients (22 ankles) were followed up for a mean of 12 mo. All patients reported significant improvement compared to their preoperative status. The mean AOFAS score improved from 42.3 ± 4.9 preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively. The mean VAS score improved from 1.9 ± 2.5 preoperatively to 0.8 ± 1.7 postoperatively.

CONCLUSION

All-arthroscopic anatomical reconstruction of the lateral collateral ligaments with LARS artificial ligament achieved a satisfactory surgical outcome for chronic ankle instability.

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Arthroscopic Reconstruction of the Anterior Tibiotalar Ligament Using a Free Tendon Graft

Deltoid ligament injuries account for 5.1% to 15.8% of ankle sprains and occur with concomitant lateral ankle sprains. The anterior tibiotalar ligament (ATTL), located within the deep layer of the deltoid ligament complex, connects the talus and the tibia on the medial side of the ankle and controls ankle eversion and rotation. If conservative treatment for chronic medial ankle instability after an ankle sprain fails, ATTL repair or reconstruction might be necessary. Arthroscopic reconstruction techniques of the lateral ankle ligaments recently have been reported. Here, we describe arthroscopic reconstruction of the ATTL using a free tendon graft (ARATTL). This technique is less invasive than other treatments and results in a more stable medial ankle joint.

Arthroscopic Reconstruction of the Anterior Talofibular Ligament, Lateral Talocalcaneal Ligament, and Calcaneofibular Ligament Using a Triangle-Shaped Tendon Graft (ALC-Triangle)

The lateral talocalcaneal ligament (LTCL) connects the talus and calcaneus on the lateral side of the hindfoot. Although its function remains has not yet been clearly elucidated, the LTCL is thought to be important for the stabilization of the subtalar joint. Ankle sprains often include not only the talocrural joint but also the subtalar joint; therefore, LTCL injuries occur at a certain rate. Moreover, surgeons often encounter and reluctantly dissect the LTCL during arthroscopic anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) reconstruction because the LTCL connects to the ATFL at the talus in 42% of people and connects to the CFL at the calcaneus in 18% of people. As a result, LTCL reconstruction might be necessary for those patients. We describe the arthroscopic reconstruction technique of the ATFL, LTCL, and CFL using a triangle-shaped tendon graft (ALC-triangle). This technique provides a possible advantage of an anatomical and stable talocrural joint and subtalar joint.

Arthroscopic Anatomic Anterior Talofibular Ligament Repair for Anterolateral Ankle Instability

Ankle instability is due to repetitive inversion injuries and is usually treated conservatively; however, after repeated sprains, chronic instability occurs and usually requires a surgical procedure. Recently, arthroscopic repair of a torn anterior talofibular ligament (ATFL) has become more popular owing to its minimal invasiveness and high efficacy. An all-inside technique allows for anatomic restoration of the injured ATFL, provides stability to the ankle joint, prevents a limitation of ankle range of motion, and may prevent arthritic development. We present an all-inside arthroscopic ATFL repair technique.

Anatomical Arthroscopic Anterior Talofibular Ligament Repair and Reconstruction Using a Free Tendon

Arthroscopic techniques for anterior talofibular ligament (ATFL) repair and reconstruction have been developed in recent years. We simultaneously performed anatomical arthroscopic ATFL repair and reconstruction using a free tendon graft. The ATFL remnant is carefully dissected only at the footprint of the superior limb of the ATFL, and a bone tunnel is created on each side of the fibula and talus. A soft suture anchor with 2 sets of threads is inserted into the fibular tunnel. One set of threads is used to grab the ATFL remnant via a lasso-loop technique, whereas the other set of threads is used to introduce the ATFL graft. The graft is first fixed with a screw in the talar tunnel. Subsequently, the ATFL remnant and the graft are tightened simultaneously by pulling the 2 sets of suture anchor threads at the fibular tunnel and are fixed with a screw. This technique provides the possible advantages of remnant preservation and promotion of load sharing by the repaired ATFL remnant and the reconstructed ATFL graft.

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.

No Difference between Percutaneous and Arthroscopic Techniques in Identifying the Calcaneal Insertion during Ankle Lateral Ligament Reconstruction: A Cadaveric Study

Background. Both percutaneous and arthroscopic techniques have been introduced in anatomic ankle lateral ligaments reconstruction. The purpose of this study was to compare these two techniques in identifying the calcaneal insertion of the calcaneofibular ligament (CFL). Methods. Fifteen fresh-frozen human ankle cadaver specimens were used in this study. Each specimen was tested in three stages. For stage 1, each specimen was evaluated under arthroscopy. After debridement was performed, the insertion of the CFL on the calcaneus was identified, and a 1.5mm Kirschner wire was drilled at the center of the insertion. For stage 2, a percutaneous technique was used to identify the center of the insertion of the CFL. A second 1.5 mm Kirschner wire was drilled through the skin marker. For stage 3, the ankle was dissected, the footprint of the CFL was identified under direct vision, and the distances between the center of the CFL insertion on the calcaneus and the two Kirschner wires were measured, respectively. Results. In the arthroscopic technique group, the mean distance from the Kirschner wire to the center of the CFL insertion in the calcaneus was 3.4 ± 1.3 mm. In the percutaneous technique group, the mean distance from the Kirschner wire to the center of the CFL insertion was 3.2 ± 1.4 mm. No significant difference was found between the two groups. Conclusion. No difference in identifying the calcaneal insertion of the CFL was found between the percutaneous and the arthroscopic ankle lateral ligaments reconstruction technique. Both techniques can be used during anatomic ligaments reconstruction in treatment of chronic ankle instability.