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Rigby RB, Ptak NA. Incidence of Medial Deltoid Ligament Instability in 226 Patients With Chronic Ankle Instability. J Foot Ankle Surg 2024; 63:245-249. [PMID: 38043601 DOI: 10.1053/j.jfas.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Abstract
The deltoid ligament is vitally important in the stability of the ankle and preventing excessive medial ankle movement. Historically, the impact of medial ankle instability has not been well understood in the setting of chronic ankle instability. A retrospective review of 226 patients treated for ankle instability between 2017 and 2022 identified 40 patients who required both medial and lateral repair. Decision for medial deltoid repair was based upon patient presentation, MRI findings, intraoperative fluoroscopy and final confirmation via arthroscopic positive "drive-through sign". Preoperative and postoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores, Patient-Recorded Outcomes Measurement Information System (PROMIS) scores, and Karlsson-Peterson Ankle Function (K&P) scores were obtained and compared. There were statistically significant improvements found in all 3 scoring systems at a mean follow-up time of 11.7 months postoperatively. In the setting of chronic ankle instability, consideration should be given to the evaluation and potential repair of the deltoid ligament in order to provide sufficient stability to the medial ankle.
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Affiliation(s)
- Ryan B Rigby
- Logan Regional Orthopedics, Intermountain Healthcare, Logan, UT.
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2
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Obionu K, Palm H, Astrup Y, Lange NB, Krogsgaard MR. A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review. Foot Ankle Surg 2024; 30:85-91. [PMID: 37926624 DOI: 10.1016/j.fas.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability. METHODS Literature search on PubMed. RESULTS Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse. CONCLUSION There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.
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Affiliation(s)
- Kenneth Obionu
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Henrik Palm
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Yvette Astrup
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Naja Bjørslev Lange
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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3
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Tong J, Li H, Li H, Hua Y. Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury. Acta Radiol 2024; 65:91-98. [PMID: 37722764 DOI: 10.1177/02841851231197508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.
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Affiliation(s)
- Jiahui Tong
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Hong Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
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Hunt KJ, Hewitt MA, Buckley SE, Bartolomei J, Myerson MS, Hogan MV, Laf Committee ISAKOS. Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons. J ISAKOS 2023; 8:239-245. [PMID: 37100118 DOI: 10.1016/j.jisako.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p = 0.005). CONCLUSION LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Kenneth J Hunt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA.
| | - Michael A Hewitt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Sara E Buckley
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Jonathan Bartolomei
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - MaCalus V Hogan
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - I S A K O S Laf Committee
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
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Kerzner B, Kaplan DJ, Khan ZA, Smith SR, Obioha OA, Jawanda H, Jackson GR, Gopinatth V, Sivasundaram L, Verma NN. Ulnar Collateral Ligament Internal Bracing Repair Technique for High-Grade Partial Proximal Tears in the Throwing Athlete. Arthrosc Tech 2023; 12:e1225-e1232. [PMID: 37533907 PMCID: PMC10391346 DOI: 10.1016/j.eats.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/17/2023] [Indexed: 08/04/2023] Open
Abstract
The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.
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Affiliation(s)
- Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J. Kaplan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shelby R. Smith
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Obianuju A. Obioha
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harry Jawanda
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R. Jackson
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Varun Gopinatth
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Lakshmanan Sivasundaram
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N. Verma
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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6
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Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes. Arthroscopy 2023; 39:1357-1365. [PMID: 36681361 DOI: 10.1016/j.arthro.2023.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023]
Abstract
Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.
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7
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McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, Mangwani J. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop 2022; 13:969-977. [PMID: 36439368 PMCID: PMC9685633 DOI: 10.5312/wjo.v13.i11.969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability.
AIM To investigate the anatomical basis for fracture instability in SER type ankle fractures.
METHODS Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt.
RESULTS All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt.
CONCLUSION If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.
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Affiliation(s)
- Daniel James McCormack
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Matthew Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey City Hospital NHS Trust, University of Surrey, Guilford GU2 7XX, United Kingdom
| | - Sheweidin Aziz
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Radwane Faroug
- Department of Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury HP21 8AL, Buckinghampshire, United Kingdom
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Georgina Wright
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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8
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Kung JE, Hallman MJ, Humbyrd CJ. Violation of the Subtalar Joint With Novel Suture Tape Augmentation of Lateral Ligament Reconstruction: A Report of 2 Cases. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221136554. [PMCID: PMC9663610 DOI: 10.1177/24730114221136554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Justin E. Kung
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mitchell J. Hallman
- Department of Orthopaedics, The Hospitals of the University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Jo Humbyrd
- Department of Orthopaedics, The Hospitals of the University of Pennsylvania, Philadelphia, PA, USA
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Kitchen BT, Mitchell BC, Cognetti DJ, Siow MY, Howard R, Carroll AN, Bastrom TP, Edmonds EW. Outcomes After Hamstring ACL Reconstruction With Suture Tape Reinforcement in Adolescent Athletes. Orthop J Sports Med 2022; 10:23259671221085577. [PMID: 35425845 PMCID: PMC9003649 DOI: 10.1177/23259671221085577] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Previous studies have suggested that suture tape-reinforced anterior cruciate ligament (ACL) grafts may have higher ultimate failure loads without stress-shielding. In patients at high risk for graft failure, such as adolescents, the addition of suture tape could have beneficial outcomes. Hypothesis: Suture tape reinforcement (STR) of ACL grafts in adolescent patients would lead to fewer graft ruptures during early recovery, without hindering subjective outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on adolescent patients with a minimum 2-year follow-up after hamstring tendon autograft ACL reconstruction; enrolled were patients from both before (n = 40) and after (n = 40) a shift in surgical technique that added STR. Both the no-STR and the STR cohorts were contacted yearly to obtain patient-reported outcome data for visual analog scale (VAS; range, 0-10) for pain score, Single Assessment Numeric Evaluation, Lysholm score, Tegner activity score, patient satisfaction score (range, 0-100), and return to previous level of sport (yes/no). The cohorts were then matched based on follow-up duration, excluding those with follow-up of <2 years and >3 years to maintain consistency in duration of follow-up. Graft failure was defined as either graft rupture or recurrent instability symptoms, and failures occurring from index procedure to the 3-year mark were recorded for calculations of failure rate. Results: There were no differences between cohorts in mean age [STR, 15.7 years (range, 9.5-18.7 years); no STR, 14.9 years (range, 9.3-18.8 years)], follow-up duration, laterality, or graft size. While not statistically significant, 2 (5%) patients in the STR cohort experienced graft rupture compared with 7 (17.5%) patients in the no-STR cohort. The Tegner score was significantly higher in the STR cohort (P = .017); no between-group differences were seen on the other outcome scores. A subanalysis of the STR cohort comparing small-diameter grafts (<8 mm) with grafts ≥8 mm also demonstrated no difference in outcome measures, with 1 graft failure in each cohort. Conclusion: Study outcomes indicated that patients treated with ACL reconstruction and STR experienced a significant improvement in Tegner scores while at the same time maintaining the other subjective outcomes.
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Affiliation(s)
- Brock T. Kitchen
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Brendon C. Mitchell
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Daniel J. Cognetti
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Matthew Y. Siow
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Roland Howard
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Alyssa N. Carroll
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Tracey P. Bastrom
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Eric W. Edmonds
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
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10
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Lan R, Piatt ET, Bolia IK, Haratian A, Hasan L, Peterson AB, Howard M, Korber S, Weber AE, Petrigliano FA, Tan EW. Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211045978. [PMID: 35097476 PMCID: PMC8532228 DOI: 10.1177/24730114211045978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.
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Affiliation(s)
- Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric T. Piatt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander B. Peterson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Mark Howard
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Shane Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric W. Tan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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11
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Ikuta Y, Nakasa T, Sumii J, Nekomoto A, Adachi N. Quantitative Analysis of Deltoid Ligament Degradation in Patients With Chronic Ankle Instability Using Computed Tomographic Images. Foot Ankle Int 2021; 42:952-958. [PMID: 33703931 DOI: 10.1177/1071100721997070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotational ankle instability (RAI) is associated with the faster onset of severe ankle osteoarthritis via dysfunction of the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. No specific clinical examination is available for RAI, and diagnostic imaging has limitations in evaluating ligament degradation. This study investigated the deltoid ligament degeneration using Hounsfield unit (HU) values on computed tomography (CT) images. METHODS Patients were enrolled in this retrospective analysis if they had undergone magnetic resonance imaging (MRI) and CT scans of the ankle. The chronic ankle instability (CAI) group comprised 20 ankles with CAI (9 men, 11 women; mean age, 28.7 years) and the control group comprised 28 ankles (16 men, 12 women, mean age, 41.3 years). The average HU values of the deep posterior tibiotalar ligament (dPTL) that constitutes the deltoid ligament were measured on coronal CT images, and MRI results were used as a reference. All patients were subdivided based on the MRI findings of dPTL injury such as fascicular disruption, irregularity, and the loss of striation. RESULTS A strong negative correlation was identified between age and HU values for all patients (Spearman ρ = -0.63; P < .001). The mean HU values of the dPTL for participants aged <60 years were 81.0 HU for the control group (21 ankles) and 69.5 HU for the CAI group (P = .0075). No significant differences in the HU values were observed for the dPTL among the MRI subgroups. CONCLUSION In addition to the conventional imaging examination such as stress radiographs and MRI, HU measurements of CT images could be useful for quantitatively and noninvasively evaluating degenerative changes in the deltoid ligament for CAI patients to assist the diagnosis of RAI. LEVEL OF EVIDENCE Level III. case-control study.
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Affiliation(s)
- Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Sports Medical Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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12
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Abstract
Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017.
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Affiliation(s)
- Nuno Corte-Real
- Department of Orthopaedics, Hospital de Cascais Dr. José de Almeida, Portugal
| | - João Caetano
- Department of Orthopaedics, Hospital de Cascais Dr. José de Almeida, Portugal
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13
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Abstract
Chronic deltoid instability (CDI), or medial ankle instability, can happen following traumas of the foot and ankle, predominantly rotational injuries. CDI is frequently underdiagnosed or misdiagnosed. Long-term residual instability can lead to ankle posttraumatic arthritis. Adequate assessment of patients with suspected CDI is paramount. Conservative treatment can be tried for stable or mildly unstable cases, but surgical treatment is usually needed for the more severely unstable patients, or when conservative measures fail. Few reconstruction techniques have been proposed in the setting of posttraumatic CDI. This article describes our preferred technique for reconstruction of the deep components of the deltoid ligament.
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Affiliation(s)
- Cesar de Cesar Netto
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - John E Femino
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA
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14
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Espinosa N, Klammer G. The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat? Foot Ankle Clin 2021; 26:391-405. [PMID: 33990260 DOI: 10.1016/j.fcl.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.
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Affiliation(s)
- Norman Espinosa
- Institute for Foot and Ankle Reconstruction, Beethovenstrasse 3, Zurich 8002, Switzerland.
| | - Georg Klammer
- Institute for Foot and Ankle Reconstruction, Beethovenstrasse 3, Zurich 8002, Switzerland
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15
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Abstract
Although far less common than lateral ankle injuries, medial ankle sprains have been reported to result in significantly greater time lost and long-term disability when not diagnosed and treated accurately. Adequate diagnosis is paramount and the most important aspect is to determine whether the lesion is stable or unstable. Evidence confronting surgical versus conservative treatment in acute deltoid ligament lesions is largely anchored in the setting of ankle fractures. Ultimately treatment decisions rely on the clinical and imaging appraisal of each individual patient. This article discusses the isolated acute deltoid ligament impairment.
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Affiliation(s)
- Gastón Slullitel
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina.
| | - Juan Pablo Calvi
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina. https://twitter.com/pieijs
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16
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Halai MM, Richards M, Daniels TR. What's New in Foot and Ankle Surgery. J Bone Joint Surg Am 2021; 103:850-859. [PMID: 33784261 DOI: 10.2106/jbjs.21.00146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Mansur M Halai
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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17
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Shazadeh Safavi K, Rezvani A, Janney CF. Allograft Deltoid Reconstruction for Chronic Deltoid Disruption in a High-Level Military Operator: A Case Report. Mil Med 2021; 187:e535-e538. [PMID: 33538818 DOI: 10.1093/milmed/usab027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/21/2021] [Indexed: 11/12/2022] Open
Abstract
We present a unique case of chronic deltoid ligament disruption in a 34-year-old high-level military operator with a 12-month history of acute-onset medial ankle pain. Magnetic resonance imaging showed an isolated chronic disruption of the superficial and deep deltoid ligament. The patient was managed operatively with a semitendinosus allograft. No complications were observed during the intra- or perioperative periods. At 12-month follow-up, the patient reported near-complete pain resolution and was able to return to unrestricted active duty. Use of allograft ligamentous reconstruction of the deltoid ligament in a highly active soldier was successful, allowing return to unrestricted active duty.
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Affiliation(s)
- Kiya Shazadeh Safavi
- School of Medicine, The University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Aryan Rezvani
- College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA
| | - Cory F Janney
- Department of Orthopedics, Naval Medical Center, San Diego, CA 92134, USA
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18
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Mansur NSB, Lemos AVKC, Baumfeld DS, Baumfeld TS, Prado MPD, Raduan FC, Nery CAS. Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011420986150. [PMID: 35097429 PMCID: PMC8702971 DOI: 10.1177/2473011420986150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The high prevalence of ankle sprains in the population produces a significant number of patients with lateral instability. Persistence of this condition may lead to the progressive involvement of medial structures, causing a multidirectional rotational instability. Methods: This is a retrospective study with patients diagnosed with multidirectional instability who underwent ankle arthroscopy with medial (arthroscopic tensioning) and lateral repair (arthroscopic Bröstrom) between January 2018 and January 2020. All patients were evaluated for pain and function according to the visual analog scale (VAS) score and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score at a mean of 14.8 months (5-27 months) in follow-up. A total of 30 ankles (29 patients) were included in the study. Results: The AOFAS score increase from a 49.7 (CI 5.8) to a 91.9 (CI 2.4) mean (P = .001) and was followed by significant improvement in the mean VAS score (6.8, CI 0.37-0.95, CI 0.31). The majority of patients had associated procedures (53.3%), and a low complication rate was found (16.6%). Conclusion: Combined medial and lateral arthroscopic repair might be an effective and safe alternative in the treatment of multidirectional instability. Inclusion of the deltoid ligament complex and the low invasiveness of the arthroscopic technique may improve the clinical outcomes of these patients. Level of Evidence: Level IV, retrospective case series.
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19
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Colin F, Barbier O, Cordier G. Role of surgery in the management of lesions of the medial collateral ligament of the ankle. Orthop Traumatol Surg Res 2020; 106:S195-S199. [PMID: 32900668 DOI: 10.1016/j.otsr.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/28/2020] [Indexed: 02/03/2023]
Abstract
Medial ankle instability is likely underestimated. Three types of medial collateral ligament (MCL) lesion exist: isolated lesions, in case of valgus sprain in external rotation; lesions associated with chronic lateral instability, in case of rotational instability; and lesions associated with medial insufficiency and valgus flat-foot. Diagnostic confirmation and treatment of MCL lesions, isolated or associated with chronic lateral instability, by ligament suture is at present largely arthroscopic. Chronic MCL lesions with valgus flat-foot are probably irreversible: ligament reconstruction is unreliable, and bone surgery (osteotomy, fusion) is required.
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Affiliation(s)
- Fabrice Colin
- Chirurgie Orthopédique et Traumatologie, Clinique Mutualiste Catalane, 60, rue Louis Mouillard, 66000 Perpignan, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique, HIA Sainte Anne, 2, boulevard Sainte Anne, 83000 Toulon, France.
| | - Guillaume Cordier
- Chirurgie du Sport, Clinique du Sport de Bordeaux-Mérignac, 2, rue Negrevergne, 33700 Merignac, France; Grecmip-MIFAS (Minimally Invasive Foot and Ankle Society), 2, rue Negrevergne, 33700 Merignac, France.
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20
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Lian J, Lian J, Zhong M, Jian X. Letter to the editor on "Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation". Foot Ankle Surg 2020; 26:354-355. [PMID: 31932220 DOI: 10.1016/j.fas.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/31/2019] [Indexed: 02/04/2023]
Affiliation(s)
- Jiangen Lian
- Department of Orthopaedic Surgery, Dabu People's Hospital, Dabu 514200, Guangdong Province, China
| | - Junfeng Lian
- Department of Orthopaedic Surgery, Dabu People's Hospital, Dabu 514200, Guangdong Province, China
| | - Mingjin Zhong
- Department of Sports Medicine, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, Shenzhen 518000 Guangdong Province, China.
| | - Xu Jian
- Department of Sports Medicine, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, Shenzhen 518000 Guangdong Province, China
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