Management of acute ligament injuries of the ankle

The "Ankle Instability Instrument": Cross-cultural adaptation and validation in French

BACKGROUND

Functional ankle instability affects 20-40% of individuals who have already suffered from a sprain. Such dysfunctions are difficult to diagnose. Therefore, the information provided by self-administered questionnaires is essential. Thus, the Ankle Instability Instrument (AII) was developed and initially validated in English. Our goal is to create a French version of the instrument, named AII-F, by scrupulously respecting the cultural adaptation phases and to make sure the new instrument has good psychometric properties.

METHODS

International recommendations have been rigorously followed for the cultural adaptation and the French-translation phase. Six steps are recommended: I) two initial translations from English to French; II) synthesis of the two versions; III) back-translations from French to English; IV) comparisons between the back-translations and the original questionnaire by the expert committee; V) pretest; and VI) approval of the final French version of the AII. In order to validate this French-translation, 91 subjects suffering from ankle instability matched to 91 healthy subjects were asked to complete the AII-F. The Short Form Health Survey (SF-36) was used as a comparative questionnaire as well as the French Cumberland Ankle Instability Tool (CAIT-F). The psychometric properties of the questionnaire were evaluated by determining the test-retest reliability after a 10-14-day interval, the internal consistency, construct validity, and the floor/ceiling effects.

RESULTS

The French-translation did not pose a problem and could be validated by the expert committee. The AII-F showed a very good test-retest reliability for the total score, with an Intra Class Coefficient of 0.983. The internal coherence is high with an alpha coefficient of Cronbach of 0.861. The association of the AII-F with the CAIT-F was high, for the summary of the physical component of the SF-36, meaning a great convergent validity. The other subscales of the SF-36 (mental health) were weakly correlated with the AII-F, reflecting good divergent validity. An optimal cut-off score was obtained to dissociate pathological patients from healthy subjects: when the subject responded to "yes" 5 times or more, he is considered, with a very high degree of confidence, to be pathological.

CONCLUSION

The AII-F is reliable and valid for evaluating and measuring functional ankle instability.

Arthroscopic versus open repair of lateral ankle ligament for chronic lateral ankle instability: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to analyze the current comparative studies of arthroscopic and open techniques for lateral ankle ligament repair to treat chronic lateral ankle instability.

METHODS

A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed during February 2018. Included studies were evaluated with regard to level of evidence and quality of evidence using the Modified Coleman Methodology Score. Total number of patients, patient age, follow-up time, gender ratio, surgical technique, surgical complications, complication rate, recurrent instability or revision rate, clinical outcome measures and percentage of patients who returned to sport at previous level were also evaluated. Statistical analysis was performed using RevMan, and a p value of < 0.05 was considered to be statistically significant.

RESULTS

Four comparative studies for a total of 207 ankles were included. There was a significant difference in favor of arthroscopic repair with regard to AOFAS score, and there was no significant difference with regard to Karlsson score. There was a statistically significant difference in AOFAS score in favor of the arthroscopic repair (MD; 1.41, 95% CI 0.29-2.52, I² = 0%, p < 0.05). There was no statistically significant difference in Karlsson score (MD; 0.00, 95% CI - 3.51 to 3.51, I² = 0%, n.s.). There was no statistically significant difference in total, nerve, or wound complications.

CONCLUSIONS

The current meta-analysis found that short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. There was no significant difference between arthroscopic and open repair with regards to Karlsson functional outcome score, total complication rate, or the nerve and wound complication subsets with the included studies with at least 12 months of follow-up. However, the current evidence is still limited, and further prospective trials with longer follow-up are needed.

LEVEL OF EVIDENCE

III.

Arthroscopic reconstruction of the lateral ankle ligaments: Radiological evaluation and short-term clinical outcome

PURPOSE

The purpose of this study was to describe the positioning of bone tunnels of arthroscopic anatomical reconstruction of lateral ankle ligaments (AAR-LAL) and identify radiological measurements associated with short-term clinical outcome one year after surgery.

MATERIALS AND METHODS

A total of 61 patients were included in this IRB-approved retrospective study. There were 52 men and 9 women, with a mean age of 36.3 ± 10.8 (SD) years. AAR-LAL was performed to treat chronic instability secondary to strain sequelae after failure of conservative treatment. Good short-term clinical outcome was defined by Karlsson-score≥80 (n=40) one year after surgery. Sixteen radiological measurements were studied to characterize the positionings of fibular, talar and calcaneal tunnels (FT, TT and CT, respectively). Feasibility and inter-observer agreement were calculated for each measurement. Receiver operating characteristic curves were used to identify optimal thresholds for measurements associated with outcome at univariate analysis. A binary logistic regression was used to identify independent predictors.

RESULTS

Two measurements were associated with good outcome: distance from the proximal FT entrance to the distal end of the fibula on anteroposterior (AP) view (called 'AP distal FT', P=0.005), and the ratio between the distance from TT entrance to the talo-navicular joint and the talus length on lateral view (P=0.009). Optimal thresholds were of >35mm and<0.445, respectively. At multivariate anlysis, only 'AP distal FT'>35mm remained independent predictor of good outcome (P=0.002).

CONCLUSION

Radiological evaluation of bone tunnels following AAR-LAL is feasible, reproducible, and helps predict short-term outcome after reconstruction of lateral ankle ligaments.

Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review

PURPOSE

The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability.

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane Library databases was performed during August 2017. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated.

RESULTS

Eight studies for a total of 269 ankles were included; 87.5% of studies were LOE III or IV, and the QOE in all studies was of poor or fair quality. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores ranged from 41.2 to 69.9, and postoperative AOFAS scores ranged from 90.2 to 98. All studies using AOFAS score showed an increase in postoperative outcome score of 22.8 to 54.2 at a mean follow-up of 17.1 months. Five studies used Karlsson-Peterson scores with mean postoperative score of 88.5 (range, 76.2-93.6) at a mean follow-up of 21.2 months. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 11.6% in the included studies. The overall rate of return to sport was 100%.

CONCLUSIONS

The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. However, there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure, and there are no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate (11.5%) associated with the arthroscopic procedures, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, III, and IV studies.

Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population

PURPOSE

To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus.

METHODS

A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity.

RESULTS

The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee.

CONCLUSION

The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Management of chronic lateral ankle instability in military service members

Chronic lateral ankle instability is a condition frequently encountered by orthopedic surgeons treating highly active patient populations, particularly military service members. Providers treating military service members must have a high index of suspicion for this condition when signs and symptoms of functional or mechanical instability exist. Stress testing and ankle MRI, although not definitive in sensitivity for detecting instability or other concomitant injuries, should be considered during the treatment decision-making process. Appropriate nonoperative treatment should be attempted initially; however, when nonoperative treatment fails, surgical management is warranted to prevent untoward long-term sequelae. Proper surgical treatment and subsequent postoperative management are at the discretion of the individual surgeon but must account for the concomitant diseases frequently associated with chronic lateral ankle instability. Low recurrence of lateral instability can be achieved even in high-demand military patient populations with a focused treatment plan.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Autologous osteochondral transplantation of the talus partially restores contact mechanics of the ankle joint

BACKGROUND

Autologous osteochondral transplantation procedures provide hyaline cartilage to the site of cartilage repair. It remains unknown whether these procedures restore native contact mechanics of the ankle joint.

PURPOSE

This study was undertaken to characterize the regional and local contact mechanics after autologous osteochondral transplantation of the talus.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen cadaveric lower limb specimens were used for this study. Specimens were loaded using a 6 degrees of freedom robotic arm with 4.5 N·m of inversion and a 300-N axial compressive load in a neutral plantar/dorsiflexion. An osteochondral defect was created at the centromedial aspect of the talar dome and an autologous osteochondral graft from the ipsilateral knee was subsequently transplanted to the defect site. Regional contact mechanics were analyzed across the talar dome as a function of the defect and repair conditions and compared with those in the intact ankle. Local contact mechanics at the peripheral rim of the defect and at the graft site were also analyzed and compared with the intact condition. A 3-dimensional laser scanning system was used to determine the graft height differences relative to the native talus.

RESULTS

The creation of an osteochondral defect caused a significant decrease in force, mean pressure, and peak pressure on the medial region of the talus (P = .037). Implanting an osteochondral graft restored the force, mean pressure, and peak pressure on the medial region of the talus to intact levels (P = .05). The anterior portion of the graft carried less force, while mean and peak pressures were decreased relative to intact (P = .05). The mean difference in graft height relative to the surrounding host cartilage for the overall population was -0.2 ± 0.3 mm (range, -1.00 to 0.40 mm). Under these conditions, there was no correlation between height and pressure when the graft was sunken, flush, or proud.

CONCLUSION/CLINICAL RELEVANCE

Placement of the osteochondral graft in the most congruent position possible partially restored contact mechanics of the ankle joint. Persistent deficits in contact mechanics may be due to additional factors besides graft congruence, including structural differences in the donor cartilage when compared with the native tissue.

The Treatment of Osteochondral Lesions of the Talus with Autologous Osteochondral Transplantation and Bone Marrow Aspirate Concentrate: Surgical Technique

OBJECTIVE

To present the functional results after autologous osteochondral transplantation with bone marrow aspirate concentrate in 72 patients, while placing an emphasis on the surgical technique.

METHODS

Between 2005 and 2009, 72 patients underwent autologous osteochondral transplantation under the care of the senior author. The mean patient age at the time of surgery was 34.19 years (range, 16-85 years). All patients were followed for a minimum of 1 year after surgery. The mean follow-up time was 28.02 months (range, 12-64 months). Patient-reported outcome measures were taken preoperatively and at final follow-up using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Identical questionnaires were used in all instances.

RESULTS

The mean FAOS scores improved from 52.67 points preoperatively to 86.19 points postoperatively (range, 71-100 points). The mean SF-12 scores also improved from 59.40 points preoperatively to 88.63 points postoperatively (range, 52-98 points). Three patients reported donor site knee pain after surgery, and one patient required the decompression of a cyst that developed beneath the graft site approximately 2 years after the index procedure.

CONCLUSION

Autologous osteochondral transplantation is a reproducible and primary treatment strategy for large osteochondral lesions of the talus.

The instantaneous helical axis of the subtalar and talocrural joints: a non-invasive in vivo dynamic study

Background

An understanding of rear-foot (talocrural and subtalar joints) kinematics is critical for diagnosing foot pathologies, designing total ankle implants, treating rear-foot injuries and quantifying gait abnormalities. The majority of kinematic data available have been acquired through static cadaver work or passive in vivo studies. The applicability of these data to dynamic in vivo situations remains unknown. Thus, the purpose of this study was to fully quantify subtalar, talocrural and calcaneal-tibial in vivo kinematics in terms of the instantaneous helical axis (IHA) in twenty-five healthy ankles during a volitional activity that simulated single-leg toe-raises with partial-weight support, requiring active muscle control.

Methods

Subjects were each placed supine in a 1.5 T MRI and asked to repeat this simulated toe-raise while a full sagittal-cine-phase contrast (dynamic) MRI dataset was acquired. From the cine-phase contrast velocity a full kinematic description for each joint was derived.

Results

Nearly all motion quantified at the calcaneal-tibial joint was attributable to the talocrural joint. The subtalar IHA orientation and position were highly variable; whereas, the talocrural IHA orientation and position were extremely consistent.

Conclusion

The talocrural was well described by the IHA and could be modeled as a fixed-hinge joint, whereas the subtalar could not be.

Understanding acute ankle ligamentous sprain injury in sports

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.

Ankle instability in sports

Ankle stability is integral to normal motion and to minimizing the risk of ankle sprain during participation in sport activities. The ability of the dynamic and static stabilizers of the ankle joint to maintain their structural integrity is a major component of the normal gait cycle. In sports, this quality assumes even greater importance given the range of movement and stresses imposed on the ankle during various sporting disciplines. In the general population, the incidence of ankle sprain is very high. In several studies, injuries to the lateral ankle ligaments have been shown to be the most common sports-related injuries, accounting for approximately 25% of all sports-related injuries. Furthermore, up to 80% of all ankle sprains involve the lateral ligament complex. Other studies have estimated their incidence as approximately 5000 injuries per day in the United Kingdom and 23 000 in the United States. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries among athletes, both professional and "weekend warriors" alike.