Acute lateral ankle ligament ruptures in the athlete: the role of surgery

Ability to return to sports after early lateral ligament repair of the ankle in 147 elite athletes

PURPOSE

The literature on elite athletes' ability to return to sports (RTS) after early lateral ligament repair of the ankle remains inadequate. The time needed to RTS after modified Broström repair for acute grade III lateral ligament injuries in a large cohort of elite athletes was evaluated while assessing the impact of other associated injuries.

METHODS

Prospective data from 147 elite athletes who underwent a primary lateral ligament repair for acute grade III injuries with clinical ankle instability from 2015 to 2019 with a minimum of 2-year follow-up were reviewed. Pertinent details such as characteristics of injury, time taken to RTS, impact of associated injuries on RTS and complications were recorded and analysed.

RESULTS

The average age was 24.4 years (S.D = 4.9) with 89.1% males. Approximately two-thirds of the elite athletes were football players (66.0%) and 21.1% were rugby players. Isolated lateral ligament complex injuries were sustained by 122 (83%) patients, while 25 (17%) had associated injuries (osteochondral lesions of the talus/deltoid injury/syndesmosis injury). All 147 athletes returned to their preinjury level of sports with a median time of 69 days (range 58-132 days). There was no significant difference found in time to RTS between gender, age, and types of sports. However, there was a statistically significant difference noted in the time taken to RTS earlier in patients with isolated lateral ligament injuries when compared to those with associated injuries (68.6 vs. 82.8 days; p = 0.004). Multiple conditional linear regression yielded three independent predictors of longer time taken to RTS which were associated deltoid injury (7.5 days longer; 95% CI 2.9-12.3; p = 0.002), associated syndesmosis injury (6.7 days longer; 95% CI 0.5-12.8; p = 0.034) and associated OLT (30.3 days longer; 95% CI 25.1-35.5; p = 0.000).

CONCLUSION

Early surgical repair for acute grade III lateral ligament injuries in elite athletes yielded excellent rate of RTS at 9-10 weeks and a re-injury rate of 2%. Concomitant injuries will delay RTS after surgical intervention. These findings serve as important guide to managing elite athletes following acute rupture of the lateral ligament complex.

LEVEL OF EVIDENCE

Level III.

Arthroscopic Double-Row Repair for Acute Proximal Detachment of the Lateral Collateral Ligament in a Complex Ankle Sprain

Management of ankle sprains is still being discussed. For athletes, recent studies recommend surgical treatment for acute grade III rupture, because of better long-term ankle stability. The purpose of this technical note is to describe the arthroscopic acute double-row repair for proximal disinsertion of collateral lateral ligament ankle. With the patient in dorsal decubitus under spinal anesthesia, the foot and ankle are extended beyond the edge of the surgical table. The anteromedial portal is created inside the anterior tibial tendon in which the arthroscope is introduced. The anterolateral approach is simulated with a needle under arthroscopic control, in front and under the tip of the lateral malleolus. The anterior talofibular ligament (ATFL) is released from the capsule with a beaver blade. The tip of the lateral malleolus is sharpened, and a soft anchor is impacted there. ATFL is caught with a Mini-Scorpio plier, a Lasso loop is performed to improve tissue grasping. The ligament is pressed against the anchor, with the foot in maximum dorsiflexion and eversion. A knotless anchor is impacted 5 mm above and with the threads of the soft anchor, creating a double-row fixation. The arthroscopic acute double-row repair for proximal desinsertion of collatéral lateral ligament ankle can be done especially for athletes.

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Evidence for Rehabilitation Interventions After Acute Lateral Ankle Sprains in Athletes: A Scoping Review

CONTEXT

Acute lateral ankle sprain (LAS) is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after LAS may differ from those of the general population.

OBJECTIVE

To review the literature to determine the most effective rehabilitation interventions reported for athletes returning to sport after acute LAS.

EVIDENCE ACQUISITION

Data Sources: Databases PubMed, Embase, CINAHL, SPORTDiscus, and PEDro were searched to July 2020.

STUDY SELECTION

A scoping review protocol was developed and followed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews guidelines and registered (https://osf.io/bgek3/). Study selection included published articles on rehabilitation for ankle sprain in an athletic population.

DATA EXTRACTION

Parameters included athlete and sport type, age, sex, intervention investigated, outcome measures, measurement tool, and follow-up period.

DATA SYNTHESIS

A qualitative synthesis for all articles was undertaken, and a quantitative subanalysis of randomized controlled trials and critical methodological appraisal was also conducted.

EVIDENCE SYNTHESIS

A total of 37 articles were included in this review consisting of 5 systematic and 20 narrative reviews, 7 randomized controlled trials, a single-case series, case report, position statement, critically appraised topic, and descriptive study. Randomized controlled trial interventions included early dynamic training, electrotherapy, and hydrotherapy.

CONCLUSIONS

Early dynamic training after acute LAS in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive interventions for athletes returning to sport after LAS. Despite existing research on rehabilitation of LAS in the general population, a lack of evidence exists related to athletes seeking to return to sport.

Distal insertion rupture of lateral ankle ligament as a predictor of weakened and delayed sports recovery after acute ligament repair: mid-term outcomes of 117 cases

Background

For lateral ankle ligament rupture, surgical repair has been considered for patients requiring return to high-demanding sports. However, there is a lack of systematic research regarding arthroscopic treatment followed by ligament repair for severe acute ankle sprain. The purpose of this study was to analyze the mid-term outcomes of arthroscopy followed by open anatomic lateral ankle ligament repair surgery for acute lateral ankle sprain and the impact of ligament rupture site on the outcomes.

Methods

Professional or amateur athletes with clinically- and radiologically-confirmed grade III acute lateral ankle ligament injuries undergoing ankle arthroscopy followed by open anatomic ligament repair between June 2007 and May 2017 were reviewed. Intra-articular lesions and the location of rupture were first examined under arthroscopy. Simple suture repair was performed for mid- substance ligament rupture (middle group), while suture repair with anchors were used for the ruptures near the ligament attachment site on the fibular (proximal group), talar or the calcaneal side (distal group). Outcomes were evaluated at final follow-up, including visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Tegner score, time to return to sports, resumption of pre-injury sports level, sprain recurrence and range of motion (ROM).

Results

A total of 117 patients were included for analysis, with a mean follow-up duration of 46.4 ± 16.1 months. There were 48 (41%) cases in the proximal group, 41 (35%) cases in the middle group and 28 (24%) cases in the distal group respectively. At final follow-up, all of the VAS score, AOFAS score and the Tegner score were significantly improved from the pre-operative level (p < 0.001). 12 (10%) patients complained of sprain recurrence during follow-up. 14 (12%) patients reported mild ROM restriction and 7 (6%) patients experienced transient skin numbness. The average time to return to pre-injury sports was 4.34 ± 1.11 months. The smallest proportion (86% ± 13%) of resumption of pre-injury sports level was reported from the distal group, compared with 93% ± 12% for the proximal group and 89% ± 14% for the middle group (p = 0.037). Time to return to sports was significantly longer for the distal group, with an average of 4.59 ± 1.27 months compared to 3.99 ± 1.09 months for the proximal group and 4.58 ± 0.90 months for the middle group (p = 0.009).

Conclusions

Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains. Distal rupture near the talar or calcaneal end was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level.

Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room

Objective

To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray.

Methods

We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described.

Results

Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries.

Conclusion

There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.

Acute Lateral Ankle Instability

Acute injuries to the lateral ankle complex remain common and account for 20% to 25% of musculoskeletal injuries. Initial assessment should use the Ottawa ankle rules, and grading should take into account degree of mechanical instability. Nonoperative measures are preferable for all grades of injury; however, mechanical instability is a predictor for resprains. Functional treatment after a short period of relative immobilization gives satisfactory results, and residual chronic ankle instability can be managed by repair or reconstruction. Delayed physical examination in elite athletes, along with 3T MRI, may be helpful in making a case for early surgical stabilization.

Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert

PURPOSE

The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions.

METHODS

A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects.

RESULTS

Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3-6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered.

CONCLUSIONS

Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI.

LEVEL OF EVIDENCE

V.

Tibialis Posterior Tendon Dislocation: A Review and Suggested Classification

Tibialis posterior tendon dislocation is a rarely described entity that is easily missed, resulting in delayed diagnosis and treatment. A review of the English published data on the topic showed inconsistency in the reporting of injuries and surgical management techniques, leading us to describe a novel classification system to guide treatment and future reporting. We also describe a case of tibialis posterior tendon dislocation in a professional volleyball player and our surgical technique for correction, including retromalleolar groove deepening.

Foot and Ankle Injuries in Professional Soccer Players: Diagnosis, Treatment, and Expectations

Soccer is one of the most popular sports in the world. It has undergone many changes in recent years, mainly because of increased physical demands, and this has led to an increased injury risk. Direct contact accounts for half of all injuries in both indoor and outdoor soccer and ankle sprains are the most common foot and ankle injury. There is a spectrum of foot and ankle injuries and their treatment should be individualized in these high-demand patients. An injury prevention program is also important and should the players, the trainer, responsible physician, and physical therapists.

A historical perspective on ankle ligaments reconstructive surgery

Ankle sprains are by far the most common injuries treated by sport medicine physicians. Treatment is mainly conservative, but in some cases surgical intervention is required. The aim of the present manuscript is to give an insight into the origins and developments of ankle ligaments reconstructive surgery, underlining the fundamental steps that marked the transition from a mere conservative approach to surgical treatment options. In this historical note, the most illustrious figures who contributed to this particular field of orthopaedic practice are also acknowledged. Level of evidence V.

Return to sport following acute lateral ligament repair of the ankle in professional athletes

PURPOSE

Recent literature supports early reconstruction of severe acute lateral ligament injuries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Not previously reported, predicting the time to return to training and play is important to both athlete and club. We evaluate the effectiveness and complications of lateral ligament reconstruction in professional athletes. We aim to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

METHODS

A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

RESULTS

The median return to training and sports for isolated injuries was 63 days (49-110) and 77 days (56-127), respectively. However, for concomitant injury results were 86 days (63-152) and 105 days (82-178). This delay was significant (p < 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p = 0.027, p < 0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

CONCLUSION

Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

LEVEL OF EVIDENCE

III.

A historical perspective on ankle ligaments reconstructive surgery

Ankle sprains are by far the most common injuries treated by sport medicine physicians. Treatment is mainly conservative, but in some cases surgical intervention is required. The aim of the present manuscript is to give an insight into the origins and developments of ankle ligaments reconstructive surgery, underlining the fundamental steps that marked the transition from a mere conservative approach to surgical treatment options. In this historical note, the most illustrious figures who contributed to this particular field of orthopaedic practice are also acknowledged. Level of evidence V.

The Mechanical Functionality of the EXO-L Ankle Brace: Assessment With a 3-Dimensional Computed Tomography Stress Test

BACKGROUND

A new type of ankle brace (EXO-L) has recently been introduced. It is designed to limit the motion of most sprains without limiting other motions and to overcome problems such as skin irritation associated with taping or poor fit in the sports shoe.

PURPOSE

To evaluate the claimed functionality of the new ankle brace in limiting only the motion of combined inversion and plantar flexion.

STUDY DESIGN

Controlled laboratory study.

METHODS

In 12 patients who received and used the new ankle brace, the mobility of the joints was measured with a highly accurate and objective in vivo 3-dimensional computed tomography (3D CT) stress test. Primary outcomes were the ranges of motion as expressed by helical axis rotations without and with the ankle brace between the following extreme positions: dorsiflexion to plantar flexion, and combined eversion and dorsiflexion to combined inversion and plantar flexion. Rotations were acquired for both talocrural and subtalar joints. A paired Student t test was performed to test the significance of the differences between the 2 conditions (P ≤ .05).

RESULTS

The use of the ankle brace significantly restricted the rotation of motion from combined eversion and dorsiflexion to combined inversion and plantar flexion in both the talocrural (P = .004) and subtalar joints (P < .001). No significant differences were found in both joints for the motion from dorsiflexion to plantar flexion.

CONCLUSION

The 3D CT stress test confirmed that under static and passive testing conditions, the new ankle brace limits the inversion-plantar flexion motion that is responsible for most ankle sprains without limiting plantar flexion or dorsiflexion.

CLINICAL RELEVANCE

This test demonstrated its use in the objective evaluation of braces.

Return to sport following acute lateral ligament repair of the ankle in professional athletes

PURPOSE

Recent literature supports early reconstruction of severe acute lateral ligament injuries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Not previously reported, predicting the time to return to training and play is important to both athlete and club. We evaluate the effectiveness and complications of lateral ligament reconstruction in professional athletes. We aim to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

METHODS

A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

RESULTS

The median return to training and sports for isolated injuries was 63 days (49-110) and 77 days (56-127), respectively. However, for concomitant injury results were 86 days (63-152) and 105 days (82-178). This delay was significant (p < 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p = 0.027, p < 0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

CONCLUSION

Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

LEVEL OF EVIDENCE

III.