Outcomes After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for Chronic Ankle Instability: A Systematic Review and Meta-analysis

Broström ankle ligament repair augmented with suture tape : Results of magnetic resonance imaging evaluation

BACKGROUND

The Broström procedure is an established procedure in cases of primary lateral ankle ligament repair (LALR). To improve postoperative stability an augmentation device, InternalBrace™ (Arthrex, Naples, FL) has been introduced. This study evaluates remodelling of the anterior talofibular ligament (ATFL) in patients undergoing a tape augmented Broström technique as well as clinical outcomes.

METHODS

In this study 32 patients with chronic lateral ankle instability (CLAI) receiving augmented LALR were included. Clinical outcomes were evaluated at a one-time postoperative visit between 12 and 18 months. A 3 T magnetic resonance imaging (MRI) was done to evaluate the morphology of the ATFL. Statistical analysis was completed with the free software and environment R version 3.6.3 (Bell Laboratories, Murray Hill, NJ, USA) and P-values < 0.05 were considered statistically significant.

RESULTS

The mean follow-up time was 15.3 ± 1.8 months with a return to sport time of 4.0 ± 2.4 months. The average AOFAS (American Orthopaedic Foot and Ankle Society Score) score was 94.4 ± 7.2, the FAOS (Foot and Ankle Outcome Score) demonstrated 87.3 ± 10.4 points and the FFI (Foot Function Index - 2 scores (pain and function score)) was 22.9 ± 20.1 and 15.4 ± 10.4, respectively. The MRI findings demonstrated an average length of the ATFL of 18.6 ± 4.3 mm and the width was 3.6 ± 0.9 mm. A clear differentiation between the ATFL and the augmentation device could be shown in 28 cases. The Fisher's exact test could not depict a significant correlation between the presence of a bone marrow edema and the tension of the augmentation device with a level of significance of α = 0.05.

CONCLUSION

An anatomical healing tendency of the ligament repair and good integrity of the augmentation device could be shown based on MRI findings. The lateral ligament repair augmented with suture tape is an effective and safe procedure regarding surgical treatment in chronic lateral ankle instability producing good clinical outcome.

Advances in Diagnosis and Management of Lateral Ankle Instability: A Review of Current Literature

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

Return to sports after ankle reconstruction with tendon grafts in chronic lateral ankle instability: A systematic review and meta-analysis

Purpose

Anatomic reconstruction using grafts is being performed more frequently in athletes experiencing recurrent chronic lateral ankle instability (CLAI). The purpose of the study was to systematically review the current literature to determine the rates of return to sports (RTS) along with timing in patients with CLAI undergoing ligament reconstruction.

Methods

The databases PubMed, Scopus, Cochrane, and Embase were searched based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles quoting on the return to sports rate after lateral ankle reconstruction were included. The rates of return to any sports, return to pre-injury sports, and return to competitive sports along with the timing of return were evaluated and a proportion meta-analysis was performed.

Results

A total of 720 patients in 20 studies met our inclusion criteria. The RTS rates for any sports were 95.3%, and 84.3% for pre-injury sports The average time taken for return to sports was 17 weeks. Postoperative functional outcomes, ankle stability, and ROM were significantly improved in comparison to preoperative status.

Conclusion

The RTS rates following lateral ankle reconstruction in CLAI showed a high return to any sports, but moderate to high rates for the pre-injury or competitive level of sports.

Level of evidence

Level of evidence II.

Minimally Invasive Reconstruction of the Ankle Lateral Ligament Complex in Chronic Ankle Instability: Clinical Outcomes, Return to Sport and Recurrence Rate at Minimum Follow up of 5 Years

Background: Chronic ankle instability is a common condition that develops after lateral ankle sprains. Many surgical techniques have been described in case of failure of conservative treatment. The purpose of this paper is to present the results in terms of clinical outcomes, return to sport and recurrence rate after reconstruction of the lateral ligament complex of the ankle with a minimally invasive approach at a minimum follow up of five years. Methods: This retrospective study involved forty-seven patients treated for chronic ankle instability from January 2013 to November 2017. The clinical outcomes were evaluated with the American Orthopedic Foot and Ankle Society ankle and hindfoot score (AOFAS score), the University of California–Los Angeles Rating Scale (UCLA Rating Scale), the Karlsson–Peterson ankle instability score and the Halasi scale at a mean follow up time of 80 months. Results: The mean age of the patients was 42 years (23–63). The mean VAS pain score decreased from 5.6 (2–9) pre-operatively to 0.7 (0–7) post-operatively. The mean UCLA Rating Scale score improved from 7.7 (4–8) before surgical treatment to 9.2 (6–10) afterwards. The AOFAS score increased from a pre-operative mean value of 66.5 (40–95) to a post-operative mean value of 94 (88–100) and the Halasi scale from a pre-injury mean value of 4.3 (2–8) to 4.5 post-operatively (2–8). The mean Karlsson–Peterson ankle instability score increased from 71 (40–90) pre-operatively to 87.9 (70–90) post-operatively. During this period of follow up, the procedure survival rate was 95.7%, with two cases of recurrence of ankle sprain post-operatively after twelve months in one case and forty months in the other case. Conclusions: The described technique of reconstruction of the anterior talofibular and calcaneofibular ligament with a minimally invasive approach with a semitendinosus autograft is a viable treatment option for chronic ankle instability and enables the majority of patients to regain their activity and sport level with a low recurrence rate at a mid-term follow up.

Double-bundle reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon

BACKGROUND

Anatomic anterior talofibular ligament (ATFL) reconstruction with autologous single-bundle tendon has been widely used in the treatment of ATFL injury. However, there are few clinical reports of using the peroneus brevis tendon (PBT) for double-bundle ATFL reconstruction. The aim of this study was to investigate the clinical effect of double-bundle ATFL reconstruction with PBT.

METHODS

This was a retrospective review of all patients diagnosed with ATFL injury presenting from August 2019 to December 2021. Fifty-three patients were selected after screening based on the inclusion and exclusion criteria. The following data were compared before and after surgery: Visual Analogue Scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), the pain interference (PI) and physical function (PF) scores of the Patient-Reported Outcomes Measurement Information System (PROMIS), the diameter and width of PBT in ultrasound and muscle strength.

RESULTS

All functional scores (VAS, PI/PF, AO-FAS, KAFS) and muscle strength were significantly improved at the last follow-up (P < 0.05). The diameter and width of the PBT on ultrasound postoperation were smaller than those preoperatively.

CONCLUSION

Double-bundle ATFL reconstruction with the partial PBT technique is a feasible, anatomic reconstruction technique for chronic lateral instability of the ankle, which meets the anatomical characteristics of the double bundle of the ligament, and the absence of partial PBT does not affect the peroneal muscle strength.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Patient-reported outcomes following free flap lower extremity reconstruction: A systematic review and meta-analysis

PURPOSE

Free flap reconstruction in the lower extremity has shown success for the management of large and complex defects, restoration of function, and favorable aesthetic outcomes. Patient-reported outcomes (PROs) have not been well explored in previous literature. This meta-analysis aimed to provide a comprehensive summary of PROs after free flap reconstruction in the lower extremity.

METHODS

We searched MEDLINE and Embase from 1946 to 2021 for studies reporting on PROs following free flap reconstruction in the lower extremity.

RESULTS

Overall, 53 studies were included, and 11 studies reported validated PRO measures for meta-analysis. A total of 1953 patients underwent reconstruction with 1958 free flaps for lower limb defects with a mean follow-up of 3.26 (0.25-7.83) months. The mean postoperative Lower Extremity Functional Scale (LEFS) scores were 60.3 (±12) out of 80 points (4 studies, 85 patients). The mean postoperative AOFAS scores were 75.1 (±15) out of 100 points (4 studies, 68 patients). The mean postoperative SF-36 scores were 88.1 (±8.0) out of 100 points; mental health component was 48.7 (±8.9), and physical component was 38.4 (±8.2), out of 50 points (4 studies, 88 patients).

CONCLUSION

Our findings demonstrated that patients report improved physical health, mental health, and function following lower extremity reconstruction with free flaps. Patients reported similar improvements in functional scores following lower extremity reconstruction regardless of their free flap type. Furthermore, patients with myocutaneous flaps may have improved mental health and worse physical health scores when compared to perforator flaps. The evidence profiles presented in this review indicate that additional research is needed to help guide future decision-making.

Anatomic reconstruction using the autologous gracilis tendon achieved less sprain recurrence than the Broström-Gould procedure but delayed recovery in chronic lateral ankle instability

PURPOSE

To compare the return-to-activity and long-term clinical outcomes between anatomic lateral ligament reconstruction using the autologous gracilis tendon and modified Broström-Gould (MBG) procedure in chronic lateral ankle instability (CLAI). It was hypothesised that there was no difference between the two techniques.

METHODS

From 2013 to 2018, 30 CLAI patients with grade III joint instability confirmed by anterior drawer test underwent anatomic reconstruction of lateral ankle ligament with the autologous gracilis tendon (reconstruction group) in our institute. Another 30 patients undergoing MBG procedure (MBG group) were matched in a 1:1 ratio based on demographic parameters. The post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner activity score, Karlsson-Peterson score, surgical complications, return-to-activities and work were retrospectively evaluated and compared between the two groups.

RESULTS

All subjective scores significantly improved after the operation (all with p < 0.001) without difference between the two groups (all n.s.). The MBG group showed a significantly higher proportion of postoperative sprain recurrence than the reconstruction group (26.7% vs. 0, p = 0.002). The reconstruction group showed a significantly longer period to start walking with full weight-bearing (10.5 ± 6.9 vs. 7.0 ± 3.1 weeks, p = 0.015), jogging (17.1 ± 8.9 vs. 12.7 ± 6.9 weeks, p = 0.043) and return-to-work (13.5 ± 12.6 vs. 8.0 ± 4.7 weeks, p = 0.039) than the MBG group.

CONCLUSIONS

Both anatomic reconstruction using the autologous gracilis tendon and MBG procedure could equally achieved reliable long-term clinical outcomes and the tendon reconstruction showed a relatively lower incidence of postoperative sprain recurrence but delayed recovery to walking, jogging and return-to-work. The MBG procedure was still the first choice with rapid recovery but the tendon reconstruction was recommended for patients with higher strength demand.

LEVEL OF EVIDENCE

III.

Ultimate Load Measuring System for Fixation of Soft Tissue to Bone

BACKGROUND

The initial ultimate load for graft fixation is one of the essential factors in the reconstruction of lateral ankle ligaments. Several anchoring devices have been developed to fix the substitute ligament into the bone. A fair comparison of these fixation methods warrant a reproducible examination system. The purpose of this study was to make an experimental animal model and to compare the initial ultimate loads of 3 graft fixation methods, including the use of EndoButton (EB), interference screw (IFS), and a novel socket anchoring (SA) technique.

METHODS

Porcine calcaneus bones and 5-mm-wide split bovine Achilles tendons were used as fixation bases and graft materials, respectively. Both ends were firmly sutured side-by-side, using the circumferential ligation technique as a double-strand substitute that was 45 mm in length. Porcine calcanei with similar characteristics to adult human calcanei were mounted on a tensile testing machine, and substitutes were fixed into bones using the 3 fixation methods. A polyester tape was passed through the tendon loop and connected to a crosshead jig of the testing machine. The initial ultimate loads were measured in 15 specimens for each fixation method to simulate a lateral ankle ligament (LAL) injury.

RESULTS

The ultimate loads (ULs) were 223.6 ± 52.7 N for EB, 229.7 ± 39.7 N for SA, and 208.8 ± 65.3 N for IFS. No statistically significant difference was observed among the 3 groups (P = .571). All failures occurred at the bone-ligament substitute interface.

CONCLUSION

The initial ULs in all 3 fixation methods were sufficient for clinical usage. These values were larger than the UL of the anterior talofibular ligament; however, these were smaller than the UL of the calcaneofibular ligament.

CLINICAL RELEVANCE

In an experimental animal model, ULs for SA, EB, and IFS techniques showed no significant difference. All failures were observed in the fixation site of the calcaneus and were overwhelmingly related to suture fixation failure.

High return to sports and return to work rates after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability

PURPOSE

To evaluate clinical outcomes as well as return to sports (RTS) and return to work (RTW) rates following anatomic lateral ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability (CLAI) in a high-risk population, and to compare these outcome parameters between patients having received a gracilis tendon autograft (GT) and free split peroneus brevis tendon (PBT) autograft.

METHODS

Twenty-eight consecutive patients, who were diagnosed with CLAI, presenting with ≥ 1 risk factor (ligamentous hyperlaxity, insufficient substance of native ligament and/or high-demand athlete), who underwent ankle ligament reconstruction with a tendon autograft between January 2011 and December 2018, were included in this retrospective study. At 63.7 ± 28.0 months (24-112), 23 patients with a mean age of 29.7 ± 10.9 years were available for follow-up. The Karlsson Score, the Foot and Ankle Outcome Score (FAOS), the Tegner Activity Scale and the visual analog scale (VAS) for pain were collected at a minimum follow-up of 24 months. RTS and RTW were evaluated by questionnaire. A subgroup analysis with regard to the graft used for ankle ligament reconstruction (GT versus PBT) was performed.

RESULTS

Patients reported a Karlsson score of 82.1 ± 17.5 (37-100), a FAOS score of 87.8 ± 8.4 (73-99), a median Tegner activity scale of 5.0 (IQR 4-6) and a VAS for pain of 0.5 ± 0.9 (0-4) at rest and of 2.0 ± 2.1 (0-7) during activities at final follow-up. Postoperatively, 96% of patients had returned to sports after 8.3 ± 6.2 months. All patients (100%) had returned to work at 3.5 ± 5.7 (0-24) months, with 87% reporting an equal or improved working ability compared to that preoperatively. Postoperatively, exercise hours per week were significantly reduced compared to preoperatively in patients with a split PBT (n = 12; 13.0 ± 12.9 to 5.6 ± 6.4 h, p = 0.038) autograft as opposed to patients with a GT autograft (n = 11; 13.1 ± 8.7 to 12.4 ± 7.1 h, n.s.). No other group differences were observed.

CONCLUSION

Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory.

LEVEL OF EVIDENCE

IV.

Lateral ankle instability-induced neuroplasticity in brain grey matter: A voxel-based morphometry MRI study

OBJECTIVES

The deficits in sensory pathways caused by peripheral edema, pain, and inflammation of the damaged ligaments may induce maladaptive changes within the central nervous system. The purpose of this study was to determine whether patients with lateral ankle instability (LAI) exhibit morphological differences of brain grey matter when compared with healthy controls, and then assess the relationships between the observed differences and the characteristics of patients.

DESIGN

Cross-sectional.

METHODS

Thirty patients with LAI and 32 healthy controls without LAI underwent MRI scans using anatomical T1 sequences. A voxel-wise general linear model was used to compare the grey matter volume throughout the whole brain between patients and controls. Linear regression analyses were performed for the grey matter volume within the significant clusters to assess their relationship with age, sex, the existence of acute injury, pain level, sports activity level, and the duration of LAI within the patient group.

RESULTS

The grey matter volume of a cluster within the cerebellar vermis (Vermis_4_5 in automated anatomical labeling template) was significantly reduced in patients with LAI (Gaussian Random Field corrections with two-tailed p-cluster < 0.05 and p-voxel < 0.001). Multivariate linear regression analysis revealed that the duration of LAI tended to be passively associated with the grey matter volume of this LAI-related vermal cluster (p = 0.092).

CONCLUSIONS

Participants with LAI exhibited a reduced grey matter volume of a cluster within the cerebellar vermis compared with participants without LAI, and the degree of volume reduction tended to be positively associated with the duration of LAI.

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

[Lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability]

Objective

To assess the effectiveness of lateral ligament reconstruction with autogenous partial peroneus longus tendon for chronic lateral ankle instability.

Methods

Between September 2014 and November 2018, 32 patients (32 sides) with chronic lateral ankle instability were treated with lateral ankle ligament reconstruction by using autogenous anterior half of the peroneus longus tendon. There were 25 males and 7 females, with an average age of 28.5 years (range, 20-51 years). The disease duration was 6-41 months (mean, 8.9 months). The preoperative Karlsson-Peterson ankle score was 53.7±9.7. The talar tilt angle was (14.9±3.7)°, and the anterior talar translation was (8.2±2.8) mm. Six patients combined with osteochondral lesion of talus and 4 patients combined with bony impingement.

Results

All incisions healed by first intention postoperatively. All patients were followed up 12-53 months (mean, 22.7 months). At last follow-up, the Karlsson-Peterson ankle score was 85.2±9.6; the talar tilt angle was (4.3±1.4)°; the anterior talar translation was (3.5±1.1) mm. There were significant differences in all indexes between pre- and post-operation ( P<0.05). Seventeen patients were very satisfied with the results, 10 patients were satisfied, 4 patients were normal, and 1 patient was unsatisfied. After operation, the ankle sprain occurred in 7 cases, the tenderness around the compression screws at calcaneus in 5 cases, the anterolateral pain of ankle joint over 6 months in 4 cases. No patient had discomfort around the reciepient sites. At last follow-up, the ultrasonography examination showed that there was no significant difference in the density and diameter between bilateral peroneus longus tendons in 12 cases.

Conclusion

For chronic lateral ankle instability, the lateral ankle ligament reconstruction with the autogenous partial peroneus longus tendon is a safe and effective surgical option.

Chronic Lateral Ankle Instability: Surgical Management

Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Open anatomic reconstruction is an effective method of stabilization. Ankle arthroscopy is a recommended to address intra-articular disorder before stabilization. An anatomic approach provides full range of motion, stability, and return to sport and activity. Allograft or suture tape augmentation can be useful for patients with generalized ligamentous laxity, patients with high body mass index, and elite athletes. Allograft reconstruction may be especially useful in revision procedures. Arthroscopic approach to lateral ankle ligament stabilization may provide good outcomes, with long-term data still limited.

Revision Surgery for Failed Lateral Ankle Stabilization

Although most primary lateral ankle ligament repairs have a high success rate, as with any surgery, failures and the need for revision can occur. Nonanatomic lateral ankle ligament repairs have fallen out of favor because of the increased stiffness and resultant change in mechanics of the functioning tendon that is normally used. Allograft anatomic lateral ankle ligament reconstruction for revision surgery has gained popularity over the last few years. This article discusses the factors that can lead to failure and the revision technique.