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Hong G, Kong X, Zhang L, Zheng Y, Fan N, Zang L. Comparative analysis of arthroscopic technique for anterior talofibular and calcaneofibular ligament reconstruction versus open modified brostrom-gould procedure in chronic lateral ankle instability management. J Orthop Surg Res 2024; 19:312. [PMID: 38802920 PMCID: PMC11131230 DOI: 10.1186/s13018-024-04800-1] [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: 12/22/2023] [Accepted: 05/19/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Chronic Lateral Ankle Instability (CLAI) is a common condition treated using either Anterior Talofibular and Calcaneofibular Ligament (ATFL and CFL) reconstruction or Modified Brostrom Procedure (MBP). However, the comparative efficacy of these approaches is not well-studied. METHODS In this study, clinical data were retrospectively collected from 101 patients diagnosed with CLAI who underwent either ATFL and CFL reconstruction (n = 51) or the MBP (n = 50). Patients were comparable in terms of age, sex, Body Mass Index (BMI), post-injury duration, preoperative American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, Visual Analog Score (VAS), Anterior Talar Translation, and Talar Tilt Angle. RESULTS The post-operative measures showed no significant differences in AOFAS Score, Karlsson Score, and VAS between both treatment groups. However, patients who underwent ATFL and CFL reconstruction showed significantly lower follow-up Anterior Talar Translation (mean = 4.1667 ± 1.3991 mm) and Talar Tilt Angle (mean = 5.0549 ± 1.6173°) compared to those who underwent MBP. Further, patients treated with ATFL and CFL reconstruction experienced a significantly longer postoperative recovery time (median = 6 weeks) compared to MBP (median = 3 weeks). CONCLUSIONS Although both therapeutic techniques were generally effective in treating CLAI, the ATFL and CFL reconstruction approach delivered superior control of Anterior Talar Translation and Talar Tilt Angle. However, its longer recovery time merits further study to optimize the balance between therapeutic efficacy and recovery speed.
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Affiliation(s)
- Gang Hong
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China
| | - XiaoChuan Kong
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China
| | - Le Zhang
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China
| | - YinFeng Zheng
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China
| | - Ning Fan
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China
| | - Lei Zang
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, NO. 5 Jingyuan Road, Shijingshan District, Beijing, 100043, China.
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Guyonnet C, Vieira TD, Wackenheim FL, Lopes R. Arthroscopic Modified Broström Repair with Suture-Tape Augmentation of the Calcaneofibular Ligament for Lateral Ankle Instability. Arthrosc Tech 2024; 13:102887. [PMID: 38584641 PMCID: PMC10995735 DOI: 10.1016/j.eats.2023.11.015] [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: 08/22/2023] [Accepted: 11/04/2023] [Indexed: 04/09/2024] Open
Abstract
Surgical repair of acute or chronic lateral instability of the ankle may be unsuccessful in the presence of associated anterior fibulotalar ligament (AFTL) and calcaneofibular ligament (CFL) injury. This Technical Note presents an arthroscopic double-row repair technique of the AFTL associated with suture tape augmentation of the CFL. The patient is in the supine position with the ankle hanging over the edge of the surgical table. The anteromedial portal is created inside the anterior tibial tendon, and the anterolateral portal is created under arthroscopic control. The ATFL is released from the capsule with a beaver blade. The calcaneal tunnel is created percutaneously at the footprint of the CFL. A soft anchor is impacted at the tip of the lateral malleolus with thread and tape. With the foot in the neutral position, the tape is then passed into the calcaneal tunnel and attached with an interference screw to strengthen the CFL. The ATFL is grasped with a Mini-Scorpion suture passer and pressed against the anchor with the foot in neutral position. A knotless anchor is impacted 5 mm above with the threads of the soft anchor, creating double-row fixation. This technique is indicated in proximal tears of the AFTL associated with a stretched CFL.
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Affiliation(s)
- Clément Guyonnet
- Institut Médical Pérignat, Pérignat-lès-Sarliève, France
- Hôpital Privé la Châtaigneraie, Beaumont, France
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Maginnis C, Root C, Schiavo JH, Ierulli VK, Vopat B, Mulcahey MK. Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review. Am J Sports Med 2024:3635465231196157. [PMID: 38269417 DOI: 10.1177/03635465231196157] [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: 01/26/2024]
Abstract
BACKGROUND New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types. PURPOSE To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring). STUDY DESIGN Systematic review; Level of evidence, 5. METHODS An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts. RESULTS Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups. CONCLUSION HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.
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Affiliation(s)
- Connor Maginnis
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Cooper Root
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie H Schiavo
- Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Victoria K Ierulli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Bryan Vopat
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
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Hu D, Wang N, Wang H, Fan D, Teng Q, Zheng X, Hou H. Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients. BMC Musculoskelet Disord 2024; 25:48. [PMID: 38200504 PMCID: PMC10777501 DOI: 10.1186/s12891-023-07085-3] [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: 08/02/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND To compare the clinical efficacies of arthroscopic anterior talofibular ligament suture augmentation repair and modified suture augmentation repair in patients with chronic ankle instability (CAI). METHODS From October 2019 to August 2020, 100 patients with CAI were enrolled after propensity score matching analysis and observed for two years. Among them, 50 underwent modified suture augmentation repair and the other 50 underwent suture augmentation repair. The clinical efficacies of CAI treatments were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) clinical rating scale, visual analog scale (VAS), and anterior drawer test scores. RESULTS The postoperative AOFAS score of the modified suture augmentation repair group (83.8 ± 11.3) was significantly higher than that of the suture augmentation repair group (76.3 ± 11.3; P = 0.001). The VAS (P = 0.863) and anterior drawer test (P = 0.617) scores were not significantly different between the two treatment groups. CONCLUSION Both the modified suture augmentation repair and suture augmentation repair demonstrated good clinical efficacies. The AOFAS score of the modified suture augmentation repair group was superior to that of the conventional suture augmentation repair group. Thus, modified suture augmentation repair is a feasible and practical surgical technique for CAI treatment.
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Affiliation(s)
- Dahai Hu
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
- International School, Jinan University, Guangzhou, 510632, Guangdong, China
| | - Nan Wang
- Department of Clinical Medicine, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Huajun Wang
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Dongyi Fan
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Qiang Teng
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Xiaofei Zheng
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China.
| | - Huige Hou
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China.
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Galanis A, Karampinas P, Vlamis J, Vavourakis M, Papagrigorakis E, Vlachos C, Zachariou D, Pneumaticos S. Pure ankle dislocation after modified Broström repair for chronic lateral instability: Case report and literature review. Trauma Case Rep 2023; 48:100935. [PMID: 37928720 PMCID: PMC10622876 DOI: 10.1016/j.tcr.2023.100935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 11/07/2023] Open
Abstract
Ankle dislocation with no concomitant malleolar fracture is an overwhelmingly rare injury, and only a relatively limited number of cases have been reported. Diligent management regarding the treatment of these injuries is requisite to attain an auspicious outcome. Lateral ankle instability is a frequent condition that can derive from recurrent sprains, predominantly at a young age. Broström repair, with its modifications and updates, has been established as the optimal solution when treating chronic lateral unsteadiness. We present a peculiar case of a posteromedial ankle dislocation without accompanying fracture in a patient operated on many years before the injury for chronic lateral instability with a modified Broström procedure. No similar case could be retrieved in the existing literature. After the initial clinical and radiological assessment, urgent closed reduction of the dislocation was achieved, and the foot was immobilized. Further imaging was carried out to evaluate the features of the injury. It was deduced that the repairs from the previous operation were intact. The patient was operated on to repair the distal tibiofibular syndesmosis. The postoperative course was uneventful, and absolute functional capacity was eventually accomplished. Demonstrating this rare case, we accentuate the role of implementing the modified Broström procedure in the surgical treatment of chronic lateral ankle instability.
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Affiliation(s)
- Athanasios Galanis
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Panagiotis Karampinas
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - John Vlamis
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Michail Vavourakis
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Eftychios Papagrigorakis
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Christos Vlachos
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Dimitrios Zachariou
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
| | - Spiros Pneumaticos
- 3rd Department of Orthopaedic Surgery, National & Kapodistrian University of Athens, KAT General Hospital, Athens, Greece
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Flaherty DJ, McGuigan J, Cullen SE, Pillai A. Brace for Impact: A Retrospective Analysis of the Modified Broström-Gould Procedure With and Without Internal Brace Augmentation. Cureus 2023; 15:e44563. [PMID: 37790020 PMCID: PMC10544822 DOI: 10.7759/cureus.44563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background Chronic lateral ankle instability (CLAI) is caused by lateral ankle ligament weakness or rupture secondary to recurrent sprains. The surgical management has traditionally involved a modified Broström-Gould (MBG) procedure with or without internal brace (IB) augmentation. This study aims to demonstrate the improved outcomes for patients undergoing an MBG procedure with IB augmentation for CLAI. Methodology A retrospective analysis was performed among 40 patients undergoing an MBG procedure with or without IB for CLAI at a large teaching hospital between January 2012 and June 2019. Functional outcomes were measured using the Manchester-Oxford Foot Questionnaire (MOxFQ). Clinic letters were reviewed to assess additional outcomes including postoperative complications, revision surgery rate, time in a plaster cast, and time to full weight-bearing. Results A total of 23 patients were included in the study, with seven undergoing both MBG and IB procedures and 16 undergoing MBG intervention alone. The average age was 37.1 years in the IB group and 35.7 years in the MBG group. The mean MOxFQ overall raw scores (10.9 vs. 33.6, p < 0.016), standing and walking MOxFQ subscale (4 vs. 15.2, p < 0.012), pain MOxFQ subscale (4.86 vs. 10.9, p < 0.042), and social interaction subscale (2 vs. 7.5 p < 0.023) all showed significantly better results for the IB group versus the MBG group. Patients in the IB group had significantly less number of weeks in plaster than the MBG group and were able to fully weight bear sooner (4.14 vs. 6, p < 0.01). The MBG group suffered a postoperative complication in seven patients compared to zero in the IB group (p < 0.057). There were three re-ruptures in the MBG group requiring further revision surgery compared to zero in the IB group (3 vs. 0, p < 0.53). Conclusions MBG surgery with IB augmentation for CLAI appears to have better outcomes in terms of overall function and may have fewer overall complications. The IB group displayed a lower recurrence of pain, less time in a plaster cast, and a quicker return to walking.
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Affiliation(s)
| | - Jamie McGuigan
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, GBR
| | - Samuel E Cullen
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, GBR
| | - Anand Pillai
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, GBR
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Yoshimoto K, Noguchi M, Maruki H, Tominaga A, Ishibashi M, Okazaki K. Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Knee Surg Sports Traumatol Arthrosc 2022; 31:2183-2191. [PMID: 36396801 DOI: 10.1007/s00167-022-07211-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair. METHODS A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores. RESULTS Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy. CONCLUSION Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kensei Yoshimoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-Ku, Tokyo, 162-0054, Japan.,Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-Ku, Tokyo, 157-8550, Japan
| | - Masahiko Noguchi
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-Ku, Tokyo, 162-0054, Japan. .,Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-Ku, Tokyo, 157-8550, Japan. .,Department of Orthopaedic Surgery, Saitama Medical University Hospital, Moroyama, Saitama, Japan.
| | - Hideyuki Maruki
- Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-Ku, Tokyo, 157-8550, Japan.,Department of Orthopaedic Surgery, Saitama Medical University Hospital, Moroyama, Saitama, Japan
| | - Ayako Tominaga
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-Ku, Tokyo, 162-0054, Japan.,Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-Ku, Tokyo, 157-8550, Japan
| | - Mina Ishibashi
- Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-Ku, Tokyo, 157-8550, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-Ku, Tokyo, 162-0054, Japan
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Dias S, Lewis TL, Alkhalfan Y, Ahluwalia R, Ray R. Current concepts in the surgical management of chronic ankle lateral ligament instability. J Orthop 2022; 33:87-94. [PMID: 35874042 PMCID: PMC9305620 DOI: 10.1016/j.jor.2022.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022] Open
Abstract
Background/aims Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI). Methods The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI. Results Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes. Conclusion Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.
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Affiliation(s)
- Shiluka Dias
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Thomas L. Lewis
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Raju Ahluwalia
- King's College Hospital MTC, London; King's College Hospital Diabetic Foot Unit & King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Robbie Ray
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
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