Plausible mechanisms of and techniques to assess ankle joint degeneration following lateral ankle sprains: a narrative review

All-Inside Arthroscopic and Open Techniques of the Modified Broström Procedure for the Treatment of Lateral Ankle Instability: Comparison of the Times to Return to Play

Background and Objectives: Lateral ankle injuries are commonly encountered injuries, and the open modified Broström operation (OMBO) is the primary treatment option. Recently, an arthroscopic modification of the Broström operation (AMBO) was developed; many studies have shown that there are no significant differences in clinical and radiological outcomes between the two surgical methods. However, no studies have been conducted comparing the two surgical methods in terms of return to play (RTP) time. This study assesses the time to RTP and the functional clinical outcomes. Materials and Methods: Sixty patients were enrolled from January 2012 to July 2014. They were segregated into two cohorts: the AMBO group comprised 30 patients, while the OMBO group comprised another 30 patients. Each participant underwent standardized treatment and rehabilitation regimens and RTP time was measured using seven questions that explored the times to return of painless walking, running, jumping, squatting, climbing stairs, and rising up on the heels and toes. We compared the time intervals from the onset of instability to the date of surgery. Clinical outcomes were evaluated before the surgery, 6 weeks after surgery, and 6 months after surgery. The assessments included the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the pain visual analog scale (VAS) score, subjective satisfaction with rehabilitation, and activity level. Results: In terms of RTP, AMBO was associated with a shorter interval to walking without pain (7.07 ± 2.96 weeks) relative to OMBO (11.03 ± 8.58 weeks). No disparities were observed in the time to return to play (RTP) between OMBO and AMBO. While there were no discrepancies in the 6-month postoperative AOFAS or VAS scores, the 6-week postoperative VAS score was notably lower in the AMBO group compared to the OMBO group. AMBO provided a faster RTP in terms of two of the seven questions in a group exhibiting high-level physical activity. The rate of subjective satisfaction with rehabilitation was higher for AMBO than for OMBO. Conclusions: Aside from walking, the duration to return to play and the clinical outcomes were similar between AMBO and OMBO treatments for lateral ankle instability. AMBO is a good treatment option and should be carefully considered for athletes with lateral ankle instability. AMBO demonstrated positive outcomes in a group with higher activity levels compared to others, particularly in terms of time to RTP, subjective satisfaction, and postoperative pain.

Mechanical and Sensorimotor Outcomes Associated With Talar Cartilage Deformation After Static Loading in Those With Chronic Ankle Instability

CONTEXT

Those with chronic ankle instability (CAI) demonstrate deleterious changes in talar cartilage composition, resulting in alterations of talar cartilage loading behavior. Common impairments associated with CAI may play a role in cartilage behavior in response to mechanical loading.

OBJECTIVE

To identify mechanical and sensorimotor outcomes that are linked with the magnitude of talar cartilage deformation after a static loading protocol in patients with and those without CAI.

DESIGN

Cross-sectional study.

SETTING

Laboratory setting.

PATIENTS OR OTHER PARTICIPANTS

Thirty individuals with CAI and 30 healthy individuals.

MAIN OUTCOME MEASURES(S)

After a 60-minute off-loading period, ultrasonographic images of the talar cartilage were acquired immediately before and after a 2-minute static loading protocol (single-legged stance). Talar cartilage images were obtained and manually segmented to enable calculation of medial, lateral, and overall average talar thickness. The percentage change, relative to the average baseline thickness, was used for further analysis. Mechanical (ankle joint laxity) and sensorimotor (static balance and Star Excursion Balance Test) outcomes were captured. Partial correlations were computed to determine associations between cartilage deformation magnitude and the mechanical and sensorimotor outcomes after accounting for body weight.

RESULTS

In the CAI group, greater inversion laxity was associated with greater overall (r = -0.42, P = .03) and medial (r = -0.48, P = .01) talar cartilage deformation after a 2-minute static loading protocol. Similarly, poorer medial-lateral static balance was linked with greater overall (r = 0.47, P = .01) and lateral (r = 0.50, P = .01) talar cartilage deformation. In the control group, shorter posterolateral Star Excursion Balance Test reach distance was associated with greater lateral cartilage deformation (r = 0.42, P = .03). No other significant associations were observed.

CONCLUSIONS

In those with CAI, inversion laxity and poor static postural control were moderately associated with greater talar cartilage deformation after a 2-minute static loading protocol. These results suggest that targeting mechanical instability and poor balance in those with CAI via intervention strategies may improve how the talar cartilage responds to static loading conditions.

Dorsiflexion and Hop Biomechanics Associate with Greater Talar Cartilage Deformation in Those with Chronic Ankle Instability

PURPOSE

This study aimed to identify associations between dorsiflexion range of motion (DFROM), functional hop test performance, and hopping biomechanics with the magnitude of talar cartilage deformation after a standardized hopping protocol in individuals with and without chronic ankle instability (CAI).

METHODS

Thirty CAI and 30 healthy individuals participated. Ankle DFROM was assessed using the weight-bearing lunge test. Four different functional hop tests were assessed. Three-dimensional kinematics and kinetics were sampled during a 60-cm single-leg hop. We calculated cartilage deformation after a dynamic loading protocol consisting of sixty 60-cm single-leg forward hops by assessing the change in average thickness for the overall, medial, and lateral talar cartilage. Linear regressions examined the associations between cartilage deformation magnitude and DFROM, functional hop tests, and hop biomechanical variables after accounting for body weight and time since the initial ankle sprain.

RESULTS

In CAI group, lesser static DFROM (ΔR2 = 0.22) and smaller peak ankle dorsiflexion angle (ΔR2 = 0.17) was associated with greater medial deformation. Greater peak vertical ground reaction force (vGRF) (ΔR2 = 0.26-0.28) was associated with greater medial and overall deformation. Greater vGRF loading rate (ΔR2 = 0.23-0.35) was associated with greater lateral and overall deformation. Greater side hop test times (ΔR2 = 0.31-0.36) and ankle plantarflexion at initial contact (ΔR2 = 0.23-0.38) were associated with greater medial, lateral, and overall deformation. In the control group, lesser side hop test times (ΔR2 = 0.14), greater crossover hop distances (ΔR2 = 0.14), and greater single-hop distances (ΔR2 = 0.21) were associated with greater overall deformation.

CONCLUSIONS

Our results indicate that lesser static DFROM, poorer functional hop test performance, and hop biomechanics associate with greater talar cartilage deformation after a dynamic loading protocol in those with CAI. These factors may represent targets for therapeutic interventions within this population to slow ankle posttraumatic osteoarthritis progression.

Talar-Cartilage Deformation and Spatiotemporal Gait Patterns in Individuals With and Those Without Chronic Ankle Instability

CONTEXT

Individuals with chronic ankle instability (CAI) present with alterations in the compositional structure of their talar articular cartilage. These alterations likely influence how the talar cartilage responds to the loading associated with activities of daily living, such as walking. Ultrasonography has emerged as an alternative imaging modality for assessing the amount of cartilage deformation in response to loading because it is clinically accessible and cost effective for routine measurements.

OBJECTIVES

To (1) compare talar-cartilage deformation in response to a standardized exercise protocol between those with and those without CAI and (2) examine the association between spatiotemporal walking gait parameters and cartilage deformation.

DESIGN

Case-control study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A volunteer sample of 24 participants with self-reported CAI (age = 23.2 ± 3.9 years, body mass index [BMI] = 25.1 ± 3.7 kg/m2) and 24 uninjured controls (age = 24.3 ± 2.9 years, BMI = 22.9 ± 2.8 kg/m2).

MAIN OUTCOME MEASURE(S)

Spatiotemporal walking gait was first assessed from 5 self-selected trials using an electronic walkway with data sampled at 120 Hz. An 8- to 13-MHz linear-array ultrasound transducer placed transversely in line with the medial and lateral malleoli captured 3 images before and after a standardized loading protocol consisting of 30 single- and double-limb squats, 2-minute single-limb balance, and 10 single-legged drops from a 40-cm-height box.

RESULTS

After controlling for BMI, we found that the participants with CAI had greater deformation than the uninjured control participants (P = .034). No other between-groups differences were observed (P values > .05). No significant partial correlations were noted between talar-cartilage deformation and spatiotemporal gait parameters when controlling for BMI (P > .05).

CONCLUSIONS

Individuals with CAI had greater talar-cartilage deformation in response to a standardized exercise protocol than control individuals. The amount of talar-cartilage deformation was not associated with the spatiotemporal walking gait.

Gait Biomechanics and Balance Associate with Talar and Subtalar T1ρ Relaxation Times in Those with Chronic Ankle Instability

PURPOSE

This study aimed to determine associations between T1ρ relaxation times of talar and subtalar articular cartilage and commonly altered gait biomechanics and postural control outcomes in those with chronic ankle instability (CAI).

METHODS

Fifteen individuals with CAI (21.13 ± 1.81 yr) completed a T1ρ magnetic resonance imaging as well as a postural control and an overground gait assessment. Talocrural and subtalar cartilage was segmented manually to calculate T1ρ relaxation times. Greater T1ρ relaxation times were interpreted as decreased proteoglycan content. Pearson product-moment bivariate correlations examined the relationships between T1ρ relaxation times and the gait biomechanics and postural control outcomes.

RESULTS

Across multiple variables, worse postural control demonstrated moderate to strong associations (range, 0.433-0.642 and -0.713) with greater talar T1ρ relaxation times. At the subtalar joint, greater T1ρ relaxation times were associated with lower peak vertical ground reaction forces, lower average vertical ground reaction force loading rates, and lower peak loading rates (range, -0.438 to -0.622). At the talar dome, greater talar T1ρ relaxation times were associated with increased knee extensor moments (r = 0.457), as well as greater knee flexion (r = 0.482) and knee adduction (r = 0.407) at initial contact. Larger step spatiotemporal gait parameters also associated with greater talar and subtalar T1ρ relaxation times (range, 0.434-0.697).

CONCLUSIONS

In individuals with CAI, worse postural control and altered kinematic, kinetic, and spatiotemporal outcomes demonstrate moderate to strong associations with greater talar T1ρ and/or subtalar relaxation times (i.e., less proteoglycan content). Associations between modifiable neuromechanical variables and greater T1ρ relaxation times may represent potential therapeutic interventions to mitigate ankle joint degeneration in those with CAI.

Influence of Landing in Neuromuscular Control and Ground Reaction Force with Ankle Instability: A Narrative Review

Ankle sprains are generally the most common injuries that are frequently experienced by competitive athletes. Ankle sprains, which are the main cause of ankle instability, can impair long-term sports performance and cause chronic ankle instability (CAI). Thus, a comprehensive understanding of the key factors involved in repeated ankle strains is necessary. During jumping and landing, adaptation to the landing force and control of neuromuscular activation is crucial in maintaining ankle stability. Ankle mobility provides a buffer during landing, and peroneus longus activation inhibits ankle inversion; together, they can effectively minimize the risk of ankle inversion injuries. Accordingly, this study recommends that ankle mobility should be enhanced through active and passive stretching and muscle recruitment training of the peroneus longus muscles for landing strategies should be performed to improve proprioception, which would in turn prevent ankle sprain and injury to neighboring joints.

Talar and Subtalar T1ρ Relaxation Times in Limbs with and without Chronic Ankle Instability

OBJECTIVE

The primary aim was to determine differences in talocrural and subtalar joint (STJ) articular cartilage composition, using T1ρ magnetic resonance imaging (MRI) relaxation times, between limbs in individuals with unilateral chronic ankle instability (CAI) and compare with an uninjured control. Our secondary purpose was to determine the association between talocrural and STJ composition in limbs with and without CAI.

DESIGN

T1ρ MRI relaxation times were collected on 15 CAI (11 females, 21.13 ± 1.81 years, body mass index [BMI] = 23.96 ± 2.74 kg/m²) and 15 uninjured control individuals (11 females, 21.07 ± 2.55 years, BMI = 24.59 ± 3.44 kg/m²). Talocrural cartilage was segmented manually to identify the overall talar dome. The SJT cartilage was segmented manually to identify the anterior, medial, and posterior regions of interest consistent with STJ anatomical articulations. For each segmented area, a T1ρ relaxation time mean and variability value was calculated. Greater T1ρ relaxation times were interpreted as decreased proteoglycan content.

RESULTS

Individuals with CAI demonstrated a higher involved limb talocrural T1ρ mean and variability relative to their contralateral limb (P < 0.05) and the healthy control limb (P < 0.05). The CAI-involved limb also had a higher posterior STJ T1ρ mean relative to the healthy control limb (P < 0.05). In healthy controls (P < 0.05), but not the CAI-involved or contralateral limbs (p>0.05), talocrural and posterior STJ composition measures were positively associated.

CONCLUSIONS

Individuals with CAI have lower proteoglycan content in both the talocrural and posterior STJ in their involved limbs relative to the contralateral and a healthy control limb. Cartilage composition findings may be consistent with the early development of posttraumatic osteoarthritis.

Slower visuomotor reaction time in division-I collegiate athletes with a history of ankle sprain

The purpose of this study was to compare visuomotor reaction time (VMRT) in collegiate athletes based on ankle sprain history. Participants included athletes with ankle sprain history (n = 18) and athletes with no ankle sprain history (n = 33). Participants completed an upper-extremity VMRT task which was comprised of eight wireless light-emitting diode sensors. The difference between reaction time (sec) and the number of "Hits" and "Misses" were compared between groups. The ankle sprain history group had significantly slower VMRT compared to the no ankle sprain history group with moderate effect sizes. However, there was no difference in the number of "Hits" or "Misses" between groups, despite observing moderate effect sizes. This result suggests that VMRT may be a potential target for prevention and rehabilitation strategies in individuals with ankle sprains. However, further research is needed to better understand the role of VMRT on the risk of ankle sprains.

Acute Vibration Feedback During Gait Reduces Mechanical Ankle Joint Loading in Chronic Ankle Instability Patients

BACKGROUND

Individuals with chronic ankle instability (CAI) exhibit altered vertical ground reaction forces (vGRF), a laterally shifted center of pressure, and an inverted foot position during walking. These neuromechanical alterations are linked with altered ankle joint loading in this population. Vibration-based gait retraining improves center of pressure positioning but effects on neuromechanical variables influencing joint loading remains unknown.

RESEARCH QUESTION

Do patients with CAI exhibit altered vGRF and ankle joint contact forces (JCF) after receiving a single session of vibration-based gait retraining?

METHODS

Ten individuals with CAI underwent a single session of vibration-based gait retraining. Kinematic and kinetic data were collected during walking on an instrumental treadmill with force plates embedded in it. Following a baseline gait assessment without feedback, participants walked at a self-selected speed for 10 minutes while receiving feedback. Data was collected during an early (1 st and 2 nd minute) and late adaptation phase (9 th and 10 th minute) and, compared to baseline values. Impact and propulsive vGRF variables (i.e. peak, time to peak, and loading rate) were obtained. Musculoskeletal modeling was used to calculate ankle JCF variables (peak, impulse, and loading rate) during stance phase.

RESULTS

Propulsive vGRF and ankle JCF outcomes were significantly reduced during the early and late adaptation phases (p ≤ 0.039).

SIGNIFICANCE

These results indicate that vibration-based gait retraining can immediately reduce propulsive vGRF and ankle JCF and may represent a modality that could help restore appropriate ankle joint loading patterns in those with CAI.

Lateral Ankle Sprain and Subsequent Ankle Sprain Risk: A Systematic Review

OBJECTIVE

To evaluate the evidence regarding the association between lateral ankle sprain (LAS) history and the subsequent LAS risk, as well as sex differences in the observed associations.

DATA SOURCES

PubMed, CINAHL, and SPORTDiscus were searched through July 2020 for articles on LAS history and incidence during the study period.

STUDY SELECTION

Studies were included if they were prospective in nature and the authors reported the number of participants with and those without a history of LAS at study initiation as well as the number of participants in each group who sustained an LAS during the investigation.

DATA EXTRACTION

Data were study design parameters as well as the number of participants with and those without an LAS history and the number of subsequent LASs that occurred in both groups. Risk ratios (RRs) with 95% CIs compared the risk of LAS during the study period between those with and those without an LAS history for each investigation.

DATA SYNTHESIS

A total of 19 studies involving 6567 patients were included. The follow-up periods ranged from 14 weeks to 2 years. Assessment scores indicated the studies were of moderate to high quality. A significantly higher risk of LAS during the study period was observed among those with a history of LAS in 10 of 15 studies (RR range = 1.29-6.06). Similar associations were seen in 4 of 6 studies of all-male samples (RR range = 1.38-8.65) and 1 of 4 studies with an all-female sample (RR = 4.28).

CONCLUSIONS

Strong evidence indicates that a previous LAS increased the risk of a subsequent LAS injury. Men with a history of LAS appeared to be at a higher risk of sustaining a subsequent LAS, but women were not. However, further data are needed to draw definitive conclusions from the limited number of sex-specific studies.

Acceleration and Jerk After a Jump Stabilization Task in Individuals With and Without Chronic Ankle Instability

Studies have demonstrated that individuals with chronic ankle instability (CAI) have diminished dynamic stability. Jerk-based measures have been utilized to examine dynamic balance because of their ability to quantify changes in acceleration and may provide an understanding of the postural corrections that occur during stabilizing following a jumping task. The purpose of this study was to compare acceleration and jerk following a jump stabilization task between individuals with CAI and the uninjured controls. Thirty-nine participants volunteered to participate in this case control study. Participants completed a jump stabilization task requiring them to jump off 2 feet, touch a marker set at 50% of their maximal vertical jump height, land on a single limb, and maintain balance for 3 seconds. Acceleration was calculated as the second derivative, and jerk was calculated as the third derivative of the displacement of the resultant vector position. Participants with CAI had greater acceleration (mean difference = 55.6 cm/s2; 95% confidence interval, 10.3 to 100.90; P = .017) and jerk compared with the uninjured controls (mean difference = 1804.5 cm/s3; 95% confidence interval, 98.7 to 3510.3; P = .039). These results suggest that individuals with CAI made faster and more frequent active postural control corrections to regain balance following a jump compared with the uninjured controls.

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary

BACKGROUND

Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear.

PURPOSE

To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI).

RESULTS

Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups (P < .001). However, there were no significant differences in the clinical results and radiologic findings between the groups.

CONCLUSION

The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes.

Dynamic joint stiffness of the ankle in chronic ankle instability patients

BACKGROUND

While Individuals with chronic ankle instability (CAI) exhibit altered ankle joint movement and moments during stance phase of gait, the interaction or dynamic joint stiffness (DJS) between these is not fully understood. Little attention has been placed on DJS during gait, limiting our understanding of how the most common dynamic task during daily life could affect cartilage loading.

RESEARCH QUESTION

Do Individuals with CAI exhibit altered ankle DJS and mechanical energy exerted at the ankle joint during stance phase of gait?

METHODS

Eighty-four physically active individuals, consisting of 42 individuals with CAI (12 M and 30 F) and 42 control (12 M and 30 F) participants were recruited in this study. Three-dimensional gait analysis was conducted. The sagittal ankle joint angle and moment during stance phase of walking gait were obtained. Stance phase was divided into three sub-phases: controlled plantarflexion, controlled dorsiflexion, and powered plantarflexion. Ankle DJS was represented by the slope of the joint moment plotted as a function of the joint angle. The coefficient of determination was calculated to determine how accurately data fit a linear model. Net work was calculated by the difference between work produced and absorbed. Further, sex specific exploratory analyses of DJS and work between individuals with and without CAI were conducted.

RESULTS

Lower DJS during the controlled plantarflexion (CPF) sub-phase, work produced, and net work was found in the CAI group. Males with CAI exhibited lower ankle moment changes during controlled dorsiflexion (CDF) sub-phase and work absorbed. Females with CAI exhibited lower ankle moment changes during CPF and CDF sub-phases, lower DJS during the CPF sub-phase, and lower net work.

SIGNIFICANCE

Individuals with CAI have alterations in DJS and work relative to uninjured controls. Females with CAI showed greater DJS related alterations, relative to controls, than their male CAI counterparts.

The Effect of Attending Physical Rehabilitation After the First Acute Lateral Ankle Sprain on Static Postural Control in Patients With Chronic Ankle Instability

CONTEXT

Static postural control deficits are commonly documented among individuals with chronic ankle instability (CAI). Evidence suggests individuals with CAI who seek medical attention after an ankle sprain report fewer subjective symptoms. It is unknown if seeking medical attention and receiving supervised physical rehabilitation has a similar effect on objective outcomes, such as static postural control.

OBJECTIVE

To compare measures of single-limb postural control and center of pressure (COP) location between participants with CAI who did or did not self-report attending supervised rehabilitation at the time of their first lateral ankle sprain.

DESIGN

Retrospective cohort.

SETTING

Laboratory. Patients (or Other Participants): Twenty-nine participants with CAI who did (n = 14) or did not (n = 15) self-report attending supervised rehabilitation.

INTERVENTION(S)

Self-reported attendance or not of supervised rehabilitation at the time of initial injury.

MAIN OUTCOME MEASURES

Participants performed three 20-second trials of single-limb stance on a force plate with eyes open. Main outcome measures included the COP velocities, time-to-boundary (TTB) absolute minima, mean of TTB minima, and SD of TTB minima in the anteroposterior and mediolateral directions. The spatial distribution of the COP data points under the foot was quantified within 4 equally proportional sections labeled anteromedial, anterolateral, posteromedial, and posterolateral.

RESULTS

Participants who reported attending supervised rehabilitation after their initial ankle sprain had a lower COP velocity in the anterior-posterior direction (P = .030), and higher TTB anterior-posterior absolute minimum (P = .033) and mean minima (P = .050) compared with those who did not attend supervised rehabilitation.

CONCLUSIONS

Among individuals with CAI, not attending supervised rehabilitation at the time of initial injury may lead to worse static postural control outcomes. Clinicians should continue advocating for patients recovering from an acute ankle sprain to seek medical attention and provide continued care in the form of physical rehabilitation.

Autograft versus allograft tenodesis for chronic ankle instability: a single-center retrospective comparative study

Aim: To compare the outcomes of patients who underwent autograft tenodesis with those who underwent allograft tenodesis for the treatment of chronic mechanical ankle instability. Patients & methods: Ten patients who underwent allograft lateral tenodesis were compared with 15 patients who underwent lateral tenodesis using a split peroneus brevis tendon. Patients were followed up after an average time of 10.5 years. Results: No statistically significant differences concerning American Orthopaedic Foot and Ankle Society and Karlsson-Peterson scores were reported (p = n.s.). A reduced average radiographic anterior talar translation was observed in the autograft group compared with the allograft group (1.4 and 4.0 mm respectively, p < 0.001). Conclusion: Both surgical techniques significantly improved subjective and objective outcomes in patients suffering from chronic ankle instability compared with pre-operatory status. Autograft stabilization provided reduced post-operative anterior talar translation compared with allograft tenodesis.