Long-term functional outcome after surgery of chronic ankle instability. A 5-year follow-up study of the modified Evans procedure

Chronic Lateral Ankle Instability: Can We Get Even Better with Surgical Treatment?

Lateral ligament attenuation may occur after repetitive ankle sprains, creating instability. Management of chronic ankle instability requires a comprehensive approach to mechanical and functional instability. Surgical treatment, however, is indicated when conservative treatment is not effective. Ankle ligament reconstruction is the most common surgical procedure to resolve mechanical instability. Anatomic open Broström-Gould reconstruction is the gold standard for repairing affected lateral ligaments and returning athletes to sports. Arthroscopy may also be beneficial for identifying associated injuries. In severe and long-standing instability, reconstruction with tendon augmentation could be necessary.

Lateral Ligament Reconstruction With Hamstring Graft for Ankle Instability: Outcomes for Primary and Revision Cases

BACKGROUND

Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device.

RESULTS

A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (-4.94° vs -7.03°; P = .415).

CONCLUSION

Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

Revision Lateral Ankle Reconstruction 40 Years After Chrisman-Snook Procedure: A Case Report

CASE

A 70-year-old active woman presented with lateral ankle instability 40 years after a lateral ankle reconstruction procedure. Examination demonstrated gross instability, and advanced imaging revealed attenuation of her previous graft. She underwent anatomic reconstruction through a modified Brostrom-Gould technique and was able to return to hiking without pain.

CONCLUSION

Recurrent lateral ankle instability after reconstruction represents a unique challenge for orthopaedic surgeons. Utilization of a modified Brostrom-Gould procedure with suture tape augmentation is a promising alternative to allograft or autograft reconstruction for patients with active lifestyle goals in the context of recurrent instability.

Chronic Lateral Ankle Instability in Highly Active Patients: A Treatment Algorithm Based on the Arthroscopic Assessment of the Calcaneofibular Ligament

Background

Ankle sprains are common injuries that may recur as chronic conditions. We aim to describe a treatment algorithm for chronic lateral ankle instability based on the arthroscopic findings of the calcaneofibular ligament (CFL).

Methods

We assessed 67 highly active patients with chronic lateral ankle instability. They were recreational athletes or active military personnel. After clinical examination, they were all investigated further with MRI scans and stress views. Diagnostic arthroscopy followed, where the integrity of the CFL was assessed. Patients with an intact CFL were placed in group A while those with CFL tears in group B. Concomitant intra-articular pathologies, if present, were treated arthroscopically. CFL tears mandated that modified Broström-Gould reconstruction would follow. The American Orthopaedic Foot and Ankle Society (AOFAS) and Tegner scores were noted post-injury and during the 24-month follow-up.

Results

A total of 37 patients were put in group A and 30 in group B. The posterior talofibular ligament was intact in both groups. Synovitis and scar tissue were more common in group A (p = 0.01) compared to group B. Overall, no postoperative ankle instability or relapsing ankle sprain was documented. Both groups demonstrated significant improvement in their Tegner (p = 0.009) and AOFAS scores (p = 0.001) during their 24 months follow-up. Inter-rater reliability for CFL tears was moderate on clinical examination (k = 0.514) and fair on MRI, in conjunction with ankle arthroscopy (k = 0.357).

Conclusion

Our proposed algorithm offered a reliable pathway for accurate evaluation and successful treatment of chronic lateral ankle instability in high-demand groups.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

Insurance Does Not Affect Adverse Events While Awaiting Surgery for Ankle Trauma in One System

Introduction

Ankle injuries that are not properly cared for can have devastating effects on a patient’s health and ability to maintain an active lifestyle. Recommended outpatient surgery may be difficult to obtain for many groups of patients, including those without insurance or minority races. Patients who are of low socioeconomic status also have worse outcomes following trauma. The purpose of this study was to examine whether insurance status impacts the number of adverse events that patients face prior to receiving surgical treatment following an emergency department (ED) visit for an acute ankle injury.

Methods

We conducted a retrospective chart review at two medical centers within the same healthcare system. The sample included 192 patients presenting to the ED with an unstable ankle injury between October 1, 2015– May 1, 2018. We used chi-square and t-test analysis to determine differences in rates of adverse events occurring while awaiting surgery.

Results

Few (4%) patients presented as being self-pay. Neither Medicare (χ2 (1) (N = 192) = 2.389, p = .122), Medicaid (χ2 (1), (N = 192) = .084, p = .772), other insurances (χ2 (1) (N = 192) = .567, p = .452), or private insurance (χ2 (1) (N=192) = .000, p = .982) was associated with a difference in rates of adverse events. Likewise, gender (χ2 (1) (N = 192) = .402, p = .526), race (χ2 (3) (N = 192) = 2.504, p = .475), and all other demographic variables failed to show a difference in occurrence of adverse events. Those admitted to the hospital did show a lower rate of adverse events compared to those sent home from the ED (χ2 (1) (N = 192) = 5.452, p = .020). Sampled patients were admitted to the hospital at a high rate (49%).

Conclusion

The sampled facilities did not have adverse event rates that differed based on insurance status or demographic features. These facilities, with hospital-based subsidy programs and higher than expected admission rates, may manage their vulnerable populations well and may indicate their efforts to eliminate health disparity are effective.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery

CONTEXT

Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA.

OBJECTIVE

To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players.

DESIGN

Case-control study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

Data from the Retired NFL Players General Health Survey.

MAIN OUTCOME MEASURE(S)

We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities.

RESULTS

Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries.

CONCLUSIONS

Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery

CONTEXT

Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA.

OBJECTIVE

To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players.

DESIGN

Case-control study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

Data from the Retired NFL Players General Health Survey.

MAIN OUTCOME MEASURE(S)

We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities.

RESULTS

Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries.

CONCLUSIONS

Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.

Surgical Management of Lateral Ankle Instability in Athletes

Ankle sprains are common injuries involving the lateral ankle ligaments and affect athletes of all levels. Most patients heal uneventfully, but those with symptoms persisting past 3 months should be evaluated for chronic ankle instability and its associated conditions as well as for the presence of varus malalignment. Chronic ankle instability is initially treated nonoperatively, with surgical management reserved for those who have failed to improve after 3 to 6 months of bracing and functional rehabilitation. Anatomic repair using a modification of the Broström procedure is the preferred technique for initial surgery. Anatomic reconstruction with tendon graft should be considered when repair is not possible, as it maintains physiological joint kinematics. Nonanatomic reconstructions are seldom indicated. Arthroscopic repair or reconstruction of the lateral ankle ligaments is a promising new technique with results similar to those of open surgery.

Surgical treatment of avulsion fracture around joints of extremities using hook plate fixation

Purpose

This study proposed to access the clinical outcome of avulsion fractures around joints of extremities using the hook plate.

Methods

A total of 60 patients with avulsion fractures of joints admitted in our hospital between January 2011 and June 2016 were performed the surgery of hook plate fixation. Functional recovery was evaluated using the Lysholm knee score, Kaikkonen ankle injury score, Mayo elbow and wrist function score, and Neer shoulder function score.

Results

All the patients were healed within 3 months after surgery with stage I healing incision without vascular or nerve injuries. The average follow-up period was 18.1 months. At the last follow-up, no instability of joints, looseness of internal fixation or traumatic arthritis was observed. Mild joint fibrosis occurred in 5 cases. A total of 57 patients were well recovered with the excellent and good rate of 95%. Three patients with humeral avulsion fracture of the greater tuberosity had shoulder joint adhesion and peri humeral inflammation at the last follow-up due to the poor cooperation for early rehabilitation exercise. In the last follow-ups, the functional score of the affected limb was markedly greater than that in the 3-month follow-ups (p < 0.05).

Conclusion

Hook plate fixation has the therapeutic effect on treating avulsion fractures around joints of extremities with the advantages of reliable fixation, early rehabilitation after operation, high recovery rates of joint function, wide indications, and convenient uses.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

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

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

Lateral ligament repair and reconstruction restore neither contact mechanics of the ankle joint nor motion patterns of the hindfoot

BACKGROUND

Ankle sprains may damage both the lateral ligaments of the hindfoot and the osteochondral tissue of the ankle joint. When nonoperative treatment fails, operative approaches are indicated to restore both native motion patterns at the hindfoot and ankle joint contact mechanics. The goal of the present study was to determine the effect of lateral ligament injury, repair, and reconstruction on ankle joint contact mechanics and hindfoot motion patterns.

METHODS

Eight cadaveric specimens were tested with use of robotic technology to apply combined compressive (200-N) and inversion (4.5-Nm) loads to the hindfoot at 0° and 20° of plantar flexion. Contact mechanics at the ankle joint were simultaneously measured. A repeated-measures experiment was designed with use of the intact condition as control, with the other conditions including sectioned anterior talofibular and calcaneofibular ligaments, the Broström and Broström-Gould repairs, and graft reconstruction.

RESULTS

Ligament sectioning decreased contact area and caused a medial and anterior shift in the center of pressure with inversion loads relative to those with the intact condition. There were no significant differences in inversion or coupled axial rotation with inversion between the Broström repair and the intact condition; however, medial translation of the center of pressure remained elevated after the Broström repair relative to the intact condition. The Gould modification of the Broström procedure provided additional support to the hindfoot relative to the Broström repair, reducing inversion and axial rotation with inversion beyond that of intact ligaments. There were no significant differences in center-of-pressure excursion patterns between the Broström-Gould repair and the intact ligament condition, but this repair increased contact area beyond that with the ligaments intact. Graft reconstruction more closely restored inversion motion than did the Broström-Gould repair at 20° of plantar flexion but limited coupled axial rotation. Graft reconstruction also increased contact areas beyond the lateral ligament-deficient conditions but altered center-of-pressure excursion patterns relative to the intact condition.

CONCLUSIONS

No lateral ankle ligament reconstruction completely restored native contact mechanics of the ankle joint and hindfoot motion patterns.

Injuries, risk factors and prevention initiatives in youth sport

BACKGROUND

Sports injuries in young athletes are a public health issue which deserves special attention. Effective prevention can be achieved with training programmes originating from the field of physical therapy and medicine.

SOURCES OF DATA

A systematic literature search on injury prevention in youth sport was performed in the MEDLINE database.

AREAS OF AGREEMENT

For prevention programmes to reduce sports injuries, critical factors must be considered, such as training content, duration and frequency, as well as athlete compliance.

AREAS OF CONTROVERSY

Home-based programmes could be inferior to supervised training, but are efficient if compliance is high. So far prevention programmes have focused on team sports and their efficiency in individual sports remains to be proven.

GROWING POINTS

Active prevention programmes focusing specifically on the upper extremity are scarce. Initiatives enhancing the awareness of trainers, athletes and therapists about risk factors and systematic prevention measures should be encouraged.

Management of acute and chronic ankle instability

Acute lateral ankle ligament injuries are common. If left untreated, they can result in chronic instability. Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. Chronic lateral ankle instability is multifactorial. Failed nonsurgical management after appropriate rehabilitation is an indication for surgery. Of the many surgical options available, anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated. Ankle arthroscopy is an important adjunct to ligamentous repair and should be performed at the time of repair to identify and address intra-articular conditions associated with chronic ankle instability. Tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.

The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: a systematic review

Background

The assessment of outcomes from the patient's perspective becomes more recognized in health care. Also in patients with chronic ankle instability, the degree of present impairments, disabilities and participation problems should be documented from the perspective of the patient. The decision about which patient-assessed instrument is most appropriate for clinical practice should be based upon systematic reviews. Only rating scales constructed for patients with acute ligament injuries were systematically reviewed in the past. The aim of this study was to review systematically the clinimetric qualities of patient-assessed instruments designed for patients with chronic ankle instability.

Methods

A computerized literature search of Medline, Embase, Cinahl, Web of Science, Sport Discus and the Cochrane Controlled Trial Register was performed to identify eligible instruments. Two reviewers independently evaluated the clinimetric qualities of the selected instruments using a criteria list. The inter-observer reliability of both the selection procedure and the clinimetric evaluation was calculated using modified kappa coefficients.

Results

The inter-observer reliability of the selection procedure was excellent (k = .86). Four instruments met the eligibility criteria: the Ankle Joint Functional Assessment Tool (AJFAT), the Functional Ankle Outcome Score (FAOS), the Foot and Ankle Disability Index (FADI) and the Functional Ankle Ability Measure (FAAM). The inter-observer reliability of the quality assessment was substantial to excellent (k between .64 and .88). Test-retest reliability was demonstrated for the FAOS, the FADI and the FAAM but not for the AJFAT. The FAOS and the FAAM met the criteria for content validity and construct validity. For none of the studied instruments, the internal consistency was sufficiently demonstrated. The presence of floor- and ceiling effects was assessed for the FAOS but ceiling effects were present for all subscales. Responsiveness was demonstrated for the AJFAT, FADI and the FAAM. Only for the FAAM, a minimal clinical important difference (MCID) was presented.

Conclusion

The FADI and the FAAM can be considered as the most appropriate, patient-assessed tools to quantify functional disabilities in patients with chronic ankle instability. The clinimetric qualities of the FAAM need to be further demonstrated in a specific population of patients with chronic ankle instability.

The adjunctive role of imagery on the functional rehabilitation of a grade II ankle sprain

The purpose of the present study was to examine the effectiveness of imagery on muscular endurance, dynamic balance, and functional stability in athletes who sustained a grade II ankle sprain. The sample consisted of 20 active athletes (aged from 18 to 30 years) with a grade II ankle sprain, as confirmed by ultrasound testing. The participants were randomly divided into two groups of 10 participants each; one experimental and one control group. The experimental group received 12 individual sessions of imagery rehearsal in addition to a normal course of physical therapy, while the control group followed only the physical therapy treatment. Results revealed significant differences only in the variable of muscular endurance. This study partly supports the contribution of imagery to the functional rehabilitation of grade II ankle sprain. Further research should be conducted to examine the effect of imagery on the functional rehabilitation of sport injuries using other tests of functional rehabilitation along with larger sample sizes.

Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft

Many techniques have been described for surgical management of lateral ankle instability. Anatomic repair and nonanatomic reconstruction have higher recurrence rates, and may be complicated by ankle stiffness. Anatomic reconstruction should be considered in stabilization for deficiencies of the lateral ankle ligament complex, as the initial construct is stronger while maintaining normal ankle mechanics.

Mechanical contributions to chronic lateral ankle instability

Lateral ankle sprains are one of the most common athletic injuries. Even more concerning is the high recurrence rate after an initial sprain. The development of repetitive ankle sprains and persistent symptoms after injury has been termed chronic ankle instability (CAI). One of the purported causes of CAI is mechanical ankle instability (MAI).MAI results in abnormal ankle mechanics. Both hypermobility and hypomobility may change a joint's axis of rotation and result in abnormal joint mechanics. The role of hypermobility, or laxity, has been examined extensively in the literature, but more recently the role of hypomobility has also been examined. There may be a relationship between the two, with implications at the talocrural, subtalar, and inferior tibiofibular joints.Assessment and treatment should focus on both hypermobility and hypomobility and although injury may seem to be isolated to the talocrural joint, the inferior tibiofibular and subtalar joints should also be thoroughly examined.

Comparison of Modified Broström and Evans Procedures in Simulated Lateral Ankle Injury

PURPOSE

The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities.

METHODS

Six normal cadaveric ankles were loaded with inversion and internal rotation stress through the range of ankle flexion, and three-dimensional motion of the calcaneus and talus relative to the tibia were measured. An ankle stability testing device and a magnetic tracking system were used. Testing was performed in the intact condition, unstable condition after sectioning both the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), after the Gould modification of the Broström procedure, and after the Evans procedure.

RESULTS

With inversion loading, both operations resulted in a significantly more stable ankle-hindfoot complex (calcaneal-tibial) than the unstable condition, but there was restricted motion after the Evans operation from neutral to plantarflexion. Tibiotalar inversion motion approximated normal after both operations, but subtalar motion was markedly restricted in the Evans procedure throughout the range of ankle flexion. With internal rotation loading, the Broström operation stabilized the ankle-hindfoot joint complex in plantarflexion. The Evans operation improved internal rotation stability, but restricted motion in all positions. Both operations improved tibiotalar internal rotation stability, but not to normal. The subtalar internal rotation was the same as the intact condition after the Broström operation, but markedly restricted after the Evans operation through the range of ankle flexion.

CONCLUSIONS

Both operations improved ankle-hindfoot stability, but neither was successful in restoring it to normal as determined with the ankle stability testing device. The Evans procedure improved stability at the expense of creating abnormal subtalar function. The Broström operation improved stability without excessively restricting subtalar movement, but was not effective in addressing the internal rotation laxity.

Midterm results of a modified evans repair for chronic lateral ankle instability

Twenty-eight ankles in 27 patients with chronic instability were treated with a modification of the Evans procedure during a 10-year period. The diagnosis was assessed by clinical evaluation and radiographic stress tests. The reconstruction procedure consists of using the peroneal brevis tendon to repair ankle instability and restore the loss of anatomic integrity of the injured structures. Twenty-five patients (26 ankles) were available at a mean followup of 99.6 months or 8.3 years (range, 28-117 months). Midterm results were evaluated using the ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society, and postoperative radiographic stress tests. According to this scoring system, the current reconstruction procedure resulted in 92.64 points (range, 63-100 points). However, moderate restriction in hindfoot inversion was seen in nine patients (34.61%). Three ankles (11.5%) had a positive anterior drawer sign (> 8 mm). In five ankles (19.2%), there were mild degenerative joint changes. Therefore, the current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale.

Twenty-year results of the Evans operation for lateral instability of the ankle

Twenty-four patients (25 ankles), operated on using the static modification of the Evans tenodesis for lateral instability, were evaluated 19 to 21 years after surgery. Twelve of the patients (12 ankles) had excellent results, seven patients (eight ankles) had good results, three patients (three ankles) had fair results, and two patients (two ankles) had poor results. The subjective results had no clear correlation to the stress radiographs, which showed minor or moderate anterior talar translation in 10 ankles. Moreover, the difference between the surgically treated and the contralateral ankle was not significant. Static modification of the Evans tenodesis is recommended if an anatomic reconstruction of the lateral ligaments is not feasible (general laxity of joints, reoperation).