Reconstruction of the lateral ankle ligaments with bone-patellar tendon graft in patients with chronic ankle instability: a preliminary report

Rotational ankle instability: A current concept review

Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.

Ligament Augmentation Reconstruction System (LARS) for Ankle Lateral Ligament Reconstruction in Higher-Risk Patients: A 5-Year Prospective Cohort Study

Background:

The modified Broström-Gould (MBG) procedure is the gold standard for patients with chronic ankle instability (CAI), but it is relatively contraindicated for patients with higher body weight or generalized ligamentous laxity (GLL). The use of the ligament augmentation reconstruction system (LARS) is an alternative.

Hypothesis:

It was hypothesized that clinical outcomes would be similar in patients with increased body weight (>90 kg) or GLL, relative to controls.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 66 patients satisfying the inclusion criteria were invited to participate and were divided into 3 groups: controls (no risk factors for inferior clinical outcome), patients with body weight >90 kg, and patients with GLL (Beighton score, ≥5 of 9). All patients underwent imbrication of the lateral collateral ligament complex augmented with the LARS. Primary outcomes of interest were Tegner activity scale (TAS) and Foot and Ankle Outcome Score (FAOS) subscale scores. Secondary outcomes were recurrence of ankle instability, the need for further surgery, and/or complications. Patients were reviewed at 2 and 5 years postoperatively, and outcomes between groups were compared using repeated-measures analysis of variance.

Results:

Complete data were available for 63 patients (21 patients in each group). TAS improved in all groups from preoperatively to 2 years and 5 years postoperatively (P < .001 for all). Relative to the controls, the TAS scores were lower in the >90-kg group at 2 years and 5 years (P < .001 for both periods), while the GLL group had similar scores to controls at both postoperative periods. Both the >90-kg and the GLL groups showed no significant difference in improvement on any FAOS subscale scores relative to the controls, at both 2 and 5 years postoperatively. There were no recurrences, repeat surgeries, or major complications.

Conclusion:

Relative to controls, patients with body weight >90 kg or GLL had similar FAOSs, and TAS scores were lower in the >90-kg group, at 2 and 5 years, after the use of the LARS to augment lateral collateral ligament imbrication for CAI. Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated.

Effects of the Ankle Flexion Angle During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

This study aimed to evaluate the effects of the ankle flexion angle during anterior talofibular ligament (ATFL) reconstruction on ankle kinematics, laxity, and in situ force of a graft.

METHODS

Twelve cadaveric ankles were evaluated using a 6-degrees of freedom robotic system to apply passive plantar flexion and dorsiflexion motions and multidirectional loads. A repeated measures experiment was designed using the intact ATFL, transected ATFL, and reconstructed ATFL. During ATFL reconstruction (ATFLR), the graft was fixed at a neutral position (ATFLR 0 degrees), 15 degrees of plantar flexion (ATFLR PF15 degrees), and 30 degrees of plantar flexion (ATFLR PF30 degrees) with a constant initial tension of 10 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ force of the ATFL and reconstructed grafts were calculated using the principle of superposition.

RESULTS

The in situ forces of the reconstructed grafts in ATFLR 0 degrees and ATFLR PF 15 degrees were significantly higher than those of intact ankles. The ankle kinematics and laxity produced by ATFLR PF 30 degrees were not significantly different from those of intact ankles. The in situ force on the ATFL was 19.0 N at 30 degrees of plantar flexion. In situ forces of 41.0, 33.7, and 21.9 N were observed at 30 degrees of plantar flexion in ATFLR 0, 15, and 30 degrees, respectively.

CONCLUSION

ATFL reconstruction with the peroneus longus (PL) tendon was performed with the graft at 30 degrees of plantar flexion resulted in ankle kinematics, laxity, and in situ forces similar to those of intact ankles. ATFL reconstructions performed with the graft fixed at 0 and 15 degrees of the plantar flexion resulted in higher in situ forces on the reconstructed graft.

CLINICAL RELEVANCE

Fixing the ATFL tendon graft at 30 degrees of plantar flexion results in an in situ force closest to that of an intact ankle and avoids the excessive tension on the reconstructed graft.

Clinical outcomes of anterior tibiofibular ligament's distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients

PURPOSE

Treatment of chronic ankle instability (CAI) for ankle sprain patients remains a challenge. If initial treatments fail, surgical stabilization techniques including ligament reconstruction should be performed. Anterior tibiofibular ligament (ATiFL) distal fascicle transfer for CAI was recently introduced. The goal of the study is to assess the 1-year clinical effectiveness of ATiFL's distal fascicle transfer versus ligament reconstruction with InternalBrace™ (Fa. Arthrex, Naples).

METHODS

Between October 2019 and February 2021, 25 patients (14 males and 11 females) scheduled for ligament reconstruction treatment of CAI were enrolled after propensity score matching. Twelve underwent ligament reconstruction with InternalBrace™ (InternalBrace™ group) and thirteen underwent ATiFL's distal fascicle transfer (ATiFL's distal fascicle transfer group). We recorded the American Orthopedic Foot & Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), anterior drawer test grade, patient satisfaction and complications. All results of this study were retrospectively analyzed.

RESULTS

Statistically significant (p = 0.0251, independent-samples t test) differences in the AOFAS can be found between the ATiFL's distal fascicle transfer group and the InternalBrace™ group. No substantial changes in the VAS (p = 0.1778, independent-samples t test), patient satisfaction (p = 0.1800, independent-samples t test) and anterior drawer test grade (p = 0.9600, independent-samples t test) were found between the two groups. There was one patient with superficial wound infection and one patient with sural nerve injury in the InternalBrace™ group and ATiFL's distal fascicle transfer group, respectively.

CONCLUSION

This is the first study that assessed a cohort of CAI patients and suggests that the ATiFL's distal fascicle transfer operation has the potential to attain good-to-excellent clinical outcomes after 1-year recovery. The AOFAS scores were significantly higher for patients with ATiFL's distal fascicle transfer, indicating that this technique may be considered a viable option for both patients and their surgeon, while long-term outcomes should be investigated in the future.

Lack of Definition of Chronic Ankle Instability With Arthrometer-Assisted Ankle Joint Stress Testing: A Systematic Review of In Vivo Studies

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability.

Modified Broström-Gould With Gracilis Autograft Augmentation Surgery and Accelerated Noncasted Rehabilitation in High Demand Patients With Lateral Ankle Instability

Lateral ankle instability that has failed conservative management can be physically debilitating. Good outcomes are obtained from Broström-Gould augmented repair techniques, however there are few studies evaluating the use of a gracilis autograft augmentation coupled with an accelerated rehabilitation program in high functional demand patients. We believe that the modified Broström-Gould technique utilizing a Gracilis autograft will provide significant improvements in stability while maintaining normal ankle biomechanics in young, high demand patients. The prospective cohort study involved 19 patients (20 ankles) who underwent surgery for chronic lateral ankle instability by a single surgeon, at a single institution between October 2014 and April 2016. Patients were followed for 33.8 ± 11.7 (range 12-48) months. Patients were assessed both pre- and postoperatively for talar tilt angle radiographically and with both American Orthopaedic Foot and Ankle Society Ankle and Hindfoot scores and Karlsson-Peterson scores. A Tegner activity score was taken at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score increased from 68.85 ± 10.57 to 91.56 ± 5.31 points (p < .01) and mean Karlsson-Peterson score increased from 50.9 ± 15.53 to 88.11 ± 8.64 points (p value <.01) when compared preoperatively to mean postoperative follow-up of 33.8 months. Tegner activity score was 7.05 ± 0.89 at last follow-up. The technique was found to be effective in treating chronic lateral ankle instability and in combination with an accelerated rehabilitation protocol, patients returned to their premorbid level of activity with improved stability and no significant effect on donor graft site morbidity.

Early functional treatment or trivialization? - current treatment strategies in lateral ligament injuries of the ankle

Introduction: Ankle injuries are common in daily orthopaedic trauma practice, with a high incidence of lateral ligament complex (lat-lig-com) injuries of the ankle joint (AJ). Primarily, these lat-lig-com injuries heal sufficiently, although there is a risk of developing chronic ankle instability. However, there is a lack of knowledge about the clinical application and routine for rehabilitation strategies so as to prevent chronic instability. This study investigates the current rehabilitation concepts in clinical routine after ligament injuries of the AJ. Methods: Rehabilitation protocols, provided by orthopaedic and trauma surgery institutions in German speaking countries, were analysed in terms of weight-bearing, range of motion (ROM), physiotherapy and choice of orthosis. All protocols for operatively and non-operatively (nop) treated ligament ruptures of the AJ were included. Results: 120 of 213 institutions provided protocols of lat-lig-com injuries of the AJ. Regarding the orthosis, the nop-treatment group mainly used ankle braces; in contrast, the operative group preferred the use of an ankle boot. The operative group recommends 6-12 weeks for duration of orthosis in contrast to only 6 weeks in the nop group. Significant differences prevail in ROM, with free ROM in non-operative treatment from the first day after trauma (p<0.001) in contrast to a careful increase in ROM in the first 6 weeks post-operatively. Conclusion: Early functional treatment is clinical standard in rehabilitation after lat-lig-com injuries of the ankle. Regarding current literature the differences of restrictions in ROM and orthosis treatment after lat-lig-com injuries suggest a trivialization of conservative treatment in the first period after trauma compared to post-operative aftercare.

Assessment of plantaris and peroneus tertius tendons as graft materials for ankle ligament reconstructions - A cadaveric biomechanical study

Both the plantaris tendon and the peroneus tertius tendon are used as auto- and allogenous graft materials to reconstruct the ankle ligament complex. However, it is unclear to what extent these graft materials resemble the load-deformation behavior of the ankle ligaments. A total of 34 human ankle ligaments and 35 tendons were assessed mechanically deploying a quasi-static tensile testing setup. Tendons were significantly stiffer (median elastic moduli: plantaris tendon = 465.7 MPa, peroneus tertius tendon = 338.5 MPa, medial ligament = 61.4 MPa, lateral ligament = 49.3 MPa; p ≤ 0.035), but more distensible (median strain at maximum force: plantaris tendon = 15.1%, peroneus tertius tendon = 15.3%, medial ligament = 9.3%, lateral ligament = 9.6%; p ≤ 0.008) and mechanically tougher (median ultimate tensile strength: plantaris tendon = 51.0 MPa, peroneus tertius tendon = 40.5 MPa, medial ligament = 4.1 MPa, lateral ligament = 3.5 MPa; p ≤ 0.033) when compared to medial and lateral ankle ligaments. The lateral ligaments of the right ankle were significantly tougher compared to the left side (p = 0.015). The elastic modulus of the medial ligament (r = 0.489, p = 0.045) and the peroneus tertius tendon (r = 0.517, p = 0.014) yielded an age-dependent increase. Both tendons seem biomechanically suitable graft materials to replace the medial and lateral ankle ligaments during physiological loading. The age-dependent increase in tissue elastic properties of the medial vs. lateral ankle ligaments, and differences in ultimate tensile strength between the lateral ligaments left vs. right, may reflect the complex asymmetric loading behavior of both ankle ligaments.

Arthroscopic anterior talofibular ligament reconstructin in chronic ankle instability: Two years results

PURPOSE

In chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability.

METHODS

Eleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure.

RESULTS

At 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel.

CONCLUSIONS

Arthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity.

STUDY DESIGN

Case series.

The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis

Chronic ankle instability predominantly occurs due to multiple exercise-related diseases. Conservative treatment methods regarding this condition have not effectively improved in recent years, which is why more focus has been put on exploring different novel reconstruction procedures of the lateral ankle ligament for the treatment of chronic ankle instability.

OBJECTIVES

This study aims to obtain the overall effectiveness of various lateral ankle ligament reconstruction methods for chronic ankle ligament instability.

METHODS

We gathered data from PubMed and EMBASE databases using the keywords: ankle, malleolar, and reconstruction. Newcastle - Ottawa quality assessment was carried out for the obtained studies; effect volume combination and image drawing were performed by Stata14, and Excel was used for data statistics.

RESULTS

A total of 12 articles were included in the quantitative analysis by performing full-text reading and data inclusion. Among them, 476 patients (485 ankle joints) were treated. The results showed that the overall valid efficiency of "excellent" was 59% and "good" lateral ligament reconstruction was 26%, I²=87.3%, P = 0.000; the subgroup analysis anatomic reconstruction group I²=0.0%, P = 0.993; the autograft group I²=0.0%, P = 1.000; allograft group I²=0.0%, P = 0.993.

CONCLUSION

Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.

PURPOSE/HYPOTHESIS

This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.

RESULTS

Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.

CONCLUSION

Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.

CLINICAL RELEVANCE

This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Lateral ankle ligament anatomic reconstruction for chronic ankle instability: Allograft or autograft? A systematic review

BACKGROUND

To investigate if there is any evidence in favour of autograft or allograft use for anatomic reconstruction of lateral ankle ligaments in patients with symptomatic chronic ankle instability.

METHODS

A literature search was performed in PubMed MEDLINE, Cochrane Library, EMBASE and Google Scholar databases, over the years 1994-2017, to identify the studies presenting clinical results of anatomic lateral ankle ligaments reconstruction using various combinations of the keywords "lateral ankle ligaments reconstruction", "anatomic reconstruction", "chronic ankle instability", "allograft", "autograft". The surgical procedure was considered anatomic if consistent with the description of lateral ankle ligaments made by Burks and Morgan in 1994.

RESULTS

Among the 89 papers matching the search terms, only 12 could be included in which 357 anatomic lateral ankle ligaments reconstructions were performed. One was a comparative case series (level of evidence III - LOE III) while other papers were retrospective case series (LOE IV), the mean Modified Coleman Methodology Score (MCMS) was fair: 56.7 (SD±5.2). Due to the low level of evidence of the available literature only a qualitative analysis was performed. The limited evidence from the studies analysed suggests that there is no difference in graft survivorship, graft-dependent variables, patient's satisfaction, clinical outcome measures and radiographic results between allograft and autograft.

CONCLUSIONS

Given the low number of studies, their poor methodology score and their low level of evidence it is not possible to determine if allograft is better or safer than autograft.

LEVEL OF EVIDENCE

Level IV, review paper of level III and level IV studies.

Anatomic reconstruction of anterior talofibular ligament with tibial tuberosity-patellar tendon autograft for chronic lateral ankle instability

INTRODUCTION

Anatomic repair of the anterior talofibular ligament (ATFL) is challenging when the local ligamentous tissue is severely attenuated. Anatomic reconstruction of the ATFL with tibial tuberosity-patellar tendon (TT-PT) autograft is a feasible choice that can avoid the complicated tendon-bone healing and restore ankle stability.

MATERIALS AND METHODS

From 2009 to 2015, 31 chronic lateral ankle instability (CLAI) patients (31 ankles), who had a serious injury on the ATFL only, were treated with anatomic reconstruction of ATFL with TT-PT. American orthopedic foot and ankle society ankle-hindfoot score (AHS), visual analog scale for pain score (VAS), Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion were used to evaluate the clinical outcomes before and after operation. Radiographically, talar tilt angles and anterior drawer were assessed in pre- and postoperative ankle stress views.

RESULTS

Among the 31 ankles, 17 ankles with single-bundle ATFL and 14 ankles with double-bundle ATFL were found at operation. At a mean follow-up of 42 months (24-82 months), all patients were satisfied with the procedure. Mean AHS significantly increased from 60.5 ± 8.2 to 93.5 ± 4.8. Mean Karlsson-Peterson score significantly increased from 55.2 ± 11.0 preoperatively to 91.2 ± 6.9 at final follow-up. Average VAS significantly decreased from 5.9 ± 1.6 preoperatively to 1.4 ± 1.0 at the latest follow-up. Mean Tegner activity level was 3.7 ± 0.9 before operation, compared with 7.0 ± 0.8 after operation. On stress radiographs, mean talar tilt angle was 17.0 ± 3.4° before operation and 3.8 ± 2.1° at the latest follow-up. In addition, mean anterior tibiotalar translation was 7.5 ± 2.2 mm before operation and 1.8 ± 1.1 mm at the latest follow-up.

CONCLUSION

Anatomic reconstruction of the ATFL using a TT-PT autograft allows bone-bone healing in talus and tendon-tendon/periosteum healing in fibula rather than requiring tendon-bone healing, which is an alternative choice for treating CLAI caused by single ATFL insufficiency.

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.

Currently used imaging options cannot accurately predict subtalar joint instability

PURPOSE

To give a systematic overview of current diagnostic imaging options and surgical treatment for chronic subtalar joint instability.

METHODS

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, and SpringerLink. Twenty-three imaging studies and 19 outcome studies were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the methodologic quality of the imaging articles, while the modified Coleman Score was used to assess the methodologic quality of the outcome studies.

RESULTS

Conventional radiographs were most frequently used to assess chronic subtalar joint instability. Talar tilt, anterior talar translation, and subtalar tilt were the three most commonly used measurement methods. Surgery often included calcaneofibular ligament reconstruction.

CONCLUSION

Current imaging options do not reliably predict subtalar joint instability. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. Recognition of subtalar joint instability as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

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.

Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft

BACKGROUND

This study aimed to report our institution's experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament.

METHODS

This retrospective study included 32 consecutive patients with chronic lateral ankle instability who underwent surgery from January 2013 to December 2014. All patients had failed to resolve with conservative treatment. A total of 32 ankles underwent AHPLT transfer. Patients returned for a clinical and radiologic follow-up evaluation at an average of 28 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, and Karlsson scores, and the radiographic assessment including talar tilt and anterior talar translation.

RESULTS

Thirty-two patients (32 ankles) (100%) returned for final evaluation. All patients had an excellent or good outcome on patient subjective self-assessment, pain scores, AOFAS scores, and Karlsson scores at final follow-up. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was significantly reduced from a preoperative mean of 14.1±4.2° to 3.4±1.3° postoperatively (P<.001), and the anterior drawer was significantly reduced from a preoperative mean of 13.8±3.4mm to 3.6±1.5mm after lateral ankle ligamentous reconstruction (P<.001).

CONCLUSIONS

AHPLT transfer to reconstruct the lateral ligament resulted in a high percentage of successful results, with excellent ankle stability and not affected of ankle motion.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: A 5-Year Randomized Controlled Trial

BACKGROUND

"Ankle sprain" is a common injury, and >20% of patients may develop chronic instability for which surgery is indicated. The modified Broström-Gould (MBG) procedure remains the gold standard; however, there are a number of relative contraindications to this procedure, and the longer-term outcomes after the MBG have been questioned. An alternative procedure is augmentation of a primary repair with a ligament augmentation reconstruction system (LARS).

PURPOSE

To conduct a randomized controlled trial testing the null-hypothesis that there is no difference in patient scored outcomes and activity levels, between patients undergoing a MBG procedure compared with those undergoing a primary repair with LARS augmentation, for lateral ligament instability of the ankle.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients who satisfied the inclusion criteria were invited to take part in the study. Patients were randomly allocated to undergo the LARS or MBG procedure. Both groups followed similar postoperative rehabilitation. Patients completed the Foot and Ankle Outcome Score (FAOS) before surgery and then at 1, 2, and 5 years after surgery. Tegner activity scores were recorded at 5years. The scores in the 2 groups were compared via statistical analysis ( P < .05).

RESULTS

Of the 50 patients satisfying the inclusion criteria, 47 agreed to take part in the study. Twenty-two were randomized to the LARS group and 25 to the MBG group. At 5 years, follow-up data were complete for 20 patients in the LARS group and 21 in the MBG. There were 2 failures in the MBG group and 0 in the LARS group. The LARS group had significantly better improvement in total FAOS at 1 year (mean ± SD, 92.4 ± 2.5 vs 78.2 ± 3.4, P = .005), 2 years (94.0 ± 3.0 vs 78.0 ± 5.2, P = .003), and 5 years (93.7 ± 6.0 vs 75.1 ± 5.5, P = .002) after surgery. The 5-year Tegner activity scores were higher in the LARS group (8.25 ± 1.1 vs 7.2 ± 0.9, P = .03).

CONCLUSION

Among physically active patients with chronic lateral ligament instability, primary repair combined with LARS results in better total FAOS at 5-year follow-up and higher Tegner activity scores as compared with the MBG procedure.

REGISTRATION

ACTRN12618000906257 (Australia New Zealand Clinical Trial Registry).

Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases

INTRODUCTION

Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results.

HYPOTHESIS

We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately.

MATERIALS AND METHODS

Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs.

RESULTS

The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability.

DISCUSSION

Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination.

LEVEL OF EVIDENCE

IV, Case-series.

Effect of Initial Graft Tension During Calcaneofibular Ligament Reconstruction on Ankle Kinematics and Laxity

BACKGROUND

Although a variety of surgical procedures for lateral ankle ligament reconstruction have frequently been reported, little is known about the effects of initial graft tension. Purpose/Hypothesis: The purpose was to investigate the effects of initial graft tension in calcaneofibular ligament (CFL) reconstruction. It was hypothesized that a high degree of initial graft tension would cause abnormal kinematics, laxity, and excessive graft tension.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a 6 degrees of freedom robotic system to apply passive plantarflexion-dorsiflexion motion and multidirectional loads. A repeated-measures experiment was designed with the CFL intact, CFL transected, and CFL reconstructed with 4 initial tension conditions (10, 30, 50, and 70 N). The 3-dimensional path and reconstructed graft tension were simultaneously recorded.

RESULTS

The calcaneus in CFL reconstruction with an initial tension of 70 N had the most eversion relative to the intact condition (mean eversion translations of 1.2, 3.0, 5.0, and 6.2 mm were observed at initial tensions of 10, 30, 50, and 70 N, respectively). The calcaneus also moved more posteriorly with external rotation as the initial tension increased. The reconstructed graft tension tended to increase as the initial tension increased.

CONCLUSION

Ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. Moreover, excessive initial graft tension caused excessive tension on the reconstructed graft.

CLINICAL RELEVANCE

This study indicated the importance of initial graft tension during CFL reconstruction. Overtensioning during CFL reconstruction should be avoided to imitate a normal ankle.

Comparative Evaluation Between Anatomic and Nonanatomic Lateral Ligament Reconstruction Techniques in the Ankle Joint: A Computational Study

Biomechanical studies have indicated that the conventional nonanatomic reconstruction techniques for lateral ankle sprain (LAS) tend to restrict subtalar joint motion compared to intact ankle joints. Excessive restriction in subtalar motion may lead to chronic pain, functional difficulties, and development of osteoarthritis (OA). Therefore, various anatomic surgical techniques to reconstruct both the anterior talofibular and calcaneofibular ligaments (CaFL) have been introduced. In this study, ankle joint stability was evaluated using multibody computational ankle joint model to assess two new anatomic reconstruction and three popular nonanatomic reconstruction techniques. An LAS injury, three popular nonanatomic reconstruction models (Watson-Jones, Evans, and Chrisman–Snook) and two common types of anatomic reconstruction models were developed based on the intact ankle model. The stability of ankle in both talocrural and subtalar joint were evaluated under anterior drawer test (150 N anterior force), inversion test (3 N·m inversion moment), internal rotational test (3 N·m internal rotation moment), and the combined loading test (9 N·m inversion and internal moment as well as 1800 N compressive force). Our overall results show that the two anatomic reconstruction techniques were superior to the nonanatomic reconstruction techniques in stabilizing both talocrural and subtalar joints. Restricted subtalar joint motion, which is mainly observed in Watson-Jones and Chrisman–Snook techniques, was not shown in the anatomical reconstructions. Evans technique was beneficial for subtalar joint as it does not restrict subtalar motion, though Evans technique was insufficient for restoring talocrural joint inversion. The anatomical reconstruction techniques best recovered ankle stability.

The effect of smoking on the outcomes of lateral ankle ligament reconstruction

BACKGROUND

Although smoking is known to be harmful to the musculoskeletal system, no studies have investigated its effects on the outcomes of ankle ligament surgery. We determined the effects of smoking on the clinical and radiological outcomes of lateral ankle ligament reconstruction using tendon allografts according to smoking status.

METHODS

From among 105 patients with chronic ankle instability who were treated with anatomical reconstruction of the anterior talofibular ligament and the calcaneofibular ligament using semitendinosus tendon allografts and bio-tenodesis screws, 70 ankles, from 23 smokers and 47 non-smokers, were analyzed. Visual analog scale (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, Karlsson scores and complications were routinely determined at each follow-up visit. Anterior translation and the talar tilt angle on radiographic stress views were also assessed.

RESULTS

The mean follow-up period was 21.8 months (12-68 months). No significant differences were observed between the two groups with respect to age, gender, body mass index, or the duration of preoperative symptoms. The mean preoperative pain VAS scores were 5.8 and 5.3 among non-smokers and smokers, respectively. Postoperatively, the mean pain VAS score improved to 1.4 in both groups (p < 0.001). Clinical and radiographic measures did not show significant changes according to the presence of smoking after surgery. However, two wound complications, 1 delayed healing and 1 superficial necrosis, occurred in non-smokers, whereas five, 2 delayed healing, 2 superficial infections and 1 superficial necrosis in smokers (p = 0.035).

CONCLUSION

The radiographic outcomes of smokers were comparable to those of non-smokers in the short term, whereas wound complications were more common in the smoker group.

Ankle ligament reconstruction after wide resection of the osteosarcoma of the distal fibula: a case report

BACKGROUND

Restoration of the lateral ankle after distal fibulectomy is a difficult reconstructive procedure. Many surgical techniques have been proposed. This report shows another fibular reconstructive option with promising outcome.

CASE PRESENTATION

We report the case of a 30-year-old woman who presented with a solitary mass located in the lateral aspect of the ankle. The mass had grown rapidly for 2 months and caused increasing pain. Physical examination showed a 3.0 cm diameter tender, nonmobile hard mass in the lateral malleolus. Radiographs showed an osteolytic lesion involving the lateral cortex at the distal fibula. After incisional biopsy, pathologic examination found a well-differentiated intramedullary osteosarcoma. Neoadjuvant chemotherapy with doxorubicin was provided for 3 months prior to definitive surgical treatment. Magnetic resonance imaging showed persistent tumor in the biopsy site. After distal fibulectomy and wide resection, split tibialis posterior tendon transfer to the remaining peroneus brevis restored the stability of the ankle. The pain resolved within 3 months. The ankle was stable and no recurrence of the cancer was found at a 7 year follow-up.

CONCLUSION

Reconstruction following distal fibulectomy and surrounding soft tissue resection responds favorably to split tibialis posterior transfer to the remaining peroneus brevis suggesting that this technique can provide a good and functional outcome.

Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure

AIMS

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

PATIENTS AND METHODS

A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs.

RESULTS

The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon.

CONCLUSION

The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183-9.

Recent Developments in the Treatment of Ankle and Subtalar Instability

It was nearly a centenary ago that severe ankle sprain was recognized as an injury of the ankle ligament(s). With the recent technological advances and tools in imaging and surgical procedures, the management of ankle sprains - including subtalar injuries - has drastically improved. The repair or reconstruction of ankle ligaments is getting more anatomical and less invasive than previously. More specifically, ligamentous reconstruction with tendon graft has been the gold standard in the management of severely damaged ligament, however, it does not reproduce the original ultrastructure of the ankle ligaments. The anatomical ligament structure of a ligament comprises a ligament with enthesis at both ends and the structure should also exhibit proprioceptive function. To date, it remains impossible to reconstruct a functionally intact and anatomical ligament. Cooperation of the regenerative medicine and surgical technology in expected to improve reconstructions of the ankle ligament, however, we need more time to develop a technology in reproducing the ideal ligament complex.

Allograft tendon reconstruction of the anterior talofibular ligament and calcaneofibular Ligament in the treatment of chronic ankle instability

Background

The purpose was retrospectively to investigate functional and clinical outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) reconstruction using a single allograft.

Methods

Patients with severe chronic lateral instability of the ankle underwent surgery after conservative treatment failed. Ultrasounds of the ankle were performed, and if the AFTL and CFL were completely torn without enough soft tissue for repair, the ligaments were reconstructed using allograft tendon. Outcomes were assessed by clinical examination, stress radiography, ultrasound, the American Orthopaedic Foot and Ankle Society score (AOFAS), and Karlsson Ankle Functional score (KAFS) before surgery and at final follow-up.

Results

Nineteen patients, ten men and nine women with mean age of 27.9 years (range, 19–41 years), underwent reconstruction. Mean follow-up was 30 months (range, 24–40 months). At final follow-up, all patients had returned to activity without instability, pain, or limited range of motion. On stress radiography, mean talar tilt angle decreased from 17.32° ± 3.58° before surgery to 4.16° ± 1.12° at follow-up (p < 0.001). Mean anterior drawer test (ADT) distance decreased from 9.79 ± 1.01 mm before surgery to 3.97 ± 0.99 mm at follow-up (p < 0.05). Mean AOFAS improved from 64.00 ± 18.43 to 90.32 ± 5.17 points (p < 0.001), and mean KAFS improved from 50.84 ± 16.73 to 90.89 ± 5.08 points (p < 0.001). Ultrasound showed the reconstructed ligaments maintained good continuity and excellent tension. No case of infection and immunological rejection was reported.

Conclusion

This novel reconstruction technique takes into account the anatomical specialty of AFTL and CFL. This case series showed increased stability of the ankle in clinical and functional outcomes.

Trial registration

The trial registration number (TRN) and date of registration: ChiCTR-ORC-17010796, Mar 6th 2017. Retrospectively registered.

Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft

BACKGROUND

The anterior half of the peroneus longus tendon (AHPLT) has been reported to be an effective autograft for ligament reconstruction with respect to strength and safety. However, there is little information regarding donor site morbidity after harvesting the AHPLT. Furthermore, to the best of our knowledge, there has not been a study on the isokinetic evaluation of ankle plantar flexion and eversion after AHPLT harvesting.

PURPOSE

To evaluate the clinical and radiographic results after lateral ankle ligament reconstruction using the AHPLT. We further investigated whether harvesting the AHPLT for lateral ankle ligament reconstruction decreases the strength of ankle plantar flexion and eversion.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty consecutive patients (31 cases) were treated by anatomic lateral ligament reconstruction using the AHPLT. For the clinical assessment, visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson-Peterson scores were evaluated preoperatively and at the last follow-up. For the radiographic assessment, talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up. The peak isokinetic torques for ankle plantar flexion at angular velocities of 30 and 120 deg/s and eversion at angular velocities of 30 and 60 deg/s were measured at a minimum of 1 year after surgery.

RESULTS

The mean VAS score improved significantly from 6.4 ± 1.7 preoperatively to 1.6 ± 1.5 at the last follow-up ( P < .001). The mean respective AOFAS and Karlsson-Peterson scores improved significantly from 57.2 ± 12.8 and 66.9 ± 13.6 preoperatively to 89.0 ± 10.0 and 93.3 ± 5.7 at the last follow-up ( P < .001). The mean talar tilt angle improved significantly from 15.3° ± 6.2° preoperatively to 3.4° ± 3.0° at the last follow-up ( P < .001), and the mean anterior talar displacement improved significantly from 10.2 ± 3.3 mm preoperatively to 6.3 ± 1.9 mm at the last follow-up ( P < .001). No significant differences were observed between the uninvolved and involved legs in the mean peak torque for plantar flexion at angular speeds of 30 deg/s ( P = .517) and 120 deg/s ( P = .347) or for eversion at angular speeds of 30 deg/s ( P = .913) and 60 deg/s ( P = .983).

CONCLUSION

Anatomic lateral ligament reconstruction using the AHPLT showed good clinical and radiographic results without a significant decrease in the peroneus longus strength. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability.

Modified Broström Procedure for Chronic Lateral Ankle Instability in Patients With Generalized Joint Laxity

BACKGROUND

Generalized joint laxity (GJL) has been considered a risk factor for late failure of ligament reconstruction in the knee; however, it is not known whether GJL is the cause of recurrent instability after the modified Broström procedure for chronic lateral ankle instability.

PURPOSE

To compare the clinical results of the modified Broström procedure for chronic lateral ankle instability in patients with or without GJL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 100 patients (100 ankles) who underwent the modified Broström procedure were divided into 2 groups, with or without GJL, according to the Beighton criteria. Age and body mass index were matched between the 2 groups. The mean follow-up duration was 43.3 months in the laxity group (44 ankles; Beighton score ≥5) and 42.9 months in the nonlaxity group (56 ankles).

RESULTS

The mean preoperative Karlsson and American Orthopaedic Foot and Ankle Society (AOFAS) scores were a respective 53.2 and 60.9 in the laxity group and 53.9 and 62.6 in the nonlaxity group, and these scores improved to 87.4 and 89.5, respectively, in the laxity group and to 94.1 and 94.8, respectively, in the nonlaxity group at final follow-up. The mean preoperative talar tilt angle and anterior talar translation were a respective 12.5° and 8.8 mm in the laxity group and 10.8° and 8.5 mm in the nonlaxity group, and these values improved to 7.3° and 6.0 mm, respectively, in the laxity group and to 5.2° and 5.0 mm, respectively, in the nonlaxity group at final follow-up. Failure rates were 11.4% (5 patients) in the laxity group and 1.8% (1 patient) in the nonlaxity group. Significant differences were found between the 2 groups in terms of the Karlsson score, AOFAS score, talar tilt angle, anterior talar translation, and failure rate at final follow-up (P < .05).

CONCLUSION

Patients with GJL showed inferior outcomes and a higher failure rate compared with patients without GJL. Therefore, GJL appears to be a risk factor associated with recurrent instability after the modified Broström procedure.

Radiographic monitoring of the distal insertion of the calcaneofibular ligament in anatomical reconstructions of ankle instabilities: A preliminary cadaveric study

BACKGROUND

The purpose of the study therefore was to determine radiographic landmarks that support the identification of the insertion site of the distal calcaneofibular ligament (CFL) in anatomic ankle ligament reconstructions.

METHODS

In 10 lower limb cadaver specimens the midpoint of the distal CFL insertion was dissected and marked with a nail inserted orthogonally. On a standardized lateral radiograph in neutral ankle position a horizontal tangent was aligned to the deepest visible concavity of the tarsal sinus and one vertical tangent to the farthest posterior convexity of the talus. Additionally, a line was drawn from the radiographically marked distal CFL to the fibular insertion of the CFL to determine the CFL-fibular angle.

RESULTS

In relation to the radiographic tangents intersection the mean deviation of the depicted CFL nails was 2.2mm [SD ± 1.1 mm] leading to an angular, circular to slightly oval 6 mm insertion. The scatter-plot of the marked positions convened along a line from the supposed fibular CFL insertion to the intersection in all cases. The mean CFL-fibular angle was 131.7° [SD ± 3.16°].

CONCLUSIONS

Determining a virtual intersection between a horizontal tangent aligned to the deepest visible concavity of the tarsal sinus and one vertical tangent aligned to the farthest posterior convexity of the talus on a standardized lateral radiograph in neutral ankle position supports an anatomic insertion of the distal calcaneofibular ligament most probably.

Anatomical Reconstruction of Lateral Ankle Ligaments Using Free Tendon Allografts and Biotenodesis Screws

BACKGROUND

Lateral ankle instability is one of the most common musculoskeletal disorders and can result in ankle damage. This study reports on the results of the anatomical reconstruction of ligaments using semitendinosus tendon allograft and bioabsorbable tenodesis screws for chronic lateral ankle instability, as well as the functional and radiological results of this procedure.

METHODS

From February 2007 to January 2013, 70 patients (72 ankles) underwent this procedure. Six patients were lost to follow-up, and ultimately 64 patients (66 ankles) were evaluated. Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, Karlsson-Peterson ankle scores, and patient satisfaction were evaluated at a mean of 22.1 months (range, 12-68 months) postoperatively. The talar tilt angle and anterior translation were assessed radiographically in pre- and postoperative ankle stress views. The mean patient age at surgery was 30.1 years (range, 16-59 years).

RESULTS

The mean VAS pain score decreased from 5.5 to 1.3 (P < .05), and the mean AOFAS improved from 71.0 to 90.9 (P < .05). The mean Karlsson-Peterson score improved from 55.1 to 90.3, whereas talar tilt decreased from 14.8 degrees to 3.9 degrees. There was no significant difference in clinical outcomes between the pretensioned and nonpretensioned groups.

CONCLUSION

This procedure yielded successful results, including satisfactory ankle stability and clinical outcomes, in ankles with poor lateral ligament tissues.

LEVEL OF EVIDENCE

Level IV, case series.

Chronic Ankle Instability (Medial and Lateral)

Ankle ligament injuries are among the most frequent reasons for emergency consultations of athletes. A majority of these can be treated conservatively; however, up to 40% develop chronic ankle instability requiring surgical reconstruction to restore functionality.

A novel patient-specific navigational template for anatomical reconstruction of the lateral ankle ligaments

PURPOSE

We discuss the clinical effects of anatomical reconstruction of the lateral ankle ligaments to treat chronic lateral ankle instability (CAI) by creating fibular channels with a patient-specific navigational template.

METHODS

From August 2010 to February 2014, 15 patients presenting with CAI were treated by creating fibular channels with a patient-specific navigational template for anatomical reconstruction of the lateral ankle ligaments.

RESULTS

All patients were followed up for nine to 24 months postoperatively (15 months on average); no recurrent CAI was found. Pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores for patients in the calcaneofibular ligament (CFL) plus anterior talofibular ligament (ATFL) repair group were 48.3 ± 5.1 and 88.1 ± 6.7) respectively. The difference (average 39.8) showed high statistical significance (P < 0.001). Pre- and postoperative scores in the ATFL group were 50.4 ± 6.2 and 90.3 ± 7.8, respectively. The difference (average 39.9) showed high statistical significance (P < 0.001). Regarding the Good score, 14 patients were rated as "excellent and one as good (good = 100 %). No severe complications were found in the patients in this group.

CONCLUSIONS

We studied and successfully built a digital navigation template for creating fibular channels to anatomically reconstruct the lateral ankle ligament. By using the template, fibular channels could be built, and lateral ligaments could be anatomically reconstructed individually, easily and safely, which largely facilitates the treatment of CAI.

Primary ankle ligament augmentation versus modified Brostrom-Gould procedure: a 2-year randomized controlled trial

BACKGROUND

More than 20% of patients develop chronic instability following appropriate management of an 'ankle sprain'. There is little research comparing surgical techniques. 'Anatomical' procedures, such as the modified Brostrom-Gould (MBG), are generally preferred. However, not all patients are suitable for this procedure. Augmentation of a primary repair using a synthetic ligament, such as the ligament augmentation reconstruction system (LARS), is another 'anatomic' option. Our objective was to compare the clinical outcome following the MBG with that following the LARS technique using a prospective randomized clinical trial.

METHODS

Patients who satisfied the study criteria were randomly allocated to undergo the LARS procedure or the MBG procedure. All patients followed a similar rehabilitation programme. Patients completed the foot and ankle outcome score (FAOS) before surgery, and then at 1 year and 2 years following surgery. Statistical analysis was used to compare the groups (P < 0.05).

RESULTS

Forty-one patients took part in the study, 21 were randomized to the LARS group and 20 to the MBG group. The LARS group had a significantly better improvement in the total FAOS at both 1 year (25.5 standard error (SE) 3.8 versus 16.0 SE 3.3) and 2 years (27.1 SE 4.5 versus 15.8 SE 4.9) post-surgery.

CONCLUSION

Primary repair combined with LARS results in better patient-scored clinical outcome, at 2 years post-surgery, than the MBG procedure. Although longer follow-up is required, the LARS procedure may be considered as an alternative, especially in those patients for whom the MBG is relatively contra-indicated.

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes

BACKGROUND

Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period.

HYPOTHESIS

Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity.

RESULTS

The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 ± 4.7 (range, 54-72) and 94.4 ± 7.1 (range, 76-100), respectively (P < .001), and for group A: 64.1 ± 4.8 (range, 57-70) and 91.7 ± 7.7 (range, 74-100), respectively (P < .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° ± 2.6° and 7.7 ± 1.8 mm and 3.8° ± 1.5° and 4.0 ± 1.6 mm, respectively, and for group A: 10.5° ± 3.4° and 8.7 ± 2.1 mm and 4.3° ± 1.8° and 4.3 ± 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P < .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 ± 3.5 weeks) than in group A (13.4 ± 2.2 weeks) (P < .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups.

CONCLUSION

Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery.

Reconstruction of compound loss of lateral malleolus and lateral ankle ligaments with double-bundle Achilles tendon-bone allograft

Open ankle fracture, including compound loss of the lateral malleolus, lateral ankle ligaments, and overlying skin, is a severe injury and can result in ankle instability and permanent disability. Treatment of this injury is challenging and requires bone grafting and soft tissue reconstruction. In the present report, we describe a unique reconstruction technique for compound loss of the lateral malleolus, lateral ankle ligaments, and the overlying skin using a double-bundle Achilles tendon-bone allograft combined with a reverse sural fasciocutaneous flap. The patient obtained a stable ankle with nearly full range of motion and displayed satisfactory function during the follow-up period.

Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament

BACKGROUND

Anatomic reconstructions of the lateral ankle ligaments with grafts have been proposed for patients with generalized ligamentous laxity, long-standing instability with attenuated native tissues, varus hindfoot misalignment, or failed prior lateral ligament surgery and for very large patients or elite athletes because of increased demands.

HYPOTHESIS

Anatomic reconstruction of the anterior talofibular ligament (ATFL) using a semitendinosus allograft fixed with biocomposite interference fit screws would have similar biomechanical properties to the intact ATFL at time zero in a cadaveric model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Allograft reconstruction of the ATFL was performed in 6 fresh-frozen cadaveric ankles. The specimens were loaded to failure to determine the strength and stiffness of the reconstruction and compared with data from 6 cadaveric specimens with intact ATFLs.

RESULTS

The mean ultimate load to failure of the allograft reconstruction (170.7 ± 54.8 N) was not significantly different from that of the intact ATFL (154.0 ± 63.7 N). The mean stiffness of the allograft reconstruction (23.1 ± 9.3 N/mm) was also not significantly different from that of the intact ATFL (14.5 ± 4.4 N/mm).

CONCLUSION

Anatomic reconstruction of the ATFL with allografts demonstrated similar strength and stiffness to the native ligament at time zero in a fresh-frozen cadaveric model.

CLINICAL RELEVANCE

This technique of anatomic reconstruction of the ATFL with allografts has biomechanical validation for use in clinical situations where a Broström repair of the lateral ankle ligaments is unlikely to be successful or has previously failed.

Near-anatomic allograft tenodesis of chronic lateral ankle instability

BACKGROUND

Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.

METHODS

Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.

RESULTS

Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.

CONCLUSION

Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft

BACKGROUND

Multiple techniques have been described for reconstruction of the lateral ligaments of the ankle. Most require extensive exposure and dissection, which may lead to potential problems with wound healing, higher risk of nerve injury, fibrosis, and stiffness. This study reports on the results of a minimally invasive method to reconstruct the ligaments using a semitendinosus tendon autograft and achieve a stable ankle while avoiding these problems.

MATERIALS AND METHODS

From September 2006 to May 2010, 25 patients (14 males, 11 females) with chronic ankle instability underwent lateral ligament reconstruction. The average age was 32.4 (range, 17 to 62) years old. A semitendinosus autograft was harvested through 2 small knee incisions. For the ankle reconstruction, 4 small incisions of 5 mm each were made at the medial and lateral side of the fibular tip, the talar neck, and the middle of the calcaneus. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) was then performed through these small incisions. The mean final follow-up was 32.3 (range, 12 to 56) months. AOFAS questionnaires were used to measure clinical outcomes and donor site morbidity and patient satisfaction are also reported. Preoperative and postoperative stress tests were performed and radiographic parameters were measured.

RESULTS

The mean AOFAS score increased on average from 71.1 to 95.1 (P < .001). Two patients reported residual instability on uneven ground. No patient reported weakness or disability from the donor site. The satisfaction level was excellent in 20 patients and good in 5 patients. Significant improvement in stress radiographic parameters was noted for the talar tilt angle, with reduction from a mean of 14.0 to 3.8 degrees (P < .001); anterior talar displacement reduced from a mean of 12.3 to 4.6 mm (P < .001).

CONCLUSION

Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach can achieve a stable ankle while avoiding extensive exposure and risk of nerve injury.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population

BACKGROUND

Anatomic and checkrein tenodesis reconstruction techniques have been described as a means of treatment for chronic lateral ligament instability in the ankle. The current article describes a hybrid procedure using the most advantageous concepts of both techniques for use when insufficient normal ligament remains to fashion a direct repair of the anterior talofibular ligament (ATFL).

PURPOSE

The authors report the results at a minimum 1-year follow-up of 57 patients who underwent a hybrid anatomic lateral ligament reconstruction technique in the ankle.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty-seven patients underwent a hybrid anatomic lateral ligament reconstruction procedure under the care of the senior author. All patients were assessed preoperatively and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) outcome score. The mean patient age at the time of surgery was 28 years (range, 17-65 years), including 39 male and 18 female patients. The mean follow-up time was 32 months (range, 12-47 months).

RESULTS

The FAOS improved from 58 points preoperatively to 89 points postoperatively (P < .01). The SF-12 score improved from 48 points before surgery to 80 points at final follow-up (P < .01). All patients achieved mechanical stability at final clinical follow-up; 7 patients (12%) demonstrated functional instability. Functional instability was found to significantly influence not returning to sport at the previous level.

CONCLUSION

This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible.

Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws

PURPOSE

The purpose of this study was to evaluate the functional and radiographic outcomes of a novel surgical technique devised to treat chronic lateral ankle instability. The technique involves direct repair of the anterior talofibular ligament and anatomic reconstructions of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using a free semitendinosus tendon allograft and interference screws.

METHODS

This retrospective study involved a review of the records of 27 patients (28 ankles) with chronic lateral ankle instability treated from 2007 to 2009. VAS pain scores, AOFAS scores, Karlsson-Peterson ankle scores (24 ankles), and patient satisfaction were evaluated at median of 19 (12-26) months postoperatively. Radiographically, talar tilt angles and anterior talar translation were assessed in pre- and postoperative ankle stress views.

RESULTS

Median patient age at surgery was 36.5 (16-57) years. Median VAS pain score decreased from 6 (3-9) to 2 (0-4) (P < 0.05), and median AOFAS score improved from 63 (41-84) to 91 (81-100) preoperatively to final follow-up (P < 0.05). Median Karlsson-Peterson score also significantly improved from 55 (32-77) to 80 (59-100) (P < 0.05), whereas talar tilt decreased from 17.8° (10.0°-25.5°) to 6.7° (0.3°-13.0°) and the mean anterior drawer test decreased from 10.0 mm (0.6-19.4) to 4.5 mm (0.2-8.7) (P < 0.05). Eighty-eight percent (21/24) were satisfied with surgery. No complication, such as subtalar stiffness or recurrent instability, was encountered.

CONCLUSIONS

The described technique, which involves anatomic reconstruction of the ATFL and CFL using the semitendinosus tendon and interference screws with direct repair of the capsule, is a viable option for treating lateral ankle instability with stable tendon fixation and provides satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Case-series, Level IV.

Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft

PURPOSE

The purpose of our study is to evaluate the clinical results of anatomical reconstruction of the lateral ligaments with semitendinosus allograft.

METHODS

Thirty-six patients with chronic lateral instability underwent anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and the Karlsson score were used to evaluate the clinical results before and after surgery.

RESULTS

A total of 35 patients (97.2 %) (36 ankles) were followed up for a mean of 37.9 months. The mean AOFAS score improved from 42.3 ± 4.9 points preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively.

CONCLUSIONS

Anatomical reconstruction of the lateral ligaments with semitendinosus allograft achieves a satisfactory surgical outcome for chronic ankle instability.

Combined medial and lateral anatomic ligament reconstruction for chronic rotational instability of the ankle

BACKGROUND

This study aimed to extend knowledge on the arthroscopic evaluation of the unstable ankle joint and the outcome of ligament reconstruction on rotational instability. In contrast to previous studies, we investigated the combined repair of lateral and medial ligaments.

METHODS

Ninety-six patients underwent medial and lateral ligament reconstruction between 2006 and 2008, 81 of whom, with a mean age of 31.9 (range, 14 to 44) years, completed the 12-month followup and were therefore included in this study (Table 1). Clinical, radiographic, and concomitant arthroscopic examination was performed prior to the ligament stabilization. Postoperative followup included clinical and radiographic evaluation after 3, 6, and 12 months.

RESULTS

Arthroscopy showed a lesion of the anterior fibulotalar ligament (AFTL), calcaneofibular ligament (CFL), and tibiocalcanear ligament (TCL) (Deep part of deltoid ligament complex) in 67 patients. An avulsion of the proximal insertion point of the ATTL was additionally found in 14 cases. Clinical results 3 months after surgery showed a significant increase in the AOFAS-Hindfoot Score as well as a significant decrease of the Visual Analogue-Scale for pain (VAS) (p < 0.0001). This outcome persisted at the 12-month examination.

CONCLUSION

Rotational instability of the ankle joint in most cases has an injury of the lateral ligaments and a component of the deltoid, the TCL, but rarely with a combined lesion of the TCL and the anterior tibiotalar ligament (ATTL) (Superficial part of deltoid ligament complex). The combined lateral and medial ligament reconstruction with an anchor technique had a good clinical outcome with high patient satisfaction with few complications.

Results of anatomic lateral ankle ligament reconstruction with tendon allograft

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p < 0.01). The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively. The technique described restores mechanical stability in patients with chronic lateral ankle instability and may be considered in a select group of patients.

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.

Deltoid ligament reconstruction: a novel technique with biomechanical analysis

BACKGROUND

Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. We describe a novel technique that reconstructs both main limbs of the deltoid ligament in anatomic orientation while providing secure graft fixation.

MATERIALS AND METHODS

Six pairs of fresh frozen cadaveric lower extremities were utilized. Matched right and left lower limbs (one pair) were allocated either to a deltoid reconstruction group or an intact deltoid group. The anterior tibial tendon was chosen as the graft for ligament reconstruction, and was harvested from the ipsilateral specimen. Tunnels were created in the distal tibia at the deltoid origin, and at the talus (deep) and calcaneus (superficial) deltoid insertions. Following measurement, the graft was cut to the appropriate size and endobuttons weaved into both tendon ends. The graft ends were passed through the talus and calcaneus respectively. The residual graft loop was then routed through the tibial tunnel and secured proximally with a cancellous screw post and spiked washer. Following specimen mounting, a multiaxis testing apparatus with three separate motors allowed three planes (dorsiflexion/plantarflexion; inversion/eversion; and internal/external rotation) of motion. Angular rotations and linear translations of the tibia in the X-Y-Z directions were measured for a given torque in external/internal rotation, dorsiflexion/plantarflexion, or eversion/inversion, under a constant velocity of 2 degrees per second. Testing consisted of a 2 Nm preload for 20 cycles in internal rotation/external rotation and inversion/eversion prior to data collection of 10 cycles at this level of torque. Similarly, a preload of 1 Nm for 20 cycles was used in dorsiflexion/plantarflexion prior to data collection of 10 cycles at this torque level. Data were collected in the control specimens (the matched contralateral extremity) with the deltoid ligament intact, and following complete sectioning of the ligament complex (both bundles).

RESULTS

Angular displacement at a 2 Nm level torque was significantly greater in the sectioned group compared to the deltoid reconstruction group in external rotation and eversion (p = 0.006 and p = 0.017 respectively). There was no statistical difference in angular displacement between the deltoid intact and reconstructed group in external rotation and eversion when tested at 2 Nm of torque (p = 0.865 and p = 0.470, respectively). The stiffness of the reconstruction was 136.4 +/- 40.2% compared to the intact ligament. Stiffness data were statistically insignificant in both plantar flexion and dorsiflexion between the reconstructed and sectioned groups (p = 0.050 and p = 0.126).

CONCLUSION

The described reconstruction technique under low torque was able to restore eversion and external rotation stability to the talus, which was statistically similar to the intact deltoid ligament. This novel technique developed its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone.

CLINICAL RELEVANCE

This utilitarian reconstruction may be incorporated into total ankle arthroplasty, triple arthrodesis, and sports injuries to re-establish lost medial stability.