The effect of modified Broström-Gould repair for lateral ankle instability on in vivo tibiotalar kinematics

Ankle and hindfoot motion of healthy adults during running revealed by dynamic biplane radiography: Side-to-side symmetry, sex-specific differences, and comparison with walking

This study aimed to characterize ankle and hindfoot kinematics of healthy men and women during overground running using biplane radiography, and to compare these data to those previously obtained in the same cohort during overground walking. Participants ran across an elevated platform at a self-selected pace while synchronized biplane radiographs of their ankle and hindfoot were acquired. Motion of the tibia, talus, and calcaneus was tracked using a validated volumetric model-based tracking process. Tibiotalar and subtalar 6DOF kinematics were obtained. Absolute side-to-side differences in ROM and kinematics waveforms were calculated. Side-to-side and sex-specific differences were evaluated at 10 % increments of stance phase with mixed model analysis. Pearson correlation coefficients were used to assess the relationship between stance-phase running and walking kinematics. 20 participants comprised the study cohort (10 men, mean age 30.8 ± 6.3 years, mean BMI 24.1 ± 3.1). Average absolute side-to-side differences in running kinematics waveforms were 5.6°/2.0 mm or less at the tibiotalar joint and 5.2°/3.2 mm or less at the subtalar joint. No differences in running kinematics waveforms between sides or between men and women were detected. Correlations were stronger at the tibiotalar joint (42/66 [64 %] of correlations were p < 0.05), than at the tibiotalar joint (38/66 [58 %] of correlations were p < 0.05). These results provide a normative reference for evaluating native ankle and hindfoot kinematics which may be informative in surgical or rehabilitation contexts. Sex-specific differences in ankle kinematics during overground running are likely not clinically or etiologically significant. Associations seen between walking and running kinematics suggest one could be used to predict the other.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

Biomechanical improvement of anterior talofibular ligament by augmentation repair of ligament advance reinforcement system: a cadaver study

BACKGROUND

Ankle sprain are one of the most frequent sports injuries. Some individuals will develop chronic lateral ankle instability (CLAI) after ankle sprain and suffer from recurrent ankle sprain. Current surgical treatment of CAI with anterior talofibular ligament (ATFL) rupture fails to restore the stability of the native ATFL. Ligament Advance Reinforcement System (LARS) augmentation repair of ATFL was developed to improve its primary stability after repaired.

METHODS

This study was performed to evaluate whether LARS augmentation repair of ATFL had similar stability as the modified Broström repair and the intact ATFL to maintain ankle construct stability. Standardized surgical techniques were performed on eighteen fresh frozen cadaver ankle specimens. The intact ATFL group has just undergone an ATFL exploratory surgery. The modified Broström procedure is based on anatomical repair of the ATFL with a 2.9 mm suture anchor, and the LARS procedure is an augmentation procedure of the ATFL using LARS ligaments based on the modified Broström procedure. A dynamic tensile test machine was used to assess load-to-failure testing in the three groups. The ultimate failure load and stiffness were calculated and reported from the load-displacement curve. A one-way analysis of variance was used to detect significant differences (p < 0.05) between the LARS augmentation repair, the modified Broström repair and the intact ATFL, followed by least significant difference (LSD) post-hoc tests.

RESULTS

The LARS augmentation repair group showed an increased in ultimate failure to load and stiffness compared to the other two groups. There were no significant differences in ultimate failure to load and stiffness between the modified Broström and the intact ATFL, the LARS ligament for ATFL augmentation allows for improved primary stability after repair and reduced stress on the repaired ATFL, which facilitates healing of the remnant ligament.

CONCLUSIONS

The LARS augmentation repair of ATFL represents a stable technique that may allow for the ankle stability to be restored in patients with CAI after surgery.

Ability to return to sports after early lateral ligament repair of the ankle in 147 elite athletes

PURPOSE

The literature on elite athletes' ability to return to sports (RTS) after early lateral ligament repair of the ankle remains inadequate. The time needed to RTS after modified Broström repair for acute grade III lateral ligament injuries in a large cohort of elite athletes was evaluated while assessing the impact of other associated injuries.

METHODS

Prospective data from 147 elite athletes who underwent a primary lateral ligament repair for acute grade III injuries with clinical ankle instability from 2015 to 2019 with a minimum of 2-year follow-up were reviewed. Pertinent details such as characteristics of injury, time taken to RTS, impact of associated injuries on RTS and complications were recorded and analysed.

RESULTS

The average age was 24.4 years (S.D = 4.9) with 89.1% males. Approximately two-thirds of the elite athletes were football players (66.0%) and 21.1% were rugby players. Isolated lateral ligament complex injuries were sustained by 122 (83%) patients, while 25 (17%) had associated injuries (osteochondral lesions of the talus/deltoid injury/syndesmosis injury). All 147 athletes returned to their preinjury level of sports with a median time of 69 days (range 58-132 days). There was no significant difference found in time to RTS between gender, age, and types of sports. However, there was a statistically significant difference noted in the time taken to RTS earlier in patients with isolated lateral ligament injuries when compared to those with associated injuries (68.6 vs. 82.8 days; p = 0.004). Multiple conditional linear regression yielded three independent predictors of longer time taken to RTS which were associated deltoid injury (7.5 days longer; 95% CI 2.9-12.3; p = 0.002), associated syndesmosis injury (6.7 days longer; 95% CI 0.5-12.8; p = 0.034) and associated OLT (30.3 days longer; 95% CI 25.1-35.5; p = 0.000).

CONCLUSION

Early surgical repair for acute grade III lateral ligament injuries in elite athletes yielded excellent rate of RTS at 9-10 weeks and a re-injury rate of 2%. Concomitant injuries will delay RTS after surgical intervention. These findings serve as important guide to managing elite athletes following acute rupture of the lateral ligament complex.

LEVEL OF EVIDENCE

Level III.

In vivo evaluation of ankle kinematics and tibiotalar joint contact strains using digital volume correlation and 3 T clinical MRI

BACKGROUND

In vivo evaluation of ankle joint biomechanics is key to investigating the effect of injuries on the mechanics of the joint and evaluating the effectiveness of treatments. The objectives of this study were to 1) investigate the kinematics and contact strains of the ankle joint and 2) to investigate the correlation between the tibiotalar joint contact strains and the prevalence of osteochondral lesions of the talus distribution.

METHODS

Eight healthy human ankle joints were subjected to compressive load and 3 T MRIs were obtained before and after applying load. The MR images in combination with digital volume correlation enabled non-invasive measurement of ankle joint kinematics and tibiotalar joint contact strains in three dimensions.

FINDINGS

The total translation of the calcaneus was smaller (0.48 ± 0.15 mm, p < 0.05) than the distal tibia (0.93 ± 0.16 mm) and the talus (1.03 ± 0.26 mm). These movements can produce compressive and shear joint contact strains (approaching 9%), which can cause development of lesions on joints. 87.5% of peak tensile, compressive, and shear strains in the tibiotalar joint took place in the medial and lateral zones.

INTERPRETATION

The findings suggested that ankle bones translate independently from each other, and in some cases in opposite directions. These findings help explain the distribution of osteochondral lesions of the talus which have previously been observed to be in medial and lateral regions of the talar dome in 90% of cases. They also provide a reason for the central region of talar dome being less susceptible to developing osteochondral lesions.

Advanced Imaging in the Chronic Lateral Ankle Instability: An Algorithmic Approach

Imaging examinations are a fundamental part of assessing chronic lateral ankle instability (CLAI). Plain radiographs are used in the initial examination, whereas stress radiographs can be requested to actively search for instability. Ultrasonography (US) and Magnetic Resonance Imaging (MRI) allow direct visualization of ligamentous structures, with the advantage of dynamic evaluation for US, and assessment of associated lesions and intra-articular abnormalities for MRI, which plays an essential role in surgical planning. This article reviews imaging methods to diagnose and follow up on CLAI, along with illustrative cases and an algorithmic approach.

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Functional effects of arthroscopic modified Broström procedure on lateral ankle instability: A pilot study

BACKGROUND

This study aims to assess the mechanical and functional effects of the arthroscopic modified Broström procedure (AMBP) on patients with lateral ankle instability.

METHODS

Eight patients with unilateral ankle instability treated with AMBP and eight healthy subjects were recruited. Healthy subjects, preoperative and one-year postoperative patients were assessed using outcome scales and the Star Excursion Balance Test (SEBT) for dynamic postural control. One-dimensional statistical parametric mapping was performed to compare ankle angle and muscle activation curve during stair descent.

RESULTS

The patients with lateral ankle instability showed good clinical outcomes and increased posterior lateral reach during the SEBT after the AMBP (p = 0.046). The medial gastrocnemius activation after initial contact was reduced (p = 0.049), and the peroneal longus activation after initial contact was promoted (p = 0.014).

CONCLUSION

The AMBP has functional effects of promoting dynamic postural control and peroneal longus activation within one year of follow-up, which can benefit patients with functional ankle instability. However, the medial gastrocnemius activation was unexpectedly reduced post operation.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

Laboratory setting.

PATIENTS OR OTHER PARTICIPANTS

Thirty individuals with CAI and 30 healthy individuals.

MAIN OUTCOME MEASURES(S)

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

RESULTS

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

CONCLUSIONS

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

Surgical management of concurrent lateral ankle instability and osteochondral lesions of the talus increases dynamic sagittal ankle range of motion

PURPOSE

A biomechanical study, in which imaging modalities are used to strictly include patients with concurrent lateral ankle instability (LAI) and osteochondral lesions of the talus (OLT), is needed to demonstrate the static and dynamic ankle range of motion (ROM) restriction in these patients, and determine whether ankle ROM restriction can be corrected postoperatively.

METHODS

Eight patients with concurrent LAI and OLT treated with the arthroscopic modified Broström procedure and microfracture were recruited from June 2019 to January 2020. Patients were assessed using outcome scales, static ankle ROM, and a stair descent gait analysis for dynamic ankle ROM, a day prior to surgery and one year postoperatively. Eight healthy subjects were assessed using the same modalities upon recruitment. Operative outcomes and variables during stair descent were documented and compared among the preoperative, postoperative, and healthy groups. A curve analysis, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalised time series.

RESULTS

The functional outcomes of patients with concurrent LAI and OLT were significantly worse than those of healthy subjects preoperatively, but were partially improved postoperatively. Patients had decreased static and dynamic ROM preoperatively, and static ROM did not significantly increase postoperatively (preoperative, 39.6 ± 11.3; postoperative, 44.9 ± 7.1; healthy, 52.0 ± 4.6; p = 0.021). Patients showed increased dynamic ankle flexion ROM (preoperative, 41.2 ± 11.6; postoperative, 53.6 ± 9.0; healthy, 53.9 ± 3.4; p = 0.012) postoperatively, as well as increased peroneus longus activation (preoperative, 35.8 ± 12.0; postoperative, 55.4 ± 25.1; healthy, 71.9 ± 13.4; p = 0.002) and muscle co-contraction of the tibialis anterior and peroneus longus (preoperative, 69.4 ± 23.4; postoperative, 88.4 ± 9.3; healthy, 66.2 ± 18.1; p = 0.045).

CONCLUSIONS

Patients with concurrent LAI and OLT had decreased static and dynamic sagittal ankle ROM and altered neuromuscular activation patterns. The arthroscopic modified Broström procedure and microfracture did not significantly increase the static sagittal ankle ROM. However, the dynamic sagittal ankle ROM, peroneus longus activation and muscle co-contraction of the tibialis anterior and peroneus longus increased postoperatively.

LEVEL OF EVIDENCE

IV.

Percutaneous Inferior Extensor Retinaculum Augmentation Technique for Chronic Ankle Instability

OBJECTIVE

To specify indications and contraindications of the modified percutaneous inferior extensor retinaculum augmentation (PIERA) technique for chronic ankle instability cases, and to introduce technique details and report surgical outcomes and complications.

METHODS

The PIERA technique was performed on seven patients with chronic ankle instability (four females and three males, 36.4 ± 15.1 years of age, and course of symptoms of 33.7 ± 8.8 months) from June to October 2018 in this retrospective study of case series. All patients demonstrated attenuated ligamentous tissue quality, which was confirmed using preoperative ankle MRI. IER were drew up to the distal fibula using suture anchors with the ankle in neutral position for all cases, to engage the entire IER in reconstructing the stability of the ankle. Patients were assessed using American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS) score and Cumberland Ankle Instability Tool (CAIT) scores pre- and postoperatively at the last follow-up examination. Preoperative and postoperative outcome scores of patients were compared using paired t-test. A p value of less than 0.05 was regarded statistically significant.

RESULTS

Mean follow-up duration was 16.7 ± 1.6 months. The mean AOFAS score significantly improved from 66.9 ± 11.2 preoperatively to 93.7 ± 8.5 postoperatively (P = 0.001). Mean CAIT score significantly improved from 13.1 ± 4.7 preoperatively to 26.3 ± 1.8 postoperatively (P = 0.001). Patients did not report any wound healing problem, numbness, swelling, or instability at the last follow-up examination, except for one patient who reported pain and minimal stiffness, and presented an AOFAS score of less than 80 and a CAIT score below 24. All patients returned to at least recreational sport activity level.

CONCLUSION

The PIERA technique can improve the functional outcomes of patients with chronic ankle instability with few complications.

Joint Stabilization Surgery for Chronic Ankle Instability and Medial Ankle Osteoarthritis: A Critically Appraised Topic

Clinical Scenario: Patients with chronic ankle instability (CAI) who require surgical intervention are often diagnosed with medial ankle osteoarthritis (OA). Lateral joint stabilization procedures are commonly performed among this patient population to restore bony alignment and improve cartilage loading patterns to increase patient-reported function and mitigate further degenerative changes. Focused Clinical Question: What is the available evidence to support joint stabilization procedures on patient-reported outcomes and progression of radiographic OA among patients with CAI who have medial ankle OA? Summary of Key Findings: An electronic search of relevant databases was performed to identify peer-reviewed articles examining preoperative and postoperative clinical outcomes and radiographic evidence of ankle OA. A total of 3 peer-reviewed articles were retrieved. All 3 articles employed a retrospective case series study design. All 3 articles demonstrated improved patient-reported outcomes at the final follow-up visit. Two articles demonstrated that between 11% and 27% of patients progressed in at least 1stage of radiographic ankle OA between the preoperative assessment and the final follow-up visit (40-56 mo). Clinical Bottom Line: Joint stabilization surgery for patients with CAI and medial ankle OA is associated with improved clinical outcomes and a low rate of worsening radiographic joint degeneration within the first 5 years. Strength of Recommendation: Consistent evidence exists across all 3 articles. However, this evidence is based on a low-quality study design. Therefore, there is a grade-C level of evidence to support joint stabilization for improving patient-reported and radiographic outcomes within the first 5 years after surgery for patients with CAI and medial ankle OA.

Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature

INTRODUCTION

The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported.

AIMS AND OBJECTIVES

The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery.

MATERIALS AND METHODS

We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included.

MAIN RESULTS

After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play.

CONCLUSION

Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00532-0.

Decreasing the Abnormal Internally Rotated Talus After Lateral Ankle Stabilization Surgery

Background

Increased internal rotation of the talus has been found in patients with mechanical ankle instability (MAI).

Purpose/Hypothesis

To evaluate and compare the talar rotation position before and after lateral ankle lateral stabilization surgery in patients with MAI. We hypothesized that the abnormal internal talus rotation in patients with MAI will decrease after surgery for ankle lateral instability and that there will be no significant difference in internal talus rotation between the ligament repair and reconstruction groups.

Study Design

Case-control study; Level of evidence, 3.

Methods

We retrospectively studied 56 patients with MAI who underwent ankle lateral stabilization surgery after arthroscopic evaluation (repair, 36 cases; reconstruction, 20 cases). Before and after the operation, magnetic resonance images of all the participants were reviewed. The rotated position of the talus was measured and calculated by the Malleolar Talus Index at the magnetic resonance axial plane.

Results

The internal rotation of the talus decreased significantly after ankle lateral stabilization surgery in patients with MAI as compared with before surgery (mean ± SD, 83.3° ± 3.3° vs 86.7° ± 3.9°; P < .01). However, there was no statistically significant difference between the ligament repair and reconstruction groups before or after the operation.

Conclusion

Abnormal internal rotation of the talus in patients with MAI was decreased after ankle lateral stabilization surgery.

Abnormalities of foot and ankle alignment in individuals with chronic ankle instability: a systematic review

Background

To prevent recurrent ankle sprain, it is important to clarify the pathology of chronic ankle instability (CAI). An association has been reported between CAI and abnormalities of foot posture and ankle alignment. There is no consensus on the types of these abnormalities that occur in individuals with CAI. The objective of this systematic review is to clarify the relevance of abnormality of foot posture and ankle alignment for CAI.

Methods

A systematic computerized literature search was performed of the PubMed, CINAHL, SPORTDiscus, Web of Science, and the Cochrane Register of Clinical Trials databases. The selected studies either compared CAI patients with a control group or CAI ankles with contralateral healthy ankles and specifically reported foot posture and alignment of the ankle in the outcomes. They were written in English and published prior to June 2021. The methodological quality of the included studies was evaluated using a 16-question index. Data were extracted independently by two reviewers, and the certainty of evidence was assessed using GRADE approach.

Results

Sixteen studies including 872 patients of high to low methodological quality were included. These showed there was significant anterior displacement and internal rotation of the talus in CAI ankles (low evidence), but there was no consensus on fibular alignment or foot posture.

Conclusions

This review showed there was significant anterior displacement and internal rotation of the talus in CAI ankles but found no consensus on the characteristics of fibular and foot alignment. Further investigations are required to clarify the characteristic foot and ankle malalignment in CAI to facilitate the development of efficient interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04537-6.

Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review

One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for "kinetic outcomes," "kinematic outcomes," "Broström procedure," and "lateral ligament repair." Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.

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.

The anterior talofibular ligament-posterior talofibular ligament angle decreased after ankle lateral stabilization surgery

PURPOSE

The angle between the anterior talofibular ligament (ATFL) and the posterior talofibular ligament (PTFL) is increased in patients with chronic ATFL injury. This study aimed to compare the AFTL-PTFL angle before versus after ankle lateral stabilization surgery, and to evaluate whether the ATFL-PTFL angle correlates with the ligament injury severity.

METHODS

This retrospective study included 48 patients with mechanical ankle instability treated between 2016 and 2018. After arthroscopic evaluation, all patients underwent ankle lateral stabilization surgery comprising ligament repair (n = 28) or reconstruction (n = 20). The ATFL-PTFL angle was measured in the axial plane on pre- and postoperative MRI. Comparisons were made of the pre- versus postoperative ATFL-PTFL angles, and the ATFL-PTFL angle of the repair versus reconstruction groups. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic performance of the ATFL-PTFL angle in selecting the surgical technique.

RESULTS

The postoperative ATFL-PTFL angle was significantly decreased compared with preoperatively. The ATFL-PTFL angle was significantly smaller in the repair group than the reconstruction group preoperatively and postoperatively. The area under the ROC curve was 0.741 (P < 0.01). The optimal cutoff point for the selection of ligament reconstruction was an ATFL-PTFL angle of 89.4° (sensitivity 0.85, specificity 0.61).

CONCLUSION

The ATFL-PTFL angle decreases after ankle lateral stabilization surgery. The ATFL-PTFL angle is related to the severity of the ATFL injury. Ankle lateral ligament reconstruction should be considered when the ATFL-PTFL angle is > 89.4°.

LEVEL OF EVIDENCE

Level III.

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.

Assignment of local coordinate systems and methods to calculate tibiotalar and subtalar kinematics: A systematic review

The introduction of biplane fluoroscopy has created the ability to evaluate in vivo motion, enabling six degree-of-freedom measurement of the tibiotalar and subtalar joints. Although the International Society of Biomechanics defines a standard method of assigning local coordinate systems for the ankle joint complex, standards for the tibiotalar and subtalar joints are lacking. The objective of this systematic review was to summarize and appraise the existing literature that (1) defined coordinate systems for the tibia, talus, and/or calcaneus or (2) assigned kinematic definitions for the tibiotalar and/or subtalar joints. A systematic literature search was developed with search results limited to English Language from 2006 through 2020. Articles were screened by two independent reviewers based on title and abstract. Methodological quality was evaluated using a modified assessment tool. Following screening, 52 articles were identified as having met inclusion criteria. Methodological assessment of these articles varied in quality from 61 to 97. Included articles adopted primary methods for defining coordinate systems that included: (1) anatomical coordinate system (ACS) based on individual bone landmarks and/or geometric shapes, (2) orthogonal principal axes, and (3) interactive closest point (ICP) registration. Common methods for calculating kinematics included: (1) joint coordinate system (JCS) to calculate rotation and translation, (2) Cardan/Euler sequences, and (3) inclination and deviation angles for helical angles. The methods each have strengths and weaknesses. This summarized knowledge should provide the basis for the foot and ankle biomechanics community to create an accepted standard for calculating and reporting tibiotalar and subtalar kinematics.

Modern Open and Minimally Invasive Stabilization of Chronic Lateral Ankle Instability

Chronic lateral ankle instability is the sensation of the ankle giving way along with recurrent sprains, chronic pain and swelling of the ankle for 1 year. The lateral ankle complex comprises the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The anterior talofibular ligament is the most commonly injured ligament of the lateral ankle. Evaluation comprises a history and physical with concomitant imaging to confirm the diagnosis and can be used to evaluate for concurrent pathology. The most popular treatment is a direct anatomic repair; however, additional options can be used in specific patient populations.

Magnetic Resonance Imaging T2* Mapping of the Talar Dome and Subtalar Joint Cartilage 3 Years After Anterior Talofibular Ligament Repair or Reconstruction in Chronic Lateral Ankle Instability

BACKGROUND

Cartilage degeneration is a common issue in patients with chronic lateral ankle instability. However, there are limited studies regarding the effectiveness of lateral ligament surgery on preventing talar and subtalar joint cartilage from further degenerative changes.

PURPOSE

To longitudinally evaluate talar and subtalar cartilage compositional changes using magnetic resonance imaging T2* mapping in anatomic anterior talofibular ligament (ATFL)-repaired and ATFL-reconstructed ankles and to compare them with measures in asymptomatic controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2015 and December 2016, patients with chronic lateral ankle instability who underwent anatomic ATFL repair (n = 19) and reconstruction (n = 20) were prospectively recruited. Patients underwent 3.0-T magnetic resonance imaging at baseline and 3-year follow-up. As asymptomatic controls, 21 healthy volunteers were recruited and underwent imaging at baseline. Talar dome cartilage was divided into (1) medial anterior, central, and posterior and (2) lateral anterior, central, and posterior. Posterior subtalar cartilage was divided into (1) central talus and calcaneus and (2) lateral talus and calcaneus. Ankle function was assessed using the American Orthopaedic Foot & Ankle Society scores.

RESULTS

There were significant increases in T2* values in medial and lateral posterior and central talus cartilage from baseline to 3-year follow-up in patients who underwent repair. T2* values were significantly higher in ATFL-repaired ankles at follow-up for all cartilage regions of interest, except medial and lateral anterior and lateral central, compared with those in healthy controls. From baseline to 3-year follow-up, ATFL-reconstructed ankles had a significant increase in T2* values in lateral central and posterior cartilage. T2* values in ATFL-reconstructed ankles at follow-up were elevated in all cartilage regions of interest, except medial and lateral anterior, compared with those in healthy controls. ATFL-repaired ankles showed a greater decrease of T2* values from baseline to follow-up in lateral calcaneus cartilage than did ATFL-reconstructed ankles (P = .031). No significant differences in American Orthopaedic Foot & Ankle Society score were found between repair and reconstruction procedures (mean ± SD, 19.11 ± 7.45 vs 16.85 ± 6.24; P = .311).

CONCLUSION

Neither anatomic ATFL repair nor reconstruction could prevent the progression of talar dome and posterior subtalar cartilage degeneration; however, ankle function and activity levels were not affected over a short period. Patients who underwent ATFL repair exhibited lower T2* values in the lateral calcaneus cartilage than did those who underwent reconstruction.

Healthy ankle and hindfoot kinematics during gait: Sex differences, asymmetry and coupled motion revealed through dynamic biplane radiography

The aims of this study were to compare male versus female and dominant versus non-dominant kinematics in the ankle and hindfoot, and to characterize coupled motion between the subtalar and tibiotalar joints during the support phase of gait. Twenty healthy adults walked on a laboratory walkway while synchronized biplane radiographs of the ankle and hindfoot were collected at 100 frames/s. A validated tracking technique was used to measure tibiotalar and subtalar kinematics. Differences between male and female range of motion (ROM) were observed only in tibiotalar (AP and ML) and subtalar (ML) translation (all differences<1 mm and all p < 0.04). Statistical parametric mapping identified differences between kinematics waveforms of males and females in tibiotalar translation (AP and ML) and eversion, and subtalar ML translation. No differences between dominant and non-dominant sides were observed in ROM or kinematics waveforms. The average absolute side-to-side difference in the kinematics waveforms was 4.1° and 1.5 mm or less for all rotations and translations, respectively. Tibiotalar plantarflexion was coupled to subtalar inversion and eversion during the impact and push-off phases of stance (r = 0.90 and r = 0.87, respectively). This data may serve as a guide for evaluating ankle kinematics waveforms, ROM, symmetry, and restoration of healthy coupled motion after surgical intervention or rehabilitation. The observed kinematics differences between males and females may predispose females to higher rates of ankle and knee injury and suggest sex-dependent ankle reconstruction techniques may be beneficial.

Biomechanics of Ankle Ligament Reconstruction: A Cadaveric Study to Compare Stability of Reconstruction Techniques Using 1 or 2 Fibular Tunnels

Background

Anatomic lateral ankle ligament reconstruction has been proposed for patients with chronic ankle instability. A reliable approach is a reconstruction technique using an allograft and 2 fibular tunnels. A recently introduced approach that entails 1-fibular tunnel reconstruction might reduce the risk of intraoperative complications and ultimately improve patient outcome.

Hypothesis

We hypothesized that both reconstruction techniques show similar ankle stability (joint laxity and stiffness) and are similar to the intact joint condition.

Study Design

Controlled laboratory study.

Methods

A total of 10 Thiel-conserved cadaveric ankles were divided into 2 groups and tested in 3 stages-intact, transected, and reconstructed lateral ankle ligaments-using either the 1- or the 2-fibular tunnel technique. To quantify stability in each stage, anterior drawer and talar tilt tests were performed in 0°, 10°, and 20° of plantarflexion (anterior drawer test) or dorsiflexion (talar tilt test). Bone displacements were measured using motion capture, from which laxity and stiffness were calculated together with applied forces. Finally, reconstructed ligaments were tested to failure in neutral position with a maximal applicable torque in inversion. A mixed linear model was used to describe and compare the outcomes.

Results

When ankle stability of intact and reconstructed ligaments was compared, no significant difference was found between reconstruction techniques for any flexion angle. Also, no significant difference was found when the maximal applicable torque of the 1-tunnel technique (9.1 ± 4.4 N·m) was compared with the 2-tunnel technique (8.9 ± 4.8 N·m).

Conclusion

Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach.

Clinical Relevance

Demonstrating similar stability in a cadaveric study and given the potential to reduce intraoperative complications, the 1-fibular tunnel approach should be considered a viable option for the surgical therapy of chronic ankle instability. Clinical randomized prospective trials are needed to determine the clinical outcome of the 1-tunnel approach.

An automated method for defining anatomic coordinate systems in the hindfoot

The absence of a standardized method for defining hindfoot bone coordinate systems makes it difficult to compare kinematics results from different research studies. The purpose of this study was to develop a reliable and robust procedure for defining anatomical coordinate systems for the talus and calcaneus. Four methods were evaluated based upon their anatomic consistency across subjects, repeatability, and their correspondence to functional axes of rotation. The four systems consisted of: 1) interactively identified bony landmarks, 2) a principal component analysis, 3) automatically identified bony landmarks, and 4) translating the tibial coordinate system to the hindfoot bones. The four systems were evaluated on 40 tali and 40 calcanei. The functional axes of rotation were determined using dynamic biplane radiography to image the hindfoot during gait. Systems 2 and 3 were the most repeatable and consistent due to the lack of operator intervention when defining coordinate systems. None of the coordinate systems corresponded well to functional axes of rotation during gait. System 3 is recommended over System 2 because it more closely mimics established bone angles measured clinically, especially for the calcaneus. This study presents an automated method for defining anatomic coordinate systems in the talus and calcaneus that does not rely on manual placement of markers or fitting of spheres to the bone surfaces which are less reliable due to operator-dependent measurements. Using this automated method will make it easier to compare hindfoot kinematics results across research studies.

Risk Factors for Osteochondral Lesions and Osteophytes in Chronic Lateral Ankle Instability: A Case Series of 1169 Patients

Background:

Osteochondral lesions (OCLs) and bony impingement are common secondary lesions of chronic lateral ankle instability (CLAI), but the risk factors that predict OCLs and bony impingement are unknown.

Purpose:

To analyze the risk factors for the development of OCLs and osteophytes in patients with CLAI.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Patients diagnosed with CLAI at our institution from June 2007 to May 2018 were enrolled. The assessed potential risk factors were age, sex, postinjury duration, body mass index, injury side, and ligament injury type (isolated anterior talofibular ligament [ATFL] injury, isolated calcaneofibular ligament [CFL] injury, or concomitant ATFL and CFL injuries). Univariate and multivariate logistic regression analyses were performed to evaluate the association between these factors and the presence of OCLs and osteophytes.

Results:

A total of 1169 patients with CLAI were included; 436 patients (37%) had OCLs and 334 (31%) had osteophytes. The presence of OCLs was significantly associated with the presence of osteophytes (P < .001). Male sex and older age were significantly associated with the presence of OCLs in the medial and lateral talus. A postinjury duration of 5 years or longer was significantly associated with the presence of OCLs in the medial talus (odds ratio [OR], 1.532; 95% CI, 1.023-2.293; P = .038) but not in the lateral talus. ATFL and CFL injuries were both significantly associated with the presence of lateral OCLs. Risk factors for the presence of osteophytes were male sex, older age, postinjury duration 5 years or longer, and CFL injury. Patients with concomitant ATFL and CFL injuries were significantly more likely to have osteophytes than were patients with single-ligament injuries (P = .018).

Conclusion:

Risk factors for OCLs and osteophytes were postinjury duration of 5 years or longer, older age, and male sex. ATFL injury was associated with the presence of lateral OCLs, whereas CFL injury was associated with the presence of lateral OCLs and osteophytes. Patients with these risk factors should be closely monitored and treated to reduce the incidence of ankle arthritis.

Validation and application of dynamic biplane radiography to study in vivo ankle joint kinematics during high-demand activities

Ankle ligament injuries are the most common musculoskeletal injury in physically active populations. Failure to restore native kinematics post-injury often leads to long-term consequences including chronic instability and arthritis. Using traditional motion capture, it is difficult to distinguish independent motions of the tibiotalar and subtalar joints to assess the effects of injury, surgical repair, and rehabilitation on ankle joint complex (AJC) kinematics. Therefore, the aims of this study were to determine the accuracy of dynamic biplane radiography for determining in vivo AJC kinematics and arthrokinematics, and to identify sport-related movements that require the largest AJC range of motion (ROM) during support. Two subjects had three to five 1.0 mm diameter tantalum beads implanted into the tibia, fibula, talus, and calcaneus during lateral ankle ligament repair. Six months after surgery, the subjects executed seven movements while biplane radiographs were collected. Bone motion was tracked using radiostereophotogrammetric analysis (RSA) as a "gold standard", and compared to a volumetric CT model-based tracking algorithm that matched digitally reconstructed radiographs to the original biplane radiographs. Over all movements, the average tibiotalar, subtalar and tibiofibular RMS errors were 0.5 mm ± 0.2 mm, 0.8 mm ± 0.5 mm and 0.8 mm ± 0.3 mm in translation and 1.4° ± 0.4°, 1.5° ± 0.5° and 1.7° ± 0.6° in rotation, respectively. Tibiotalar joint space was determined with an average precision of 0.5 mm. ROM results indicate that jumping and a forward-to-backward push-off movement are the best of the seven sport-related movements evaluated for eliciting full ROM kinematics.

In Vivo Ankle Kinematics Revealed Through Biplane Radiography: Current Concepts, Recent Literature, and Future Directions

PURPOSE OF REVIEW

Lateral ligament repair, specifically the modified Broström-Gould (BG) procedure, has been described for patients with chronic ankle instability (CAI) after failure of nonoperative management. However, there is minimal data about native in vivo ankle bone kinematics and how repairs such as the BG procedure affect the kinematics. The objective of this review is to appraise existing literature that used biplane radiography to measure in vivo kinematics of the ankle in healthy, CAI, and BG populations.

RECENT FINDINGS

Results showed that the tibiotalar joint contributes more to dorsi/plantarflexion, the subtalar joint contributes more to inversion/eversion and internal/external rotation, and that both joints are capable of complex three-dimensional (3D) motion. Preliminary data suggests that demanding activities (as opposed to walking) are necessary to elicit kinematic differences between healthy and CAI populations. Results also indicate that the BG procedure restores static kinematics and range of motion. All but one of the studies identified in this review collected static, quasi-stance, or partial gait capture data. The strength of our current knowledge is low given the small sample sizes, exploratory nature of previous work, and lack of rigorous experimental design in previous studies. Future directions include development of an improved protocol for establishing coordinate systems in the ankle bones, continued development of a database of normal kinematics during a variety of activities, and large-scale, longitudinal studies of CAI and BG patients.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment.

METHODS

Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018.

RESULTS

One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies.

CONCLUSIONS

There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data.

LEVEL OF EVIDENCE

Level IV, review of level I, II, III and IV studies.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability

PURPOSE

Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability.

METHODS

The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health.

RESULTS

Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05).

CONCLUSIONS

The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle.

LEVEL OF EVIDENCE

Case-control, Level III.

In vivo kinematics of functional ankle instability patients during the stance phase of walking

BACKGROUND

Previous studies showed functional ankle instability (FAI) patients have morphological ligamentous abnormality, despite having no apparent joint laxity.

RESEARCH QUESTION

Whether tibiotalar and subtalar joints hypermobility exists in FAI patients during stance phase of walking, remains controversial.

METHODS

Ten unilateral FAI patients, ten unilateral lateral ankle sprain (LAS) copers and ten healthy controls were included. A dual fluoroscopy imaging system was utilized to capture the fluoroscopic images of tibiotalar and subtalar joint during the stance phase of walking. Kinematic data from six degrees of freedom were calculated utilizing a solid modeling software. The range of motion and joint excursions about six degrees of freedom were compared among the three groups. The correlations between range of motion and Cumberland Ankle Instability Tool (CAIT) scores were assessed utilizing the Spearman's correlation coefficient (r).

RESULTS

During the stance phase, the FAI patients and LAS copers showed larger tibiotalar anterior/posterior translation than the healthy controls (FAI patients, p = .013; LAS copers, p = .002). The FAI patients also showed significantly larger lateral/medial translation (p = .035) and inversion/eversion rotation (p = .003) of subtalar joints than healthy controls. By contrast, the subtalar joints of the LAS copers were not different from those of the healthy controls in the lateral/medial translation (p = .459) and inversion/eversion rotation (p = .091). CAIT scores were negatively correlated with range of motion.

SIGNIFICANCE

During the stance phase of walking, FAI patients showed significantly larger hypermobility of subtalar joints than healthy controls, contrary to the LAS copers. These findings justify the utilization of dual fluoroscopy imaging system to detect joint hypermobility in FAI patients. Treatment for FAI patients may require stabilization of the subtalar joint.

In Vivo Kinematics of Functional Ankle Instability Patients and Lateral Ankle Sprain Copers During Stair Descent

Patients with mechanic ankle instability experience increased tibiotalar and subtalar joint laxity. However, in vivo joint kinematics in functional ankle instability (FAI) patients and lateral ankle sprain (LAS) copers, especially during dynamic activities, are poorly understood. Ten FAI patients, 10 LAS copers, and 10 healthy controls were included in this study. A dual fluoroscopic imaging system was used to analyze the tibiotalar and subtalar joint kinematics during stair descent. Five key poses of stair descent were analyzed. Kinematic data from six degrees of freedom were calculated utilizing a solid modeling software. The range of motion and joint positions in each degree of freedom were compared among the three groups. The tibiotalar joints of FAI patients and LAS copers were significantly more inverted than those of healthy controls during the foot strike (p = 0.016, ηp2  = 0.264). The subtalar joints of FAI patients were significantly more anteriorly translated (pose 2, p = 0.003, ηp2  = 0.352; pose 3, p < 0.001, ηp2  = 0.454; pose 4, p = 0.004, ηp2  = 0.334), inverted (pose 4, p = 0.027, ηp2  = 0.234; pose 5,p = 0.034, ηp2  = 0.221), and externally rotated (pose 4, p = 0.037, ηp2  = 0.217; pose 5; p = 0.004, ηp2  = 0.331) than those of healthy controls during the mid-stance and the heel off. The FAI patients showed excessive tibiotalar inversion and subtalar joint hypermobility during stair descent. Meanwhile, the LAS copers maintained subtalar joint stability, and only showed excessive tibiotalar inversion in foot strike. These data provide insight into the mechanisms behind the development of FAI after initial LAS. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1860-1867, 2019.

Knotless Modified Arthroscopic-Broström Technique for Ankle Instability

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors' modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot-related complications. Level of Evidence: Level V, expert opinion.

Application of High-Speed Dual Fluoroscopy to Study In Vivo Tibiotalar and Subtalar Kinematics in Patients With Chronic Ankle Instability and Asymptomatic Control Subjects During Dynamic Activities

BACKGROUND

Abnormal angular and translational (ie, kinematic) motion at the tibiotalar and subtalar joints is believed to cause osteoarthritis in patients with chronic ankle instability (CAI).

METHODS

In this preliminary study the investigators quantified and compared in vivo tibiotalar and subtalar kinematics in 4 patients with CAI (3 women) and 10 control subjects (5 men) using dual fluoroscopy during a balanced, single-leg heel-rise and treadmill walking at 0.5 and 1.0 m/s.

RESULTS

During balanced heel-rise, 69%, 54%, and 66% of mean CAI tibiotalar internal rotation/external rotation (IR/ER), subtalar inversion/eversion, and subtalar IR/ER angles, respectively, were outside the 95% confidence intervals of control subjects. During 0.5-m/s gait, 50% and 60% of mean CAI tibiotalar dorsi/plantarflexion and subtalar IR/ER angles, respectively, were outside the 95% confidence intervals of control subjects. During 1.0-m/s gait, 62%, 65%, and 73% of mean CAI subtalar dorsi/plantarflexion, inversion/eversion, and IR/ER, respectively, were outside the 95% confidence intervals of control subjects. Patients with CAI exhibited less tibiotalar and subtalar translational motion during gait; no clear differences in translations were noted during balanced heel-rise.

CONCLUSION

Overall, the balanced heel-rise activity exposed more tibiotalar and subtalar kinematic variation between patients with CAI and control subjects. Therefore, weight-bearing activities involving large range of motion, balance, and stability may be best for studying kinematic adaptations in patients with CAI.

CLINICAL RELEVANCE

These preliminary results suggest that patients with CAI require more tibiotalar external rotation, subtalar eversion, and subtalar external rotation during weight-bearing stability exercises, all with less overall joint translation.

Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures

PURPOSE

Over 50 % of the patients with chronic lateral ankle instability present with some degree of intra-articular pathology. To date, no consensus regarding the concomitant ankle arthroscopy procedures along with ankle ligament procedures has been reached. The purpose of current study was to investigate reoperation rates and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures.

METHODS

Reoperations and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures were investigated using the PearlDiver Patient Record Database (PearlDiver Technologies, Inc.; Fort Wayne, IN, USA) between 2007 and 2011. Ankle ligament procedures, including ligament repair and reconstruction, and ankle arthroscopic procedures were investigated as primary surgery. Subsequently, the reoperation procedures, including ankle ligament procedures, arthroscopic procedures, autologous osteochondral transplantation, and ankle arthrodesis, as well as wound complications and nerve injury following primary ankle ligament procedures were identified.

RESULTS

In 8014 patients receiving ligament repair, the arthroscopic group had a significantly higher reoperation rate in comparison with the non-arthroscopic group (8.8 vs. 6.5 %, odds ratio: 1.1, [p < 0.01], 95 % confidence interval (CI) 1.2-1.7). However, the non-arthroscopic group included 29 open arthrodesis procedures following the primary surgery, whereas arthroscopic group had none. Of the 8055 patients who received a ligament reconstruction, there was no significant difference in reoperation rate between the groups (5.9 vs. 5.9 %, odds ratio: 1.0, [n.s], 95 % CI 0.8-1.2). As seen in the ligament repair group, the non-arthroscopic group had a 4.9 % rate of ankle arthrodesis as a secondary procedure. Arthroscopic group had a significantly lower rate of wound dehiscence following ankle ligament procedures than non-arthroscopic group.

CONCLUSION

Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation. However, there was a lower incidence of ankle arthrodesis and a lower rate of wound complications in the arthroscopic group when compared to those in non-arthroscopic group. Based on the results of the study, which analysed 16.069 patients, concomitant ankle arthroscopy is recommended.

LEVEL OF EVIDENCE

IV.

Effect of Direct Ligament Repair and Tenodesis Reconstruction on Simulated Subtalar Joint Instability

BACKGROUND

Subtalar instability is associated with up to 80% of patients presenting with chronic ankle instability but is often not considered in the diagnosis or treatment. Operative procedures to repair ankle instability have shown good clinical results, but the effects of these reconstruction procedures on isolated subtalar instability are not well understood. The goal of this study was to investigate the effect of the Gould modification of the Broström procedure and a new tenodesis reconstruction procedure on ankle and subtalar joint kinematics after simulating a subtalar injury.

METHODS

Kinematic data were collected on 7 cadaveric ankles during inversion through the range of ankle flexion and during internal rotation. Testing was performed on the intact foot; after sectioning the calcaneofibular ligament, cervical ligament, and interosseous talocalcaneal ligament; after the Gould modification of the Broström procedure was performed; and after tenodesis was performed and sutures from the Gould modification removed.

RESULTS

The Gould modification of the Broström procedure significantly decreased subtalar and ankle inversion motion and subtalar internal rotation compared to the unstable condition. The tenodesis method restricted internal rotation at the subtalar joint and ankle inversion compared to the intact state.

CONCLUSION

Both operative procedures improved stability of the ankle complex, but tenodesis was unable to restore subtalar inversion and restricted ankle inversion in maximum plantarflexion.

CLINICAL RELEVANCE

The Gould modification of Broström ligament repair may be a favorable operative procedure for the restoration of subtalar and ankle joint kinematics.

Arthroscopic Repair of Ankle Instability

Arthroscopic lateral ankle stabilization procedures have been described for many years. New technological advances and a deeper understanding of the pathobiomechanics involved in chronic lateral ankle instability have allowed an expansion of arthroscopic approaches to this common pathology. As experience is gained and outcomes within the patient profile are understood, the authors feel that the arthroscopic approach to lateral ankle stabilization may prove superior to traditional methods secondary to the risk and traditional complications that are mitigated within minimally invasive arthroscopic approaches. Additionally, the arthroscopic approach may allow a quicker return to ballistic sport and decrease time for rehabilitation.

Treatment of chronic lateral ankle instability using the Broström-Gould procedure in athletes: long-term results

PURPOSE

this study was conducted to evaluate long-term results following treatment of chronic lateral ankle instability using the Broström-Gould technique in athletes.

METHODS

eighteen athletes involved in competitive sports at different levels, who suffered from chronic lateral ankle instability, underwent Broström-Gould ligamentoplasty between 2000 and 2005. The results of the surgery were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scale.

RESULTS

the results at 10-15 years of follow-up were excellent in 94.5% of these cases and good in the remaining 5.5%. An increase of 31.2 points in the AOFAS scale score was recorded at follow-up (with the score rising to 98.8, from 67.6 preoperatively). All the athletes returned to their respective sports at the same level as prior to the surgery. Imaging at long-term follow-up showed no signs of arthritic degeneration.

CONCLUSIONS

the results of this study show that the Broström-Gould technique is an effective procedure for the treatment of chronic lateral ankle instability in the athlete, giving excellent long-term results.

LEVEL OF EVIDENCE

therapeutic case series, level IV.

Normative rearfoot motion during barefoot and shod walking using biplane fluoroscopy

PURPOSE

The ankle rearfoot complex consists of the ankle and subtalar joints. This is an observational study on two test conditions of the rearfoot complex. Using high-speed biplane fluoroscopy, we present a method to measure rearfoot kinematics during normal gait and compare rearfoot kinematics between barefoot and shod gait.

METHODS

Six male subjects completed a walking trial while biplane fluoroscopy images were acquired during stance phase. Bone models of the calcaneus and tibia were reconstructed from computed tomography images and aligned with the biplane fluoroscopy images. An optimization algorithm was used to determine the three-dimensional position of the bones and calculate rearfoot kinematics.

RESULTS

Peak plantarflexion was higher (barefoot: 9.1°; 95% CI 5.2:13.0; shod: 5.7°; 95% CI 3.6:7.8; p = 0.015) and neutral plantar/dorsiflexion occurred later in the stance phase (barefoot: 31.1%; 95% CI 23.6:38.6; shod: 17.7%; 95% CI 14.4:21.0; p = 0.019) during barefoot walking compared to shod walking. An eversion peak of 8.7° (95% CI 1.9:15.5) occurred at 27.8% (95% CI 18.4:37.2) of stance during barefoot walking, while during shod walking a brief inversion to 1.2° (95% CI -2.1:4.5; p = 0.021) occurred earlier (11.5% of stance; 95% CI 0.2:22.8; p = 0.008) during stance phase. The tibia was internally rotated relative to the calcaneus throughout stance phase in both conditions (barefoot: 5.1° (95% CI -1.4:11.6); shod: 3.6° (95% CI -0.4:7.6); ns.).

CONCLUSIONS

Biplane fluoroscopy can allow for detailed quantification of dynamic in vivo ankle kinematics during barefoot and shod walking conditions. This methodology could be used in the future to study hindfoot pathology after trauma, for congenital disease and after sports injuries such as instability.

LEVEL OF EVIDENCE

II.

ArthroBroström Lateral Ankle Stabilization Technique: An Anatomic Study

BACKGROUND

Arthroscopic ankle lateral ligament repair techniques have recently been developed and biomechanically as well as clinically validated. Although there has been 1 anatomic study relating suture and anchor proximity to anatomic structures, none has evaluated the ArthroBroström procedure.

PURPOSE

To evaluate the proximity of anatomic structures for the ArthroBroström lateral ankle ligament stabilization technique and to define ideal landmarks and "safe zones" for this repair.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Ten human cadaveric ankle specimens (5 matched pairs) were screened for the study. All specimens underwent arthroscopic lateral ligament repair according to the previously described ArthroBroström technique with 2 suture anchors in the fibula. Three cadaveric specimens were used to test the protocol, and 7 were dissected to determine the proximity of anatomic structures. Several distances were measured, including those of different anatomic structures to the suture knots, to determine the "safe zones." Measurements were obtained by 2 separate observers, and statistical analysis was performed.

RESULTS

None of the specimens revealed entrapment by either of the suture knots of the critical anatomic structures, including the superficial peroneal nerve (SPN), sural nerve, peroneus tertius tendon, peroneus brevis tendon, or peroneus longus tendon. The internervous safe zone between the intermediate branch of the SPN and sural nerve was a mean of 51 mm (range, 39-64 mm). The intertendinous safe zone between the peroneus tertius and peroneus brevis was a mean of 43 mm (range, 37-49 mm). On average, a 20-mm (range, 8-36 mm) safe distance was maintained from the most medial suture to the intermediate branch of the SPN. The amount of inferior extensor retinaculum (IER) grasped by either suture knot varied from 0 to 12 mm, with 86% of repairs including the retinaculum.

CONCLUSION

The results indicate that there is a relatively wide internervous and intertendinous safe zone when performing the ArthroBroström technique for lateral ankle stabilization. While none of the critical anatomic structures was entrapped by the suture knots, it was evident that the IER was included in a majority of the repairs. This study further defines the proximity of adjacent anatomic structures and establishes the anatomic safe zones for the ArthroBroström lateral ankle stabilization procedure.

CLINICAL RELEVANCE

By defining this relatively risk-free zone, surgeons who are not as experienced with arthroscopic lateral ligament repair techniques may approach arthroscopic suture passage with more confidence.

Ankle instability and arthroscopic lateral ligament repair

Over the last 50 years, the surgical management of chronic lateral ankle ligament insufficiency has focused on 2 main categories: local soft-tissue reconstruction and tendon grafts/transfer procedures. There is an increasing interest in the arthroscopic solutions for chronic instability of the ankle. Recent biomechanical studies suggest the at least one of the arthroscopic techniques can provide equivalent results to current open local soft-tissue reconstruction (such as the modified Brostrom technique). Arthroscopic lateral ankle ligament reconstruction is becoming an increasingly acceptable method for the surgical management of chronic lateral ankle instability.

Functional imaging in OA: role of imaging in the evaluation of tissue biomechanics

Functional imaging refers broadly to the visualization of organ or tissue physiology using medical image modalities. In load-bearing tissues of the body, including articular cartilage lining the bony ends of joints, changes in strain, stress, and material properties occur in osteoarthritis (OA), providing an opportunity to probe tissue function through the progression of the disease. Here, biomechanical measures in cartilage and related joint tissues are discussed as key imaging biomarkers in the evaluation of OA. Emphasis will be placed on the (1) potential of radiography, ultrasound, and magnetic resonance imaging to assess early tissue pathomechanics in OA, (2) relative utility of kinematic, structural, morphological, and biomechanical measures as functional imaging biomarkers, and (3) improved diagnostic specificity through the combination of multiple imaging biomarkers with unique contrasts, including elastography and quantitative assessments of tissue biochemistry. In comparison to other modalities, magnetic resonance imaging provides an extensive range of functional measures at the tissue level, with conventional and emerging techniques available to potentially to assess the spectrum of preclinical to advance OA.

Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament

BACKGROUND

The concept of utilizing nonabsorbable suture tape fixed directly to bone to augment Broström repairs of the anterior talofibular ligament (ATFL) has been proposed. No biomechanical studies of this technique are available.

HYPOTHESIS

We hypothesized that suture tape augmentation alone and Broström repair with suture tape augmentation would have similar biomechanical properties to the intact ATFL at time zero in a cadaveric model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen cadaveric ankles were randomized into 3 groups of 6 specimens each: (1) intact ATFL, (2) suture tape augmentation, and (3) Broström repair with suture tape augmentation. The specimens were loaded to failure to determine the strength and stiffness of each construct.

RESULTS

The mean ultimate load to failure of suture tape augmentation (315.5 ± 66.8 N) was significantly higher than that of the intact ATFL (154.0 ± 63.7 N) (P = .017). The mean ultimate load of the Broström repair with suture tape augmentation (250.8 ± 122.7 N) was not significantly different from that of the intact ATFL. The mean stiffness of augmentation alone (31.4 ± 9.9 N/mm) was significantly higher than that of the intact ATFL (14.5 ± 4.4 N/mm) (P = .008). The mean stiffness of the Broström repair with augmentation (21.1 ± 9.1 N/mm) was not significantly different from that of the intact ATFL.

CONCLUSION

The ATFL with suture tape augmentation is at least as strong and stiff as the native ATFL at time zero in a fresh-frozen cadaveric model.

CLINICAL RELEVANCE

The Broström repair for lateral ankle ligament ruptures is often unsuccessful in circumstances of poor tissue quality. Augmentations, such as with suture tape, have been proposed for these situations. Suture tape used alone or in combination with the Broström repair provided increased strength and stiffness compared with the standard Broström repair, which produced an immediate strength of less than 50% of the intact ATFL. Adding strength to the Broström repair may be valuable in patients with generalized ligamentous laxity, in large patients or elite athletes, or when graft reconstruction is not feasible.

In vivo kinematics of the talocrural and subtalar joints during weightbearing ankle rotation in chronic ankle instability

BACKGROUND

Chronic ankle instability (CAI) results in abnormal ankle kinematics, but there exists limited quantitative data characterizing these alterations. This study was undertaken to investigate kinematic alterations of the talocrural and subtalar joints in CAI.

METHODS

A total of 14 male patients with unilateral CAI (mean age = 21.1 ± 2.5 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities during weightbearing passive ankle joint complex (AJC) rotation were obtained. Three-dimensional bone models created from the computed tomography images were matched with the fluoroscopic images to compute the 6 degrees-of-freedom talocrural, subtalar, and AJC kinematics.

RESULTS

In 20° plantarflexion, ankles with CAI demonstrated significantly increased anterior translation of the talocrural joint during AJC internal rotation from 5° to 7° and significantly decreased talocrural internal rotation within an AJC arc of motion from -1° to 5°. CAI joints demonstrated significantly increased internal rotation of the subtalar joint within an AJC arc of motion from -1° to 3°.

DISCUSSION

In CAI, altered subtalar internal rotation occurs with increased talocrural anterior translation and reduced talocrural internal rotation during weightbearing ankle internal rotation in plantarflexion. These results suggest that altered subtalar mechanics may contribute to CAI symptoms.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for the treatment of stage II posterior tibial tendon dysfunction: kinematic and functional results of fifty one feet

PURPOSE

Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients.

METHODS

Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO. Plantar pressure distribution and American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed 48 months after surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI).

RESULTS

In the lesser-toe region, PP, MF, CT, FTI and CA were reduced and MF in the forefoot region was increased. These changes were statistically significant. We found statistically significant correlations between AOFAS score and loading parameters of the medial midfoot.

CONCLUSIONS

Study results reveal that FDL tendon transfer and MDCO leads to impaired function of the lesser toes during the stance phase. However, there seems to be a compensating increased load in the forefoot region.