Comparison of the Modified Broström Procedure for Chronic Lateral Ankle Instability With and Without Subfibular Ossicle

Magnetic Resonance Imaging Has Utility in Clinical Decision-Making for Children and Adolescents With Symptomatic Subfibular Ossicles

Treatment of children with chronic ankle pain, lateral instability, and the presence of a subfibular ossicle (SO) can be challenging. When will these patients respond to nonoperative management, and when will they require surgery? The purpose of this study was to investigate the utility of magnetic resonance imaging (MRI) in clinical decision-making for patients with symptomatic SOs.

METHODS

We performed a retrospective study of pediatric patients with lateral ankle pain, recurrent sprains, and radiographs showing SOs who had undergone an MRI as part of their diagnostic work-up. We identified 22 patients from the senior author's registry of pediatric patients with lateral ankle injuries. Eleven were girls, and 11 were boys, ages ranging from five to 19 years. Eleven involved the left ankle; 11 involved the right. Positive MRIs showed a high-intensity signal between the SO and the distal fibular epiphysis; negative MRIs had a low-intensity signal. The main outcome measure was operative versus non-operative treatment.

RESULTS

 Sixteen of the 22 patients had positive MRIs, and six had negative MRIs. Twelve of the 16 patients with positive MRIs had undergone an operation. All six patients with negative MRIs responded to nonoperative management.

CONCLUSIONS

MRI has utility in clinical decision-making for symptomatic patients with SOs. Patients with negative MRI sequences responded to nonoperative management. Most patients with positive MRI sequences will require surgery to alleviate their symptoms and return to full activities.

LEVEL OF EVIDENCE

IV.

A Randomized Comparison Between Anterior Talofibular Ligament Repair Using Broström Operation with and without an Internal Brace

The aim of the study was to compare the intermediate-term (>24 months) clinical outcomes between anterior talofibular ligament repair using Broström operation with and without an internal brace. Nineteen patients underwent surgery using an arthroscopic traditional Broström repair with an internal brace technique (IB) and Eighteen patients underwent surgery using an arthroscopic traditional Broström repair without an internal brace technique (TB) . All patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). According to FAAM, sports activity scores of TB and IB groups were 83.33 ± 5.66 and 90.63 ± 6.21 at the final follow-up (p = .02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Total medical expense was more in the IB group (p < .001). It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life.

A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure

BACKGROUND

Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability.

METHODS

Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years.

RESULTS

Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001).

CONCLUSION

A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Comparison of arthroscopic and open Brostrom-Gould surgery for chronic ankle instability: a systematic review and meta-analysis

BACKGROUND

Approximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI) requiring surgical intervention. There has been growing interest among surgeons regarding whether arthroscopic techniques can replace open Brostrom-Gould surgery in treating CLAI. The purpose of this study was to pool the results of multiple studies comparing the treatment effects of these two fixation approaches.

METHODS

Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on CLAI that were repaired using the arthroscopic or open Broström-Gould technique. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, complications, and time efficiency.

RESULT

A total of 686 patients from 11 studies were included in the analysis. Among them, 351 patients underwent open repair, and 335 underwent arthroscopic Brostrom-Gould surgery. The present study revealed that arthroscopic and open Brostrom-Gould techniques demonstrated no significant differences in talar tilt, talar anterior translation, complication rate, and time to return to previous level of activity. Furthermore, no significant differences were observed in AOFAS, K-P, VAS, and Tegner scores at the 2-year follow-up. However, significant differences were noted between the two surgical approaches in terms of early weight-bearing (WMD = - 1.33 weeks, 95% CI = [- 1.91, - 0.76], P = 0.17, I2 = 40%), as well as AOFAS scores (WMD = 1.00, 95% CI = [0.05, 1.95], P = 0.73, I2 = 0%), K-P scores (WMD = 1.57, 95% CI = [0.49, 2.64], P = 0.15, I2 = 47%), and VAS scores (WMD = - 0.15, 95% CI = [- 0.60, 0.29], P < 0.08, I2 = 61%) within the first postoperative year.

CONCLUSIONS

Our findings support that arthroscopic repair yields comparable outcomes to open surgery. Consequently, we advocate for adopting arthroscopic repair as a preferred alternative to the conventional open Broström-Gould procedure for treating chronic lateral ankle instability.

Advancement of Periosteal and Capsular Complexes With or Without Augmentation Using a Free Graft From Lower Extensor Retinaculum: A Comparative Study With Propensity Score Matching

Background

This study compared the outcome of the L-shaped (L-AD) advancement of the periosteal and capsular complexes with or without augmentation using a free graft of the lower extensor retinaculum (AUG) in patients with chronic lateral ankle instability.

Methods

A matched pair analysis was performed of retrospectively collected medical records of patients undergoing lateral ankle ligament repair who had completed at least 2 years of follow-up. Patients who underwent L-AD with AUG and patients undergoing L-AD alone were matched for age, sex, stress radiography findings, and body mass index. Patients with general joint laxity, osteoarthritic changes in the ankle, and subtalar symptoms and who underwent simultaneous surgical treatment for conditions other than that for lateral ankle ligament were excluded. A total of 46 patients were included in the study (23 patients in each group). Clinical outcome scores and postoperative mechanical instability were compared.

Results

The median American Orthopaedic Foot & Ankle Society (AOFAS) score improved significantly (P < .001) from 72 to 97 in the L-AD alone group and from 77 to 100 in the L-AD with AUG group. The mean (±SD) talar tilt angles improved significantly from 11.1 to 4.7 degrees postoperatively (P < .001) in the L-AD alone group vs 9.7 to 5.2 degrees (P < .001) in the L-AD with AUG group. The mean anterior drawer distances were improved significantly postoperatively from 6.4 to 4.7 mm (P < .001) in the L-AD alone group, and from 6.5 to 4.5 mm (P < .001) in the L-AD with AUG group.

Conclusion

The L-AD technique significantly improved AOFAS scores and mechanical instability of ankles with chronic lateral instability with a very low complication rate. Additional augmentation using a free graft showed no advantages in the ankle with a talar tilt of <20 degrees.

Level of Evidence

Level III, retrospective case-control series.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

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

Treatment of Symptomatic Subfibular Ossicle by Excision and Modified Broström Procedure for Skeletally Immature Patients

BACKGROUND

Ossicle resection combined with ligament repair using the modified Broström procedure (MBP) is generally associated with favorable results in adults with symptomatic subfibular ossicles; however, the surgical results of this approach in skeletally immature patients remain unclear. The purpose of this study was to investigate the midterm clinical outcomes and radiographic outcomes including leg length and physeal growth of skeletally immature patients after this procedure.

METHODS

Twenty-six consecutive skeletally immature patients who underwent ossicle resection combined with the MBP were retrospectively evaluated. Clinical scores were evaluated using the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Karlsson-Peterson score, and Tegner score. The talocrural angle, fibular length on radiographs, and tape-measured leg length between the 2 ankles were also measured at the final follow-up. Time of return to sports and postoperative complications were also evaluated.

RESULTS

Fourteen girls (53.8%) and 12 boys (46.2%) had surgery at a mean age of 12.7±2.4 years. Mean postoperative follow-up time was 40.0±10.8 months. Mean VAS pain score improved from 4.1 preoperatively to 0.5 at final follow-up (P < .05). Mean AOFAS score, Karlsson score, and Tegner score all improved from 62.0, 54.0, and 2.8 preoperatively to 95.5, 94.0, and 5.4 (P < .05), respectively, at final follow-up. Median time of return to sports was 17.0 weeks. Mean talocrural angle, fibular length, and tape-measured leg length of the injured ankle were not significantly different from those of the contra-side at the final follow-up. All patients were satisfied with the results; repeat ligamentous injury occurred in 2 patients (7.7%). We had no cases of wound infection, nerve injury, compartment syndrome, or any other complications.

CONCLUSION

Ossicle resection combined with the MBP performed in skeletally immature patients with symptomatic subfibular ossicles resulted in improved clinical outcomes without disruption of fibular physeal growth by an average of 3.3-year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Comparison of symptomatic unstable ankle with and without os subfibulare

BACKGROUND

This study aimed to compare the patients background, clinical scores, condition of the lateral ligament, mechanical instabilities, and chondral lesions in ankles with symptomatic os subfibulare compared to those in ankles with chronic lateral instability without os subfibulare.

METHODS

Of the 212 ankles with a chronic lateral instability that were surgically treated, 72 ankles had an os subfibulare. All ankles were examined by arthroscopy during surgery. Age, sex, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores, remnant condition of the lateral ligaments, and chondral lesions were compared between ankles with symptomatic os subfibulare and ankles with chronic lateral instability without os subfibulare.

RESULTS

There were no statistically significant differences between the groups in terms of the sex ratio (males: females, 35:37 vs. 53:87, n.s.) and the AOFAS Ankle-Hindfoot Scale scores (median; 75 vs. 77, n.s.). There were statistically significant differences in patient age (median: 20 vs. 24.5 years, p < 0.01), talar tilt angle (median: 9.0° vs 12.0°, p < 0.01), anterior drawer distance (6.2 vs. 7.0 mm, p < 0.01), chondral lesions (G0:G1:G2:G3, 35:21:66:5 vs. 40:44:27:29, p < 0.01), condition of the anterior talofibular ligament (intact: repairable remnant: poor remnant, 0:70:2 vs. 1:112:27, p < 0.01), and condition of the calcaneofibular ligament (intact: repairable remnant: poor remnant, 44:26:2 vs. 77:35:28, p < 0.01) between the groups.

CONCLUSION

This study suggests that the condition of the lateral ligaments including mechanical instability and cartilage of the ankle were less severe in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The patients' age was lower in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The clinical scores and gender ratio were not statistically different between the group.

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.

Outcomes of ossicle resection and anatomic reconstruction of lateral ligaments for chronic ankle instability with large malleolar accessory ossicles

BACKGROUND

Malleolar accessory ossicles can be found in patients with chronic lateral ankle instability (CLAI). Ossicle resection combined with the modified Broström procedure is the most commonly used surgical method. However, an unrepairable gap after ossicle resection often occurs in patients with large ossicles.

PURPOSE

This study analysed the clinical outcomes of ossicle resection and anatomic ligament reconstruction (ALR) for CLAI with large malleolar accessory ossicles.

METHODS

This study was a retrospective case series. Since 2014, we have adopted ALR for patients with difficulties using the modified Broström procedure after ossicle resection. Sixteen patients with chronic ankle instability and malleolar accessory ossicles were treated with this method between December 2014 and February 2018. The average age of the patients at the time of surgery was 28.9 (range, 16-65) years. They were followed up for an average time of 26.9 (range, 12-47) months. The clinical outcomes were evaluated using the Visual Analogue Scale, Karlsson-Peterson ankle scoring system, subjective satisfaction of patients, and radiographic parameters.

RESULTS

All unrepairable cases occurred in patients with ossicles larger than or equal to 10 mm. The VAS score improved from 3.5 ± 1.6 preoperatively to 1.4 ± 1.0 at the final follow-up (p < 0.05), and the Karlsson-Peterson score improved significantly from 52.7 ± 15.1 to 86.4 ± 8.2 (p < 0.05). There was also an obvious change in the varus talar tilt angle (15.4 ± 2.0° vs 6.2 ± 1.6°, p < 0.05) and anterior talar displacement (14.3 ± 2.1 mm vs 6.3 ± 1.4 mm, p < 0.05). Fourteen patients (87.5%) were satisfied (excellent or good) with their clinical outcomes.

CONCLUSION

If modified Broström procedure is difficult to accomplish effectively after ossicle resection for chronic ankle instability with large malleolar accessory ossicles, ALR is a viable option with satisfactory clinical results.

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.

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.

All-Inside Arthroscopic Modified Broström Technique to Repair Anterior Talofibular Ligament Provides a Similar Outcome Compared With Open Broström-Gould Procedure

PURPOSE

To introduce an all-inside modified Broström technique to suture the anterior talofibular ligament (ATFL) and inferior extensor retinaculum (IER) under arthroscopy and to compare its outcomes with those of the conventional open procedure.

METHODS

All patients who underwent arthroscopic or open repair of the ATFL between June 2014 and December 2017 were included in this study. Visual analog scale (VAS), Karlsson and Peterson (K-P), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot, and Tegner activity scores, as well as manual anterior drawer test (ADT), were used to evaluate the patients preoperatively and ≥2 years after surgery. The Sefton grading system was used to assess the level of satisfaction after surgery. Detailed surgical data and intraoperative findings were documented at the time of surgery.

RESULTS

A total of 67 patients, 31 in the arthroscopic group and 36 in the open group, were included in this study (43 men and 24 women, mean body mass index 24.00, range 19.53 to 30.03). The surgical duration in the arthroscopic group (median, 34 minutes; range, 25 to 74) was significantly shorter than that in the open group (mean, 43.08 ± 8.11 minutes; 95% confidence interval [CI] 40.34 to 45.83) (P = .007). At the last follow-up, the subjective functional scores and ADT results improved significantly in both cohorts (P < .001). However, no significant difference was found in the VAS score (1.74 ± 1.24, 95% CI 1.29 to 2.2, in the open group versus 1.58 ± 1.2, 95% CI 1.18 to 1.99, in the arthroscopic group; P = .581), AOFAS score (91.71 ± 5.46, 95% CI 89.71 to 93.71, versus 90.67 ± 5.59, 95% CI 88.78 to 92.56; P = .444), K-P score (87.52 ± 7.59, 95% CI 84.73 to 90.3, versus 88.75 ± 5.56, 95% CI 86.87 to 90.63; P = .446), and ADT evaluation (normal: 96.77% versus 94.44%, P = .557) between the arthroscopic and open groups, respectively. In addition, 28 cases (90.32%) in the arthroscopic group and 32 (88.89%) in the open group achieved satisfactory results based on the Sefton grading system (P = .736). Seventeen patients (47.2%) in the open group and 18 patients (58.1%) in the arthroscopic group underwent Tegner evaluation after surgery, which showed no significant difference (5, interquartile range [IQR] 1 in the open group versus 5, IQR 3 in the arthroscopic group; P = .883). Complications were reported in 4 (11.1%) and 2 (6.5%) patients who underwent open and arthroscopic surgeries, respectively (P = .813).

CONCLUSIONS

Both open and arthroscopic modified Broström surgeries generated favorable outcomes, with a significant improvement compared with the preoperative condition. Compared with the open Broström-Gould procedure, the all-inside arthroscopic modified Broström technique produced equivalent functional and clinical results at a minimum of 2 years after the operation, with a shorter surgical duration. Arthroscopic repair might be a safe and viable alternative to open surgery for lateral ankle stabilization.

LEVEL OF EVIDENCE

III.

Bone Mineralization Changes in the Subchondral Bone of the Medial Gutter in Chronic Lateral Ankle Instability

BACKGROUND

Chronic ankle instability (CAI) induces osteoarthritis (OA) by inflicting abnormal stresses on the medial gutter. It is important to detect early OA change and to explore factors likely to induce the OA. The purpose of this study was to evaluate subchondral bone change in the medial gutter of CAI using computed tomography (CT) scans.

METHODS

Thirty-five ankles with CAI (CAI group) and 35 ankles without CAI (control group) were included. The region of interest (ROI) in the subchondral bone of the medial gutter on CT axial images was set on the tibia and talus. The Hounsfield unit (HU) in ROIs was measured and corrected by the HU of the fibula in the same slice. HU ratios were compared between the CAI and control groups. In the CAI group, the relationship between the HU ratio and the talar tilt angle (TTA), OA change, and the anterior talofibular ligament (ATFL) remnant quality were analyzed.

RESULTS

The mean HU ratio in the CAI group was significantly higher than that in the control. In the CAI group, HU ratios in ≥10 degrees of TTA were significantly higher than those in <10 degrees. But there was no significant difference in the HU ratios with or without OA change in the medial gutter. A good-quality ATFL remnant showed a low HU ratio compared with that with poor quality.

CONCLUSION

CAI patients exhibited subchondral bone change in the medial gutter, which suggests that the elimination of instability may help to prevent or decrease the development and/or progression of osteoarthritis.

LEVEL OF EVIDENCE

Level III, comparative series.

Functional Comparison of Horizontal Mattress Suture Versus Free-Edge Suture in the All-Inside Arthroscopic Broström-Gould Procedure for Chronic Lateral Ankle Instability

Objective

To compare the clinical outcomes of horizontal mattress suture vs free‐edge suture in the all‐inside arthroscopic Broström–Gould procedure.

Methods

This retrospective cohort study included 68 chronic lateral ankle instability (CLAI) patients who underwent either a horizontal mattress suture or a free‐edge suture all‐inside arthroscopic Broström–Gould procedure from January 2014 to January 2017. Patients were divided into two groups based on the suture fashion during the all‐inside arthroscopic Broström–Gould procedure. In the horizontal mattress suture group (n = 31), anchor sutures were used to suture the ATFL, capsule, and inferior extensor retinaculum in horizontal mattress suture fashion. In the free‐edge suture group (n = 37), anchor sutures were used to suture the ATFL, capsule, and inferior extensor retinaculum in free‐edge suture fashion. The Visual Analogue Scale (VAS) score, the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), Anterior Talar Translation (ATT), the rate of return to sports, and ankle proprioceptive recovery were compared in both groups.

Results

The operative times and duration of hospitalization between the two groups were comparable (all P > 0.05). The VAS, AOFAS, ATT, the rate of return to sports, and ankle proprioceptive recovery were comparable between the horizontal mattress suture and free‐edge suture groups at 1 and 2 years after surgery. Patients of the free‐edge suture group achieved better KAFS 1 and 2 years after the surgery compared with those of the horizontal mattress suture group. In both groups, incisions were healed by first intention, and complications such as infection, implant reactions, tendon injury, and nervous or vascular injuries were not observed. The ankle proprioceptive recovery in horizontal mattress suture and free‐edge suture groups showed no significant differences at 1 and 2 years after surgery. The mean time of the return to full activity for patients in the horizontal mattress suture group was 10.38 ± 2.02 (range 8 to 12) weeks vs 8.63 ± 2.31 (range 8 to 12) weeks for those in the free‐edge suture group (P = 0.001, power = 0.907). The exercise participation rates were comparable between groups (P > 0.05). At the 2‐year follow‐up, all patients regained normal activities and ankle stability, and no recurrence of CLAI or revision surgery was recorded.

Conclusion

All‐inside arthroscopic Broström–Gould surgery for the treatment of CLAI ensures a better functional effect (KAFS) and better recovery time when free‐edge suture is used instead of horizontal mattress suture.

Anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up

PURPOSE

The aim of this study was to compare long-term outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) repair and reconstruction at 5-10 years after surgery.

METHODS

Forty-five patients who underwent surgical repair or reconstruction of both ATFL and CFL were retrospectively investigated in this study. American Orthopedic Foot and Ankle Society (AOFAS), Karlsson Score, and Tegner activity scale were used to evaluate the ankle function at a follow-up of 5-10 years. Ultrasound examination was used to evaluate the ATFL and CFL, and MRI was used to evaluate the cartilage.

RESULTS

At final follow-up, no patient had recurrent ankle instability. There were no significant differences in AOFAS (92.6 ± 6.5 vs 89.6 ± 3.4; n.s.) or Karlsson Score (93 ± 8.2 vs 90.6 ± 5.0; n.s.) between the reconstruction group (twenty patients) and the repair group (twenty-five patients) postoperatively. There were also no significant differences in activity level as measured by the Tegner activity score (6 (range 4 to 8) vs 6 (range 5 to 7); n.s.). Five patients in the reconstruction group complained of some tightness of the ankles. Ultrasound showed the reconstructed ligaments maintained good continuity and were thicker than the repaired ligaments.

CONCLUSION

Patients in both the repair and the reconstruction cohort had high patient satisfaction with the outcomes and high function and activity levels that indicated recreational sports participation over a long period.

LEVEL OF EVIDENCE

III.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability

Background

Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.

Purpose

To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.

Results

A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.

Conclusion

No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography

Background

The purpose of this study was to determine the diagnostic accuracy of ultrasonography for the diagnosis of avulsion fractures of the distal fibula for lateral ankle sprain in children and compare it to that of radiography.

Methods

Children who sustained lateral ankle sprain were prospectively surveyed. They underwent both ultrasonography and radiography at the first clinic visit to diagnose any concomitant avulsion fractures of the distal fibula. The patients underwent follow-up radiography 4 weeks later to obtain the reference standard diagnosis. The measures of diagnostic accuracy (i.e., sensitivity, specificity, positive predictive value, and negative predictive value) of the initial ultrasonography and radiography were calculated; they were then compared using the McNemar test. Totally, 52 patients (with a median age of 9 years) were analyzed.

Results

On the reference standard (follow-up) radiographs, 32 patients (62%) were found to have avulsion fractures of the distal fibula. The sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 94, 85, 91, and 89% respectively; and 81, 100, 100, and 77% respectively for radiography at the first visit. There were no significant differences in sensitivity and specificity between the two diagnostic methods (P = 0.22, 0.25).

Conclusions

Ultrasonography has a high diagnostic accuracy, which is comparable to that of radiography, for the diagnosis of avulsion fracture of the distal fibula. Ultrasonography may be used as an option of imaging modality for lateral ankle sprain in children.

Factors associated with the resilience of Tibetan adolescent survivors five years after the 2010 Yushu earthquake

Resilience contributes to the recovery of disaster victims. The resilience of Tibetan adolescents after the Yushu earthquake has not been properly studied. This study aimed to examine the current resilience and associated factors in Tibetan adolescent survivors in the hardest-hit area 5 years after the Yushu earthquake. This cross-sectional survey was conducted in the area hit the hardest by the Yushu earthquake. Data were collected from 4681 respondents in October and November 2015. Measurements included the participant characteristics, traumatic earthquake experience, the Connor-Davidson resilience scale (CD-RISC), and the social support appraisals (SS-A) scale. The individual datasets were randomized as 80% for the training set and 20% for the validation set. The mean resilience score of the Tibetan adolescent survivors was 55.0±12.3. Thirteen variables were entered into the regression equation. The three dimensions of social support (from family, from friends, from others than family/friends) were positively associated with resilience (all P<0.05), among which support from others than family/friends was the strongest (r = 0.388, P<0.001). Academic performance, activeness of participation in school activities, harmonious relationship with teachers/classmates, health over the last year, and regular physical exercise were positively associated with resilience (all P<0.05). Being female and being extremely worried about their own lives were negatively associated with resilience (both P<0.05). In conclusion, among Tibetan adolescent survivors to the Yushu earthquake of 2010, support from others than family/friends was the strongest positive factor associated with resilience, while being female and extreme worry about their own lives were negative factors. These results expand our knowledge regarding resilience in Tibetan adolescent disaster survivors.

Morphological Characteristics of Os Subfibulare Related to Failure of Conservative Treatment of Chronic Lateral Ankle Instability

BACKGROUND

The os subfibulare is usually asymptomatic and found incidentally on radiographs. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). We hypothesized that os subfibulare could interrupt the talofibular space causing impingement, resulting in chronic pain and functional instability around the lateral malleolus. The purposes of this study were to analyze morphologic characteristics of os subfibulare, and to evaluate the clinical significance of the os subfibulare in patients with CLAI.

METHODS

Between November 2011 and April 2015, 70 patients who had both computed tomography (CT) and magnetic resonance imaging (MRI) among 252 patients who visited our hospital with the symptom of lateral ankle instability were included in this study. The location of the ossicle was classified into 3 zones in reference to the attachment site of the lateral ankle ligaments. The impingement was classified into 2 groups according to the presence of talofibular encroachment. Digital radiographs were used to measure the ossicle width and shape determined by the length and width on an magnetic resonance (MR) image.

RESULTS

The most common shape of ossicles was oval, and the most common location of ossicles was at the anterior talofibular ligament (ATFL) attachment site. Sixty-one percent of patients showed talofibular impingement on coronal MR images. In 48 cases, the dimension of fibula plus os subfibulare was larger than that of the contralateral normal fibula. The larger size and talofibular impingement of the ossicle were associated with greater need for operative treatment in patients with ankle instability.

CONCLUSION

The morphologic analysis of the os subfibulare revealed that there might be impingement of the talofibular space by the ossicle in some patients. We suggest that morphologic characteristics of the os subfibulare should be considered when selecting treatment options in patients with CLAI and os subfibulare.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Absence of ATFL remnant does not affect the clinical outcomes of the modified broström operation for chronic ankle instability

PURPOSE

The modified Broström operation for chronic ankle instability has demonstrated good clinical results. Absence of ligamentous tissue is a risk factor for recurrence of ankle instability after surgery. This study evaluated the effect of quality of ligament tissue (anterior talofibular ligament, ATFL) on prognosis, in a cohort of patients with chronic ankle instability after the modified Broström operation.

METHODS

This was a retrospective case series. Overall, 60 patients underwent the modified Broström operation for chronic ankle instability (mean follow-up, 30.1 [range, 24-47] months). Presence of ATFL remnant was assessed on ultrasound, magnetic resonance imaging, and arthroscopy in all patients. Foot and ankle outcome score (FAOS) was used to evaluate functional outcomes. Clinical outcomes were compared by the condition of the ligament remnant. Association with other risk factors was evaluated using multiple linear regression analysis.

RESULTS

ATFL was visible in 51/60 cases on ultrasound. Thirty, 22, and eight patients had thin or absent; normal thickness; and thick ATFL on magnetic resonance imaging, respectively. ATFL was visible in 15 patients on arthroscopy and nonvisible or not clear in 45. No significant differences occurred in FAOS with the presence of ATFL remnant on ultrasound, arthroscopy, and the grade of ATFL thickness on magnetic resonance imaging. No correlation was found between FAOS and the thickness of ATFL.

CONCLUSION

The results suggest that the modified Broström operation for patients with chronic ankle instability was good, regardless of the presence or absence of ATFL remnant.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Anterior talofibular ligament (ATFL) repair using two suture anchors produced better functional outcomes than using one suture anchor for the treatment of chronic lateral ankle instability

PURPOSE

To compare the function and activity level after one-anchor repair versus two-anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability.

METHODS

All patients who underwent arthroscopic surgical ATFL repair using suture anchors were included in this study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score) and Tegner activity score were used to evaluate ankle function at a follow-up of a minimum of 2 years. A magnetic resonance imaging (MRI) scan was performed to evaluate the repaired ATFL.

RESULTS

A total of 51 patients with chronic ankle instability were included in this study. Among them, 20 patients accepted a one-anchor repair procedure (one-anchor group), and the other 31 patients accepted a two-anchor repair procedure (two-anchor group). At the final follow-up, there was no significant difference in the AOFAS score between the one-anchor group and the two-anchor group (90 ± 9 vs 91 ± 10; ns). However, the mean Karlsson score of the two-anchor group (88 ± 12) was significantly higher than that of the one-anchor group (80 ± 14) (p = 0.04). There was a significant difference in activity level as measured by the Tegner activity score (5 ± 1 vs 4 ± 1; p < 0.001) between the two-anchor group and the one-anchor group after surgery. Patients in the two-anchor group (68%) had a significantly higher percentage of sport participation compared to those in the one-anchor group (30%) (p = 0.01).

CONCLUSION

Compared with a one-anchor repair, a two-anchor repair of the lateral ankle ligament produced better functional outcomes. Arthroscopic ATFL repair with two anchors provided a minimally invasive technique with a higher rate of return to sports than repair with one anchor. The present study showed its clinical relevance by maintaining the advantage of ATFL repair using two anchors regarding the clinical function.

LEVEL OF EVIDENCE

III.

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.

Arthroscopic Stabilization of Unstable Os Subfibulare

Os subfibulare is an ossicle at the tip of the lateral malleolus. The ossicle is sometimes symptomatic and presents with local pain or lateral ankle instability. The purpose of this Technical Note is to describe the details of arthroscopic stabilization of the os subfibulare. It is indicated for symptomatic mechanical lateral ankle instability resulting from an unstable os subfibulare. The technique has the advantages of minimally invasive surgery, evaluation and treatment of concomitant ankle pathology, and preservation of integrity of the anterior talofibular ligament.

Lower Signal Intensity of the Anterior Talofibular Ligament is Associated with a Higher Rate of Return to Sport After ATFL Repair for Chronic Lateral Ankle Instability

BACKGROUND

The treatment strategy for anterior talofibular ligament (ATFL) injury is usually determined by the ATFL remnant condition during surgery. Preoperative magnetic resonance imaging (MRI)-based signal intensity of the ATFL remnant, represented by the signal/noise ratio (SNR) value, can reveal the ATFL remnant condition. Thus far, there is a lack of evidence regarding the relationship between the ATFL remnant condition and functional outcomes.

PURPOSE/HYPOTHESIS

The purpose was to quantitatively evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. The hypothesis was that a lower preoperative SNR is related to a better clinical outcome, particularly a higher rate of return to sport.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

First, a preliminary study was performed to measure the ATFL SNR in preoperative MRI, the results of which suggested that a preoperative SNR >10.4 was indicative of a poor ATFL condition. Then, a cohort study was retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between January 2009 and August 2014. Accordingly, the patients were divided into 2 groups: high SNR (HSNR; ≥10.4) and low SNR (LSNR; <10.4). Functional outcomes based on the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner Activity Scale were then compared between the HSNR group and the LSNR group.

RESULTS

Ultimately, 70 patients were available for the final follow-up: 37 in the HSNR group and 33 in the LSNR group. No significant difference was detected between the HSNR group and the LSNR group in terms of the AOFAS score, KAFS, or Tegner Activity Scale (P > .05 for all) preoperatively. At the final follow-up, the mean ± SD AOFAS score in the LSNR group (92 ± 6) was higher than that in the HSNR group (87 ± 12), although no significant difference was detected postoperatively (P = .16). The mean KAFS in the LSNR group (94 ± 7) was significantly higher than that in the HSNR group (88 ± 11) postoperatively (P = .03). At follow-up, the mean Tegner score in the LSNR group (6; range, 3-7) was significantly higher than that in the HSNR group (5; range, 1-8) postoperatively (P = .03). Patients in the LSNR group had a significantly higher percentage of sports participation than those in the HSNR group (91% vs 65%, P = .02) postoperatively.

CONCLUSION

A lower signal intensity in the ATFL ligament based on preoperative MRI is associated with a better clinical outcome, particularly a higher rate of return to sport.

Stabilizing lateral ankle instability by suture tape - a cadaver study

BACKGROUND

Suture tape is a recent development to augment a Brostrom repair at least during the healing phase of the native tissues used for stabilization of the lateral ankle ligaments. The purpose of this study was to evaluate whether suture tape is an effective mechanical stabilizer against anterior talar drawer in a cadaver experiment when tested with a validated arthrometer.

METHODS

Different stability conditions were created in 14 cadaveric foot and leg specimens. Following anterior talofibular ligament (ATFL) dissection, isolated suture tape ATFL reconstruction was compared to the unaltered specimens, to the condition with ATFL cut, to the ATFL plus calcaneofibular ligament (CFL) cut conditions, and to the ATFL, CFL, and posterior talofibular ligament transected specimens. Three-dimensional bone-to-bone movement between fibula and calcaneus were simultaneously recorded using bone pin markers. Anterior translation was analysed between 20 and 40 N anterior talar drawer load, applied by an ankle arthrometer. Test conditions were compared using non-parametric statistics.

RESULTS

Dissection of ATFL increased anterior talar drawer in arthrometer and bone pin marker analyses (p = 0.003 and 0.004, respectively). When the CFL was additionally cut, no further increase of the anterior instability could statistically be documented (p = 0.810 and 0.626, respectively). Following suture tape reconstruction of the ATFL, stability was not different from the unaltered ankle (p = 0.173).

CONCLUSIONS

Suture tape augmentation of the ATFL effectively protects the unstable anterolateral ankle in the sagittal plane. The CFL does not seem to stabilize against the anterior talar drawer load.

Effect of Modified Broström Procedure With Periosteal Flap Augmentation After Subfibular Ossicle Excision on Ankle Stability

BACKGROUND

The study evaluated the clinical and radiographic outcomes of the modified Broström procedure (MBP) with periosteal flap augmentation after large subfibular ossicle excision for chronic lateral ankle instability (CLAI).

METHODS

Twenty-two CLAI cases with a large ossicle (≥10 mm) were treated consecutively using the MBP with periosteal flap augmentation after ossicle excision. The mean follow-up duration was 20 months (12-33). For clinical assessment, the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Karlsson-Peterson score were evaluated preoperatively and at the last follow-up. For radiographic assessment, the size of the ossicle was measured by magnetic resonance imaging, and the talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up.

RESULTS

The VAS, AOFAS, and Karlsson-Peterson scores improved from 6.3, 68.7, and 56.9 preoperatively to 1.6, 94.5, and 92.4 at the last follow-up, respectively. The mean size of the ossicles was 14.8 mm (11-21 mm). The talar tilt angle and anterior talar displacement improved from 11.2 degrees and 8.3 mm preoperatively to 4.4 degrees and 3.9 mm at the last follow-up, respectively.

CONCLUSION

MBP combined with periosteal flap augmentation after ossicle excision provided good clinical and radiographic outcomes in CLAI with a large ossicle.

LEVEL OF EVIDENCE

Level IV, case series.

Return to Play after Modified Broström Operation for Chronic Ankle Instability in Elite Athletes

Background

This study assessed the average time to return to training and official game participation after modified Broström operation (MBO) in elite athletes.

Methods

Sixty athletes diagnosed with lateral ankle instability underwent MBO from October 2011 to December 2013. Their average age was 19.3 years, and the average follow-up time was 28.8 months. We measured the time sequence of three phases of rehabilitation: start of personal training, start of team training, and start of the first official game after recovery. Patients were divided into an early return to play (RTP) group and late RTP group. The groups were compared to identify possible risk factors affecting the RTP time.

Results

The mean length of time to return to personal training was 1.9 months, return to team training was 2.9 months, and return to competitive play was 3.9 months. There were no significant differences of any variables including age, sex, body mass index, level of sports, grade of instability, presence of os subfibulare, and preoperative functional score between the early RTP and late RTP groups.

Conclusions

The RTP was 83.3% at 4 months after lateral ankle ligament repair and 100% at 8 months postoperatively. The results provide reference data for orthopedic surgeons in evaluating surgical results and informing patients about expectations after surgery in terms of performance level and timing of return to sports.

Presence of Subfibular Ossicle Does Not Affect the Outcome of Arthroscopic Modified Broström Procedure for Chronic Lateral Ankle Instability

PURPOSE

To evaluate the clinical and radiological outcomes of the all-inside, arthroscopic, modified Broström procedure (MBP) used to treat chronic lateral ankle instability (CLAI) according to subfibular ossicle (SFO) status.

METHODS

Between January 2013 and September 2016, we retrospectively analyzed CLAI patients who underwent the arthroscopic MBP. When performing the arthroscopic MBP, SFO was removed with all inside technique regardless of size. Patients who were not followed for more than a minimum of 12 months after surgery were excluded. The patients were divided into 2 groups: ankles with SFOs were assigned to the SFO group and the others to the non-SFO (NSFO) group. The evaluation tools used included the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, a pain visual analog scale, and the talar tilt angle.

RESULTS

Following the inclusion criteria, we included 125 patients (125 ankles) in this study. The SFO group consisted of 26 patients and the NSFO group consisted of 99 patients. The preoperative scores in the 2 groups shows no significant difference except for AOFAS scores. The final AOFAS scores in both groups improved compared with the preoperative scores (18.4 ± 16.3 and 22.1 ± 21.6 for the SFO and NSFO groups, respectively). The final follow-up visual analog scale scores also improved in both groups (5.0 ± 1.7 and 5.2 ± 1.4, respectively). The mean ± standard deviation talar tilt improved from 8.7 ± 5.0° preoperatively to 4.6 ± 3.6° at the final follow-up in the SFO group, and from 7.3 ± 4.4° preoperatively to 3.2 ± 3.0° at the final follow-up in the NSFO group. Neither the preoperative nor final talar tilt angle differed between the 2 groups (P = .300 and P = .072, respectively).

CONCLUSIONS

All-inside arthroscopic MBP after SFO resection was as successful as the same surgery without SFO resection. The clinical outcomes of the SFO and NSFO groups did not differ. Both groups achieved successful radiological outcomes at the last follow-up. All-inside arthroscopic MBP is a reliable treatment for CLAI patients regardless of SFO status.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Return to Play after Modified Broström Operation for Chronic Ankle Instability in Elite Athletes

Background

This study assessed the average time to return to training and official game participation after modified Broström operation (MBO) in elite athletes.

Methods

Sixty athletes diagnosed with lateral ankle instability underwent MBO from October 2011 to December 2013. Their average age was 19.3 years, and the average follow-up time was 28.8 months. We measured the time sequence of three phases of rehabilitation: start of personal training, start of team training, and start of the first official game after recovery. Patients were divided into an early return to play (RTP) group and late RTP group. The groups were compared to identify possible risk factors affecting the RTP time.

Results

The mean length of time to return to personal training was 1.9 months, return to team training was 2.9 months, and return to competitive play was 3.9 months. There were no significant differences of any variables including age, sex, body mass index, level of sports, grade of instability, presence of os subfibulare, and preoperative functional score between the early RTP and late RTP groups.

Conclusions

The RTP was 83.3% at 4 months after lateral ankle ligament repair and 100% at 8 months postoperatively. The results provide reference data for orthopedic surgeons in evaluating surgical results and informing patients about expectations after surgery in terms of performance level and timing of return to sports.

Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability

BACKGROUND

The surgical treatment of chronic ankle instability (CAI) relies chiefly on anterior talo-fibular ligament (ATFL) repair (with or without augmentation) or anatomical reconstruction with a tendon graft. Arthroscopy enables not only a complete assessment and the same-stage treatment of concomitant articular lesions, but also an accurate assessment of ligament lesions. Pre-operative imaging studies (MRI, CT, US) may fail to provide sufficient detail about chronic ATFL lesions to guide the decision between repair and reconstruction. The aim of this study was to develop an arthroscopic classification of chronic ATFL lesions designed to assist in selecting the optimal surgical technique.

MATERIAL AND METHODS

Sixty-nine anterior ankle arthroscopy videos recorded before surgery for CAI were studied retrospectively. ATFL dissection was performed in all patients. Based on the video analysis, five ATFL grades were identified: 0, normal ATFL thickness and tension; 1, ATFL distension with normal thickness; 2, ATFL avulsion with normal thickness; 3, thin ATFL with no resistance during the hook test; and 4, no ATFL, with a bald malleolus. Intra- and interobserver reproducibility of the arthroscopic classification of chronic ATFL lesions was evaluated by computing the kappa coefficients (κ) after assessment by two independent observers.

RESULTS

All 69 ATFLs were classified as abnormal (none was grade 0). Each ATFL could be matched to a grade. Intra-observer agreement was good for both observers: κ was 0.67 with 75% of agreement for one observer and 0.68 with 76% of agreement for the other observer. Inter-observer agreement was fair to good, with κ values ranging from 0.59 to 0.88 and agreement from 70% to 91%.

DISCUSSION

Arthroscopic ATFL dissection is a simple procedure that provides a highly accurate assessment of ATFL lesions and mechanical resistance, focussing chiefly on the superior ATFL. Grade 1 and 2 lesions can be repaired using the Broström-Gould procedure, whereas grade 3 and 4 lesions require anatomic reconstruction with grafting.

CONCLUSION

This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI. It is helpful for determining the best surgical technique for stabilising the ankle. These results must be confirmed in a larger study.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients

BACKGROUND

Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques.

MATERIAL AND METHODS

Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports.

RESULTS

The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients.

DISCUSSION

Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery.

CONCLUSION

Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.

Posttraumatic Subfibular Ossicle Formation in Children: Experience in a Single Primary Care Unit

BACKGROUND

Although subfibular ossicles have been linked to various clinical problems, whether its origin is congenital or traumatic remains unclear. The objectives of this study were to determine the incidence of subfibular ossicle formation after ankle inversion in children.

METHODS

Among 896 pediatric patients who visited a single primary care unit after foot and ankle trauma, 593 patients sustaining ankle inversion injury were included in this study. For each pediatric patient, physical examination and radiographic examination were performed. The incidence of subfibular ossicle was evaluated based on initial radiographic examination. To analyze the incidence of unprecedented subfibular ossicle formation after ankle inversion injury, radiographs of 188 patients who were followed up for >6 months were evaluated according to the grade of initial injury.

RESULTS

At initial visit, 1.0% of examined ankles (12 from 1186 ankles) showed well-corticated subfibular ossicle not related to initial injuries. Overall incidence of subfibular ossicle at final follow-up after ankle inversion injury was 39.4% (74/188). Incidence of subfibular ossicle at final follow-up was associated with initial injury grade. As for the morphology of ossicle, 93.2% (55/59) of cases with wafer bone fragment at the time of initial injury became oval or round-shaped subfibular ossicle at final radiograph.

CONCLUSIONS

The chance of ossicle formation after ankle inversion injury was substantially high in pediatric population. On the basis of the findings of our study, we carefully suggest that majority, if not all, of subfibular ossicles would be posttraumatic in pediatric period.

LEVEL OF EVIDENCE

Level IV-case series.

Activity Level and Function 2 Years After Anterior Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair Procedures

BACKGROUND

The open modified Broström anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. Despite recent increases in publications regarding arthroscopic repair of the anterior talofibular ligament (ATFL) for treatment of chronic ankle instability, research is lacking that compares the functional outcomes between arthroscopic repair and open repair procedures for chronic ankle instability.

PURPOSE

To compare function and activity level after arthroscopic repair versus open repair of the ATFL in patients with lateral ankle instability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent arthroscopic or open surgical Broström repair of the ATFL between January 2012 and August 2014 were invited to participate in this study. All of the patients had consented for arthroscopic repair if feasible. In cases in which arthroscopic repair was impossible, the open modified Broström procedure was performed after arthroscopy. Patients accepted a systematic rehabilitation program postoperatively. American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score were used to evaluate ankle function preoperatively and at a minimum follow-up of 2 years. Magnetic resonance imaging (MRI) was performed to evaluate the signal to noise ratio (SNR) of the repaired ATFL.

RESULTS

A total of 60 patients were included in this study. They were assigned to 1 of 2 groups according to their surgical procedure: 23 patients underwent arthroscopic repair (arthroscopic group) and 37 patients underwent open repair (open group). No patient in either group had ankle instability at follow-up postoperatively. After surgery, the AOFAS score ( P < .001), KAFS ( P < .001), and Tegner activity score ( P < .001) increased significantly in both groups. However, no significant difference was found in AOFAS score (93.3 ± 8.9 vs 92.4 ± 8.6; P = .7), KAFS (90.3 ± 12.5 vs 89.4 ± 10.6; P = .75), and Tegner score (5 ± 2 vs 5 ± 2; P = .61) between the arthroscopic group and the open group, respectively. As well, no significant difference was found in the mean SNR value of ATFL between the arthroscopic group and the open group (9.1 ± 2.7 vs 8.8 ± 2.3; P = .39, respectively).

CONCLUSION

When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. Arthroscopic ATFL repair, as a minimally invasive technique, provided favorable outcomes.