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

Anterior Talofibular Ligament Repair in Combination With Anterior Tibiofibular Ligament Distal Fascicle Transfer for The Treatment of Chronic Lateral Ankle Instability: A Finite Element Analysis

In recent years, anterior tibiofibular ligament-distal fascicle transfers for anterior talofibular ligament augmentation repair have proposed. However, a comprehensive biomechanical study on the anterior tibiofibular ligament-distal fascicle transfer is still lacking. We are established four distinct groups, namely the normal, the anterior talofibular ligament rupture, the anterior talofibular ligament repair, and the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer. We assessed the anterior drawer test and varus stress test of the ankle in each group. Moreover, we employed the model to simulate and compute the total displacement and von-Mises stress of the talus cartilage at varying gait phases, including foot strike, tibia vertical, and toe-off phases. The results of the anterior drawer test and varus stress test revealed that the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group exhibited greater closeness to the normal group. Regarding von-Mises stress in cartilage, the three gait instants had higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Nevertheless, regarding total displacement, the toe-off phases exhibited higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Using ATiFL-DF transfer to augment ATFL repair is a potential feasible procedure. However, this procedure could potentially compromise the anterior tibiofibular ligament's contribution to the dynamic stability of the ankle. Therefore, we recommend conducting further in-depth research to ensure the suitability and success of this technique in a clinical environment.

Comparison of Knot-Tying Techniques During the Arthroscopic Broström-Gould Procedure: Semiconstrained Freehand Versus Knot Pusher Techniques

Background

The arthroscopic Broström technique with or without Gould modification has been used to treat patients with anterior talofibular ligament injury who failed nonoperative management and progressed to chronic lateral ankle instability. However, some patients develop limited range of motion over the ankle joint postoperatively.

Purpose/Hypothesis

To compare the clinical outcomes and midterm functional performance of knot-tying techniques between using a knot pusher and a semiconstrained freehand tie during arthroscopic Broström-Gould procedure with inferior extensor retinaculum (IER) augmentation. It was hypothesized that the semiconstrained freehand tie would provide better plantarflexion of the ankle joint compared with the knot pusher.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 135 consecutive patients with mild-to-moderate lateral ankle instability (mean age, 42.7 years; range, 16-78 years) who underwent an arthroscopic Broström-Gould procedure from March 1, 2016, to April 30, 2022. The patients were divided into 2 groups according to the tying technique used in the Gould modification: surgical tie using a knot pusher (KP group; n = 30) or a semiconstrained freehand tie (FT group; n = 105). Radiographic parameters and ultrasound dynamic testing were examined during the preoperative assessment. Preoperative and 2-year postoperative assessments comprised American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale for pain, and 12-Item Short Form Survey (SF-12) scores.

Results

The 2 groups had no differences in age, sex, or severity distribution in the preoperative assessment. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale pain, and SF-12 scores were significantly better at the postoperative evaluation (all P < .05) in both groups. No significant difference was noted between groups in outcome scores. In the KP group, however, 7 out of 30 patients (23.3%) developed ankle stiffness with tightness when performing plantarflexion movement. No patients in the FT group reported similar symptoms.

Conclusion

For mild-to-moderate chronic lateral ankle instability, we propose an arthroscopic Broström procedure with the addition of IER augmentation using a semiconstrained freehand tie to avoid overtightening the IER. This ensures favorable patient satisfaction and clinical outcomes without limitation of plantarflexion of the ankle joint and avoids the possible complication of stiffness with plantarflexion.

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.

Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability

PURPOSE

Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair.

MATERIALS AND METHODS

Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed.

RESULTS

The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05).

CONCLUSIONS

Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

LEVEL OF EVIDENCE: 4

High body mass index is not a contraindication for an arthroscopic ligament repair with biological augmentation in case of chronic ankle instability

PURPOSE

Obesity remains frequently mentioned as a contraindication for lateral ankle ligament repair. The aim of the study was to compare the clinical results of an arthroscopic lateral ligament repair with biological augmentation between patients with a body mass index (BMI) of more than 30 and less than 30.

METHODS

Sixty-nine patients with an isolated lateral ankle instability were treated with an arthroscopic anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER). Patients were divided into two groups according to their BMI: ≥ 30 (Group A; n = 26) and < 30 (Group B; n = 43). Patients were pre-and post-operatively evaluated, with a minimum of 2 years follow-up, and using the Karlsson Score. Characteristics of the patients, complications, ankle instability symptoms recurrence, and satisfaction score were recorded.

RESULTS

In group A, the median Karlsson Score increased from 43.5 (Range 22-72) to 85 (Range 37-100) at follow-up. Complications were observed in seven patients (27%). Nineteen patients (73%) reported that they were "very satisfied". One patient (4%) described persistent ankle instability symptoms. In group B, the median Karlsson Score increased from 65 (Range 42-80) to 95 (Range 50-100) at follow-up. Complications were observed in four patients (9%). Thirty-three patients (77%) reported that they were "very satisfied". Two patients (5%) described persistent ankle instability symptoms. Pre-operative and at last follow-up Karlsson Score, results were significantly different between the two groups. There was no significant statistical difference in favour of satisfaction score, complications and recurrence of ankle instability between the two groups.

CONCLUSION

ATFL repair with biological augmentation using IER gives excellent results for patients with BMI ≥ 30. Compared to patients with BMI < 30, they present a slightly lower preoperative and postoperative Karlsson score, however, with a similar satisfaction rate, but are at higher risk of transient superficial peroneal nerve dysesthesia.

LEVEL OF EVIDENCE

Level III.

Arthroscopic modified Broström procedure achieved similar favorable short term outcomes to open procedure for chronic lateral ankle instability cases with generalized joint laxity

PURPOSE

To compare the short-term clinical outcomes of the open versus arthroscopic modified Broström procedure in generalized joint laxity (GJL) patients.

METHODS

From January 2018 to January 2020, 64 consecutive patients with chronic lateral ankle instability (CLAI) and GJL (Beighton score ≥ 4) were prospectively enrolled into two groups: those who underwent the open modified Broström procedure (open group, n = 32) and those who underwent the arthroscopic modified Broström procedure (arthroscopic group, n = 32). Patients underwent an open or arthroscopic modified Broström procedure based on the time when they attended the clinic for consultation. All patients were followed-up at 3, 6, 12, and 24 months postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Karlsson score, and the radiographic outcomes were assessed using stress radiography at 24 months postoperatively. The time to return to work and the failure rate were also evaluated and compared.

RESULTS

Follow-up was completed for 31 patients in the open group and 30 patients in the arthroscopic group. No significant differences were found between the two groups in terms of demographic characteristics, Beighton score (6.2 ± 1.9 vs. 5.5 ± 1.4, n.s.), or duration of symptoms. There were no significant differences in the functional scores before surgery and at 6, 12 and 24 months postoperatively or in the mean anterior translation of the talus and talar tilt angle on stress radiography at 24 months postoperatively between the open and arthroscopic groups. Compared to the open group, the arthroscopic group showed a significantly earlier return to work (6.8 ± 2.1 vs. 8.1 ± 2.4 weeks, p = 0.006). There was no significant difference in terms of the failure rate between the open and arthroscopic groups (16.1% vs. 23.3%, n.s.).

CONCLUSION

Arthroscopic modified Broström procedure achieved similar short-term outcomes to the open procedure for GJL patients. Arthroscopic modified Broström procedure showed an earlier return to work than the open modified Broström procedure and was an alternative to open surgery for CLAI patients with GJL.

LEVEL OF EVIDENCE

III.

CLINICAL TRIAL REGISTRATION

This study is a prospective study NCT05284188.

Double-bundle reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon

BACKGROUND

Anatomic anterior talofibular ligament (ATFL) reconstruction with autologous single-bundle tendon has been widely used in the treatment of ATFL injury. However, there are few clinical reports of using the peroneus brevis tendon (PBT) for double-bundle ATFL reconstruction. The aim of this study was to investigate the clinical effect of double-bundle ATFL reconstruction with PBT.

METHODS

This was a retrospective review of all patients diagnosed with ATFL injury presenting from August 2019 to December 2021. Fifty-three patients were selected after screening based on the inclusion and exclusion criteria. The following data were compared before and after surgery: Visual Analogue Scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), the pain interference (PI) and physical function (PF) scores of the Patient-Reported Outcomes Measurement Information System (PROMIS), the diameter and width of PBT in ultrasound and muscle strength.

RESULTS

All functional scores (VAS, PI/PF, AO-FAS, KAFS) and muscle strength were significantly improved at the last follow-up (P < 0.05). The diameter and width of the PBT on ultrasound postoperation were smaller than those preoperatively.

CONCLUSION

Double-bundle ATFL reconstruction with the partial PBT technique is a feasible, anatomic reconstruction technique for chronic lateral instability of the ankle, which meets the anatomical characteristics of the double bundle of the ligament, and the absence of partial PBT does not affect the peroneal muscle strength.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Another Look at Fatigued Individuals with and without Chronic Ankle Instability: Posturography and Proprioception

Fatigue can impair function of the three sensory systems (vestibular, visual, and somatosensory) that control postural balance. Yet impairment may be greater among individuals with than those without chronic ankle instability (CAI). The present study used posturography assessment to extend previous findings demonstrating reduced function of the three systems in CAI participants following fatigue. Our aim in this study was to examine the influence of anaerobic and aerobic protocols on the function of these three sensory systems in individuals with and without CAI. We assessed 60 healthy physical education students (Mage = 24.3, SD = 3.4) by a Tetrax® Posturography device for Stability-Index and Fourier-frequencies [low sway (F1) visual input, medium-low sway (F2-F4) vestibular input, medium-high sway (F5-F6) somatosensory input] and by the Active Movement Extent Discrimination Assessment (AMEDA) for active ankle somatosensory ability, before and after performing anaerobic or aerobic protocols. Among participants, 45% were identified with CAI. We found significant Time effect (pre-post), CAI effect, and CAI X Time interactions for Fourier frequencies, Stability-Index, and AMEDA scores, indicating greater pre-post deterioration for those with CAI compared to those without CAI (p < .05). CI (95%) showed that, although there was a Time effect for F1, F2-F4, and F5-F6, only F5-F6 frequencies (i.e., somatosensory input) showed the CAI effect and the Time X CAI interaction. Thus, participants with and without CAI showed reduced visual, vestibular, and somatosensory ability following fatigue. While we found greater deterioration in both passive and active somatosensory ability (F5-6 and AMEDA) among individuals with CAI compared with those with no-CAI, we recommend intervention programs for improving vestibular abilities following fatigue in both those with and without CAI.

EVALUATION OF POSTURAL BALANCE INDICATORS IN HEALTHY INDIVIDUALS

OBJECTIVE

The aim: To determine and generalize the indicators of stabilometry in healthy individuals for their further use as a control group in studies of pathologies of the musculoskeletal system.

PATIENTS AND METHODS

Materials and methods: The study was conducted on a stable platform with biofeedback TYMO (Tyromotion). 30 male and female patients aged 18-25 years participated in the study. The following indicators were studied : distance traveled, medial-lateral deviation, anterior-posterior deviation, area of the statokinesiogram (COF), average speed, feedback system, Romberg index. Stabilometry was performed in a bipodal position, standing, in four functional positions: on a hard surface with eyes open and closed, on a soft surface with eyes open and closed.

RESULTS

Results: The reference values of the stabilometric parameters: the traveled distance, medio-lateral deviation, anterior-posterior deviation, the area of the statokinesiogram, the average speed, the feedback system, the Romberg index in healthy individuals aged 18-25 years were determined . When evaluating the feedback system, it was established that the visual component was 34% (32.0; 36.0), the vestibular 34% (32.0; 35.0), the somatosensory 33% (30.0; 36.0). The reflex-driven index was 0.55 (0.46, 0.62), the central nervous system (CNS)-driven index was 1.55 (1.25, 1.89) . The Romberg index M1/ M2 was 0.94 (0.78, 1.07), M2/M3 was 0.98 (0.86, 1.10).

CONCLUSION

Conclusions: The obtained indicators of movement in the sagittal plane, the area of the statokinesiogram, the average speed of movement, the feedback system (visual, vestibular, proprioceptive (somatosensory) components), the Romberg index (RI) can be considered reference values for healthy individuals aged 18-25 years .

Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture

Background

Anatomic repair of anterior talofibular ligament (ATFL) is used to manage chronic lateral ankle instability (CLAI). However, the optimal suture configuration used to repair the ATFL is not yet determined. It remains unclear whether suture configuration affects clinical outcomes in such patients.

Purpose

To compare the functional outcomes of all-inside arthroscopic ATFL repair using either a loop suture and or a free-edge suture configuration in CLAI patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

This retrospective cohort study included 71 patients with CLAI who had undergone an all-inside arthroscopic ATFL repair procedure with either loop suture (n = 36) or free-edge suture (n = 35) from February 2016 to July 2018. Comparable pre-operatively, the Visual analogy score (VAS), American Orthopedic Foot and Ankle Society scoring system (AOFAS), Karlsson Ankle Functional Score (KAFS) scoring system, Anterior Talar Translation (ATT) and Active Joint Position Sense (AJPS) were used to evaluate postoperative ankle function.

Results

There were no postoperative wound complications, implant reactions, or neurological or vascular injuries. Postoperative hospitalization, VAS, AOFAS, KAFS, AJPS and the time of return to sport were similar between the loop suture group and free-edge suture group. Requiring a longer procedure time, patients with loop suture configuration achieved better ATT.

Conclusion

All-inside arthroscopic ATFL repair procedure for CLAI treatment provides better ATT and comparable functional outcomes when a loop suture configuration is used instead of a free-edge suture configuration. A statistical difference in ATT was observed. Given the relatively short follow-up, it is questionable whether this will have any clinical relevance.

Functional results of modified Mason-Allen suture versus horizontal mattress suture in the arthroscopic Broström-Gould procedure for chronic ankle instability

Background

The arthroscopic Broström–Gould procedure (ABG) gained particular attention among clinicians and researchers due to its high rate of satisfactory results. There is a lack of evidence regarding the differences in clinical outcomes for the various suture techniques. The purpose of this study was to compare the differences in clinical effect in patients treated with one-anchor modified Mason–Allen suture or two-anchor horizontal mattress suture for chronic ankle instability (CAI).

Methods

This retrospective cohort study examined CAI patients who underwent either one-anchor modified Mason–Allen suture or two-anchor horizontal mattress suture ABG between January 2018 and January 2020. Patients were divided into two groups based on the suture knot type used and the associated number of anchors. The operative time, surgical cost, Visual Analog Scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) Score, Karlsson Ankle Functional Score (KAFS), the rate of return to sports, complications, and measured biomechanical strength using standardized equipment were compared between groups.

Results

Sixty-four CAI patients were included (one-anchor modified Mason–Allen suture group n = 30, two-anchor horizontal mattress suture group n = 34). Compared to the two-anchor horizontal mattress suture group, the one-anchor modified Mason–Allen suture group had significantly shorter operative time (p < .001) and lower surgical cost (p < .001). There were no postoperative complications in the two groups, and no significant differences in the VAS, AOFAS, KAFS, and rate of return to sports in postoperative follow-up between the two groups at 1 and 2 years after surgery. There was no statistically significant difference in biomechanical strength anterior drawer test displacement (p > .05) between the one-anchor modified Mason–Allen suture and two-anchor horizontal mattress suture at 2 years after surgery.

Conclusion

ABG using a one-anchor modified Mason–Allen suture showed comparable clinical results to a two-anchor horizontal mattress suture in the treatment of CAI at intermediate-term follow-up time. However, one-anchor modified Mason–Allen suture may be a faster, simpler, cost-effective substitute technology.

Level of evidence

Level III, comparative study.

Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques

Background

There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability.

Methods

Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24—36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded.

Results

At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77—100), 90.17 ± 4.64 (range, 85—100) and 0.53 ± 0.63 (range, 0—2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered.

Conclusions

The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization.

Nonanatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair With a High-Position Anchor versus Anatomic Repair: An Analysis Based on 3D CT

BACKGROUND

In patients with chronic ankle instability, it is important to repair the anterior talofibular ligament (ATFL) at the anatomic origin site. However, there are limited reports on the clinical outcomes according to anatomic ATFL repair.

PURPOSE

To compare the clinical outcomes after arthroscopic ATFL repair according to whether the anchor is fixed at an anatomic position.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair for chronic ankle instability and were available for a minimum 2-year follow-up. The patients were divided into 3 groups according to the anchor position at the distal fibula on 3-dimensional computed tomography: anatomic arthroscopic ATFL repair (anatomic group), subanatomic arthroscopic ATFL repair (subanatomic group), and nonanatomic arthroscopic ATFL repair (nonanatomic group). The visual analog scale for pain, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score were measured as subjective outcomes. Posturographic analysis and radiologic evaluation using stress radiographs and axial view magnetic resonance imaging were performed as objective outcomes.

RESULTS

Of 96 patients, 16 were excluded per the exclusion criteria, and 80 were evaluated (anatomic group, n = 24; subanatomic group, n = 42; nonanatomic group, n = 14). The mean age of the patients was 34.5 years, and the mean follow-up period was 27.4 months. A between-group comparison revealed significant differences in FAOS, Karlsson score, and fall risk evaluated by posturography at the final follow-up. Post hoc analysis revealed that the anatomic group had better clinical scores on the FAOS than did the nonanatomic group in all 5 domains (all P < .017). Patients in the anatomic and subanatomic groups had better Karlsson scores and fall risk than those in the nonanatomic group (P = .004 and P = .013, respectively). In terms of objective outcomes, patients in the anatomic and subanatomic groups had better outcomes in fall risk than did those in the nonanatomic group (both P = .001). There were no differences in clinical scores and objective outcomes between the anatomic and subanatomic groups.

CONCLUSION

Nonanatomic ATFL repair showed inferior outcomes when compared with anatomic ATFL repair. When arthroscopic ATFL repair is performed, the anchor should be fixed in the anatomic position to improve prognosis.