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

Both Open and Arthroscopic All-Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability

PURPOSE

To compare the return to sports and short-term clinical outcomes between the arthroscopic all-inside and the open anatomic reconstruction with gracilis tendon autograft for chronic lateral ankle instability (CLAI) patients.

METHODS

From March 2018 to January 2020, 57 CLAI patients were prospectively included with arthroscopic all-inside anatomic reconstruction (n = 31) or open anatomic reconstruction (n = 26) with gracilis tendon autograft. The patients were evaluated before operation and at 3 months, 6 months, 12 months, and 24 months after surgery. The American Orthopaedic Foot and Ankle Society score (AOFAS), visual analog scale (VAS), and Karlsson-Peterson score were evaluated at each time point, and stress radiography with a Telos device was performed before surgery and at final follow-up. The time to return to full weightbearing walking, jogging, sports, and work, Tegner activity score, and complications were recorded and compared.

RESULTS

All the subjective scores significantly improved after surgery from the preoperative level. Compared with the open group, the arthroscopic group demonstrated significantly earlier return to full weightbearing walking (8.9 vs 11.7 weeks, P < .001), jogging (17.9 vs 20.9 weeks, P = .012), and recreational sports (22.4 vs 26.5 weeks, P = .001) with significantly better AOFAS score and Karlsson score at 3 to 6 months, and better VAS score at 6 months after surgery. The 2 groups demonstrated no significant difference in the surgical duration or surgical complications. No significant difference was found in the clinical scores or stress radiographic measurements at 24 months after surgery (P > .05).

CONCLUSION

Compared with the open procedure, the arthroscopic all-inside anatomic lateral ankle ligament reconstruction with autologous gracilis tendon could achieve earlier return to full weightbearing, jogging, and recreational sports with less pain and better ankle functional scores at 3 to 6 months after surgery. Similar favorable short-term clinical outcomes were achieved for both techniques at 2 years after surgery.

STUDY DESIGN

Level I, randomized controlled trial.

Re-injury after arthroscopic anatomical reconstruction of the lateral ankle ligaments treated by a new arthroscopic anatomical reconstruction: A case report

INTRODUCTION AND IMPORTANCE

Lateral ankle ligament reconstruction failures are increasingly frequent. To our knowledge no reports of using a new arthroscopic anatomical reconstruction with a gracilis autograft to treat an ankle re-injury have been described.

CASE PRESENTATION

A 19-year-old man presented with a right ankle injury resulting in isolated lateral ankle instability. The clinical examination showed significant laxity. The MRI confirmed a grade 3 tear of the lateral ligament complex. Arthroscopic anatomical reconstruction with a gracilis autograft was performed and the patient was able to return to all of his activities. Eighteen months after the primary reconstruction, he had another high-energy injury. Despite rehabilitation, he experienced isolated lateral instability. Arthrography confirmed graft failure. The patient underwent a new anatomical reconstruction with the controlateral gracilis autograft, with no difficulties. At 6 months, he had returned to all of his activities, with no limitations or discomfort.

CLINICAL DISCUSSION

Articular hypermobility, hindfoot varus and/or excess weight should be looked for or treated to explain the graft failure. Other therapeutic options are possible for revision surgery such as non-anatomical tenodesis, allografts or artificial ligaments.

CONCLUSION

Arthroscopic anatomical reconstruction of the lateral ligaments of the ankle with a new arthroscopic anatomical reconstruction procedure seems to be feasible. Other studies are needed to define the therapeutic strategy for ligament reconstruction graft failures.

Anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation for chronic lateral ankle instability with poor remnant quality: results and complications

PURPOSE

Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients.

METHODS

One hundred and eight patients with CLAI, who were treated surgically using anatomic reconstruction with allograft tendon and suspensory fixation between April 2016 and January 2018 at our hospital, were retrospectively analysed. None of the patients had sufficient ligament remnants for the modified Broström procedure during the intraoperative evaluation. Eighteen patients were excluded. Seventeen patients were lost to follow-up and 73 patients completed the study. The mean duration of instability symptoms was 39.1 months (range, 6-480 months). The mean follow-up time was 57.5 months (range, 48-69 months). Clinical results were evaluated using the Karlsson scoring scale, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score, visual analogue scale (VAS), patients' subjective satisfaction, and incidence of complications. Mechanical stability was evaluated using the varus talar tilt angle (TTA) and anterior talar displacement (ATD).

RESULTS

The AOFAS-AH scores significantly improved from 67.7 ± 8.5 points to 89.8 ± 9.5 (p < 0.001). The Karlsson scoring scales evolved from 58.8 ± 16.5 to 88.4 ± 11.2 (p < 0.001). VAS scores significantly decreased from 2.9 ± 1.3 to 1.1 ± 1.0 (p < 0.001). On stress radiographs, TTA decreased from 15.1 ± 2.5 degrees to 5.8 ± 2.1 degrees (p < 0.001), whereas ATD reduced from 13.4 ± 2.9 mm to 5.7 ± 1.5 mm (p < 0.001). Patients' subjective satisfaction indicated 46 excellent, 20 good, 5 fair, and 2 bad results. Postoperatively, 15 cases (20.5%) did not achieve complete relief of discomfort or swelling, 9 cases (12.3%) experienced joint stiffness or decreased range of motion, and 6 cases (8.2%) had soft tissue irritation. Residual instability and reoperation are rare. Allograft rejection or wound infection was not observed.

CONCLUSION

For the CLAI patients with poor remnant quality, anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation is an effective procedure, while the top three complications in incidence were residual discomfort, joint stiffness, and soft tissue irritation.

LEVELS OF EVIDENCE

Level IV, retrospective case series.

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.

Ankle Instability

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.