Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery

BACKGROUND

Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments.

METHODS

A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention.

RESULTS

Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months.

CONCLUSION

The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The precision of technical aspects in the minimally invasive Broström-Gould procedure: a cadaveric anatomical study

BACKGROUND

A comprehensive understanding of the anatomy of the anterolateral ankle joint and its interrelationships is essential for advancing the development of minimally invasive Broström-Gould procedure, thereby enhancing surgical efficacy and minimizing postoperative complications.

METHODS

Ten fresh human ankle specimens were dissected to observe the shape and trajectory of the lateral bundle of the inferior extensor retinaculum (IER) and its relationship with the deep fascia. To observe the relationship between the ankle capsule and the anterior talofibular ligament (ATFL). The center of the insertion point of ATFL at the lateral malleolus was used as the reference point. The vertical distance from the reference point to the fibula tip, the horizontal distance from the reference point to the lateral branch of the superficial peroneal nerve, the shortest distance from the reference point to IER, the narrowest width of the IER, the angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula were measured. The tension and elasticity of ATFL was understood. To describe the minimally invasive Broström-Gould procedure according to the anatomical characteristics of the anterolateral ankle joint.

RESULTS

Among the 10 cases, 8 cases (80%) had double bundles of ATFL, 2 cases (20%) had single bundle of ATFL, and no outer superior oblique bundle was observed in IER. The vertical distance from the reference point to the fibula tip was 1.2 ± 0.3 (range 1.1-1.3) mm. The shortest distance from the reference point to the level of the superficial peroneal branch was 28.2 ± 4.3 (range 24.5-32.4) mm. The shortest distance from the reference point to IER was 12.5 ± 0.6 (range 12.1-12.9) mm, and the width of IER at this point was 7.2 ± 0.3 (range 7.0-7.6) mm. The angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula was about 60° ± 2.8° (range 58.1°-62.1°) mm. The space between the anterolateral deep fascia of the ankle joint and the ankle capsule is very small, and only a few fat granules are separated between them. The ATFL is largely fused to the ankle capsule. The ATFL exhibited high tension and poor elasticity after traction with the probe hook.

CONCLUSIONS

The results showed that in the minimally invasive Broström-Gould technique for lateral ankle stabilization, the Broström procedure actually sutured the insertion of the ATFL together with the ankle capsule to the anterior edge of the lateral malleolus. In the Gould procedure, the deep fascia was mostly reinforced with the ankle capsule. The minimum suture span was obtained when the Gould suture needle direction was at an Angle of 60° to the longitudinal axis of the fibula.

Bröstrom Repair Review

Since its introduction in 1966, the Bröstrom repair has been the workhorse for the treatment of chronic ankle instability. The procedure has expanded with the advent of arthroscopy, ultrasound, and other techniques. Because chronic ankle sprains/instability pose a barrier to athletes who perform high-level activities for a living, discussions concerning postoperative recovery and return to play criteria are important. Here we present an update on the Bröstrom-Gould procedure from preoperative management to return to play.Level of Evidence: Level V.

Technique Variation in the Surgical Treatment of Lateral Ankle Instability

INTRODUCTION

Lateral ankle sprains are the most common type of injury to the ankle and can lead to ankle instability. There are many described techniques for the surgical treatment of lateral ankle instability. The purpose of this study is to quantify the variation in surgeon technique for lateral ankle instability treatment.

METHODS

Surveys were sent to 62 orthopaedic foot and ankle surgeons regarding surgical technique for the treatment of lateral ankle instability. Clinical agreement was defined as greater than 80% agreement to assess the cohesiveness of surgical methods as described by Marx et al. Results. Response rate was 49/62 (79%). There was clinical agreement for not using bone tunnels and not using metal anchors. All other factors lacked clinical agreement. A greater average number of throws and knots (4.2 for each, range 1-6 throws, range 2-12 knots) were used by surgeons that do not believe knots cause pain compared to an average of 3.9 (range, 1-6) throws and 4.0 (range, 2-15) knots by surgeons who do believe knots cause pain. The association that surgeon who believed knots do cause pain and thus used fewer knots and throws was not statistically significant (P > .05). The preferred material by surgeons in our study are as follows: nonabsorbable braided suture (26/49, 53%), suture tape (15/49, 31%), and fiber tape (4/49, 8%). Among surgeons who use absorbable suture (34/49, 69%), there was no significant difference (P > .05) between surgeons who believe knots cause pain (23/34, 68%) and those who do not (11/34, 32%).

DISCUSSION AND CONCLUSION

Among this small sample of orthopaedic foot and ankle surgeons, there is wide variation in surgical technique for lateral ankle instability treatment and little agreement on the clinical standard of care. This disagreement highlights the need for comparative outcome studies in the treatment of ankle instability.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Medium-Term Outcomes of the Arthroscopic Brostrom Procedure: A Retrospective Analysis of 66 Patients

The arthroscopic Brostrom procedure is a minimally invasive technique that is a viable option surgeons have to treat patients with chronic lateral ankle instability (CAI). Our hypothesis was that there will be a statistically significant difference in pre- and postoperative scores and that patient satisfaction scores remained consistent at a minimum of 5 years postoperatively. Preoperative American Orthopedic Foot and Ankle (AOFAS) hindfoot scores, visual analog scale (VAS), foot function index (FFI) were compared with postoperative scores. Karlsson-Peterson (KP) scores were assessed at the final follow-up. Unpaired t tests were performed to determine if there was a statistically significant difference in AOFAS, VAS and FFI scores. Mean preoperative scores were (AOFAS) 51.8, (VAS) 7.36, and (FFI) 83.5, respectively. At the 5-year mark, the postoperative scores were 88.9, 2.24, 18.4 respectively and 83.6, for the KP scores. Furthermore, we compared those patients with a BMI <30 kg/m2 to those with a BMI ≥30 kg/m2. This comparison showed no statistically significant postoperative difference between groups at 5 years. The aim of the study was to determine the longevity of the procedure based on 5-year outcomes scores comparing preoperative and 5+-year AOFAS, VAS, and FFI scores. We found that there was a significant difference in all scores which suggests that this repair provides adequate relief of pain and improved outcomes at 5 years.

Arthroscopic all-inside ligament repair has similar or superior clinical outcomes compared to open repair for chronic ankle instability without concomitant intra-articular pathology at 5 years follow-up

PURPOSE

Open ligament repair is widely considered the gold standard treatment for chronic ankle instability. Nevertheless, arthroscopic treatment of ankle instability has gained popularity becoming the preferred technique for many surgeons. This study aimed to compare the clinical outcomes of all-inside arthroscopic versus open lateral ligament repair for chronic ankle instability at 5 years follow-up.

METHODS

Ninety consecutive patients were surgically treated for chronic ankle instability without concomitant intra-articular pathology observed on MRI: 41 patients [median age 28 (range 15-54) years] underwent an open lateral ligament repair (OLR); 49 patients [median age 30 (range 19-47) years] underwent an all-inside arthroscopic ligament repair (ALR). Functional outcomes using the Foot Functional Index (FFI), the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score, and the Foot and Ankle Ability Measure-Sports Subscale (FAAM-SS) were assessed preoperatively and at the latest follow-up. At the latest follow-up, the satisfaction rate and complications were also recorded.

RESULTS

The mean follow-up was 58 ± 17.6 (range 47-81) months. In both groups FFI, AOFAS and FAAM-SS score significantly improved compared to preoperative values (p < 0.001). There was no statistically significant difference in postoperative outcomes between groups in the AOFAS (n.s) and FAAM-SS (n.s), but the FFI results were significantly better in the ALR group (p < 0.05). No major complications were reported in either group.

CONCLUSION

Open and arthroscopic ligament repair to treat chronic ankle instability without concomitant intra-articular pathology produced excellent comparable clinical outcomes at 5 years follow-up. The complications were minimal in both study groups with no significant differences in AOFAS and FAAM-SS scores. However, arthroscopic repair showed significantly better results on the FFI. Therefore, when treating chronic lateral ankle instability, surgeons should consider arthroscopic ligament repair.

LEVEL OF EVIDENCE

III.

Anterior Talo-Fibular Ligament Reconstruction With InternalBrace™ for Chronic Lateral Ankle Instability in Pediatric Patients

INTRODUCTION

Ankle injuries and instability in a pediatric age group are common problems and often underreported. The injuries can range from a relatively benign ankle sprain to pain-limiting ankle instability that can inhibit the child from participating in sporting activities. However, conservative management and physiotherapy are the mainstay of treatment; a small group of patients present with persistent instability and benefit from surgical intervention in lateral ligament reconstruction. Our study looked at pediatric patients who had instability following failed conservative management.

METHODS

Retrospective analysis of 14 patients with Chronic lateral Ankle instability (CLAI) who underwent Modified Brostrom-Gould repair( MBG) with or without Internal brace augmentation between January 2015 and October 2020. Patients were evaluated for the visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), subjective satisfaction, and return to preinjury activity level.

RESULTS

Pain score improved from 8 (average 5-9) to 1 (average 0-3) following surgery. Functional assessment was made by assessing the Manchester Oxford questionnaire pre-and postoperatively. MOxFQ scores improved from 64 (8 SD) to 7 (15 SD). Thirteen of fourteen patients returned to normal sporting activities at the final follow-up.

CONCLUSION

Modified Brostrom-Gould with InternalBrace™ augmentation is an excellent procedure for chronic lateral ligament injuries in the Paediatric population. It can be safely performed if we respect the anatomy and the physeal growth plate. It allows faster rehabilitation and return to preinjury activity level.

Isolated Anterior Talofibular Ligament (ATFL) vs Combined ATFL and Calcaneofibular Ligament Suture Tape Augmentation for the Treatment of Lateral Ankle Instability: Are Outcomes Equivalent?

Background

The Broström procedure with suture tape augmentation has become commonplace for surgical treatment of chronic lateral ankle instability. However, there is no consensus among surgeons whether internal bracing of the ATFL alone or a combined ATFL and calcaneofibular ligament (CFL) internal brace produces superior clinical outcomes. This retrospective study aims to investigate whether isolated internal bracing of the ATFL has comparable outcomes to combined ATFL and CFL brace.

Methods

There were 85 patients from a single tertiary medical center's electronic medical record identified who underwent an ATFL or ATFL and CFL reconstruction between January 2017 and December 2020. Postoperative outcomes including patient satisfaction, ankle instability, ankle pain, and the need for revision surgery at 1-year follow-up were evaluated.

Results

Forty-eight patients underwent isolated ATFL reconstruction, and 37 underwent combined ATFL and CFL reconstruction. The choice was made between the 2 options based on surgeon preference. At 1-year follow-up, postoperative outcomes were statistically indistinguishable between the 2 treatment groups.

Conclusion

The modified Broström reconstruction with ATFL and CFL reconstruction with an internal brace did not produce superior functional outcomes measured at 1 year compared to isolated ATFL reconstruction. Further investigation of long-term functional outcomes is needed to evaluate the long-term efficacy of combined or single-ligament reconstruction.Level of Evidence: Level III, retrospective study.

Rotational ankle instability: A current concept review

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

Immediate Unrestricted Weightbearing With Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization

OBJECTIVE

To report on a series of patients treated with immediate unrestricted weightbearing with limited protection following single anchor lateral ligament stabilization.

METHODS

Patients with chronic lateral ankle ligament instability who underwent modified Broström-Gould lateral ligament reconstruction with a single double-loaded anchor were identified. Immediate unrestricted full weightbearing in a stirrup brace was allowed the first postoperative day and accelerated physical therapy was initiated from 2 weeks. Subsequent assessment was performed at a minimum of 1-year follow-up.

RESULTS

Thirteen patients with a mean age at final follow-up of 49 years (range 21-70 years). Average follow-up was 21 months (16 to 26). American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and visual analogue scale (VAS) score improved significantly (P < .05) from preoperative to postoperative, respectively (57 to 91, 5.7 to 1.5). Average postoperative Foot and Ankle Outcome Score (FAOS) was 82 (range 52-100). Short Form-12 (SF-12) scores averaged 55 and 49 on mental component and physical components, respectively, consistent with US age-matched averages. No measurable differences in range of motion, ligamentous stability, or Star Excursion Balance Test in the anterior, posterolateral, or posteromedial planes compared to the contralateral side (P > .05) were observed. No recurrence was reported.

CONCLUSION

Immediate unrestricted weightbearing in a stirrup brace following single anchor lateral ligament reconstruction is a successful protocol for the treatment of chronic lateral ankle instability.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Current concepts in the surgical management of chronic ankle lateral ligament instability

Background/aims

Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI).

Methods

The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI.

Results

Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes.

Conclusion

Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Absorbable suture anchor and knotless anchor techniques produced similar outcomes in arthroscopic anterior talofibular ligament repair

PURPOSE

The purpose of this study is to compare absorbable suture anchor with knotless anchor techniques for arthroscopic anterior talofibular ligament (ATFL) repair.

METHOD

A multicenter retrospective study was performed with 185 patients, who had undergone an arthroscopic ATFL repair procedure using absorbable suture anchor or knotless anchor between May 2017 and October 2019. The follow-up time was a minimum of 18 months. Karlsson-Peterson score, visual analogue scale (VAS), and Cumberland ankle instability tool (CAIT) were evaluated. The complications were also recorded.

RESULTS

One hundred and seven patients underwent one absorbable suture anchor repair procedure (Group A [A]), and the other seventy-eight patients underwent one knotless anchor repair procedure (Group B [B]). At the final follow-up, both Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs post 93.5 ± 5.3, P < 0.001; B, pre 59.5 ± 8.2 vs post 92.4 ± 6.3, P < 0.001), VAS score (A, pre 5.0 ± 1.3 vs post 0.5 ± 0.7, P < 0.001; B, pre 5.5 ± 1.2 vs post 0.9 ± 1.0, P < 0.001), and CAIT score (A, pre 53.1 ± 12.0 vs post 93.1 ± 6.6, P < 0.001; B, pre 51.6 ± 12.0 vs post 93.1 ± 6.5, P < 0.001) improved significantly in both groups. There was no significant difference between the two groups regarding the Karlsson-Peterson score (A, pre 61.0 ± 8.0 vs B, pre 59.5 ± 8.2, n.s; A, post 93.5 ± 5.3 vs B, post 92.4 ± 6.3, n.s), CAIT score (A, pre 53.1 ± 12.0 vs B, pre 51.6 ± 12.0, n.s; A, post 93.1 ± 6.6 vs B, post 93.1 ± 6.5, n.s) and the change ranges of VAS (A, 4.5 ± 1.0 vs B, 4.6 ± 1.2, n.s). Anchor complications were easier to occur in Group B (0/107 vs 6/78, P = 0.007). Knot irritation slightly increased in Group A (10/107 vs 0/78, P = 0.006). No significant difference was found regarding total complication rates (A, 10/107 vs B, 6/78, n.s).

CONCLUSION

Absorbable suture anchor and knotless anchor for arthroscopic ATFL repair produced similar clinical outcomes. The ankle stability scores increased significantly in both groups. However, the knotless anchor has a higher risk to loosen, deviated direction or break, while the absorbable suture anchor still has a slim chance of knot irritation.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Primary Repair, Reconstruction, and Suture Tape Augmentation All Provide Excellent Outcomes for Lateral Ligament Instability: A Systematic Review

Purpose

To analyze the literature to compare outcomes and complications following primary lateral ankle ligament repair compared with lateral ankle ligament reconstruction and the suture tape augmentation in patients with lateral ankle instability.

Methods

Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria, a systematic literature review using the PubMed/Ovid Medline database was performed (October 11, 1947, to October 1, 2019). Clinical trials that included all the following criteria were considered eligible; published in the English language; patients undergoing primary lateral ankle repair or reconstruction with/without autograft or allograft (anterior talofibular ligament, anterior talofibular ligament + calcaneofibular ligament) or suture tape augmentation; a follow-up at least 1 year; reported least 1 of the measured outcomes (The American Orthopaedic Foot Ankle Score, Karlsson Score, return to sport [RTS], complications, skin wound complications, reoperation). Surgical techniques were evaluated, and studies were subdivided by the following categories: primary repair (PR), reconstruction with graft (GR), and suture tape augmentation (STA). Complications, radiographic outcomes, functional outcome scores, and RTS were analyzed.

Results

A total of 41 of 1,991 studies met the criteria for final analysis. This included 1,920 patients who underwent surgical intervention for chronic lateral instability with at least a 1-year follow-up. There were 350 patients who had GR, 1,486 who underwent the PR, and 84 who had STA. GR group appeared to have the lowest rate of complications: GR 3.1% (11 of 350), PR 4.2% (63 of 1486), and STA 10.7% (9 of 84). Postoperative American Orthopaedic Foot Ankle Score ranged from 89.0 to 95.1 for GR and 90.0 to 98.8 for PR. Postoperative Karlsson scores ranged from 80.9 to 94.4 for GR and from 89.2 to 94.1 for PR. Anterior drawer postoperative scores ranged from 1.4 to 30.3 mm for GR, 2.7 to 8.6 mm for PR, and 4.1 to 4.2 mm for STA. Postoperative talar tilt ranged from 2.4 to 7.3° for GR, 1.9 to 6.0° for PR, and 3.6 to 4.5° for STA. RTS ranged from 9.5 to 20.4 weeks for the PR group; one study reported a RTS of 10.6 weeks for STA.

Conclusions

Excellent outcomes were noted across all intervention groups. Current literature may suggest there is no difference in functional outcomes between patients treated with PR versus GR. However, there may be a potential improvement in functional outcomes with PR versus STA.

Level of Evidence

Level IV, systematic review of Level I to Level IV studies.

Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

INTRODUCTION

Modified Brostrom Gould (MBG) repair is widely accepted procedure for chronic lateral ankle instability (CLAI), but there are limitations with regards to strength of repair and risk of reinjury and complications. Internal brace has been recently used as augmentation of standard MBG repair. It provides stronger construct, facilitates early mobilisation and protects repaired ligament with minimal surgical morbidity. The aim of present study is to compare the outcome of MBG repair without and with Internal brace augmentation (IB) in CLAI.

METHODS

Retrospective analysis of 172 patients with CLAI who underwent MBG repair with or without IBA between November 2017 and October 2019. Patients were evaluated for Visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), Patients subjective satisfaction and return to preinjury activity level.

RESULTS

148 patients were included in the study with 87 in MBG group and 61 in IB group. The mean age, average injury-surgery interval and mean follow up duration was 40.6 ± 11.2 vs 37.5 ± 14.7 years, 13.1 ± 10.3 vs 14.1 ± 8 months and mean follow up duration of 24.2 ± 5.1 vs 20.7 ± 6.0 months respectively (p > 0.05). The mean time to return to preinjury activity level was significantly better in IB group compared to MBG group of 12.1 ± 2.3 vs 20.3 ± 3.9 weeks, p < 0.001. 55 (90.2%) patients in IB and 73 (83.7%) in MBG group return to preinjury activity level. Mean postoperative VAS score (1.9 ± 1.5 vs. 1.7 ± 1.4, p = 0.428), Mean MOxFQ score (19.7 ± 22.2 vs. 18.2 ± 15.4, p = 0.674) showed no significant difference between MBG and IB group respectively, at final follow up.

CONCLUSION

The use of IB augmentation with MBG repair showed significantly better outcome in terms of early rehabilitation and return to preinjury activity level compared to isolated MBG repair. The functional outcome and VAS score were better in IB group compared to MBG group with no significant difference.

LEVEL OF EVIDENCE

Level IV retrospective study.

Single Knotless Suture Anchor Repair of Anterior Talofibular Ligament Following Distal Fibula Nonunion Excision

Anterior talofibular ligament (ATFL) tear is the most common ankle ligament injury. This can lead to recurrent ankle instability, which is detrimental to ankle function and the patient's quality of life. Currently, several techniques have shown successful outcomes for ATFL repair. In this technical note, we describe an open ATFL repair using a single knotless suture anchor at the distal fibula location. This approach is rapid, equipment-efficient, and reproducible, while promising excellent results and high patient satisfaction by restoring ATFL anatomy.

Modified arthroscopic Broström procedure using a soft anchor for chronic lateral ankle instability: Short-term follow-up results

Objectives

This study aims to examine the clinical outcomes and complications of lateral ligament reconstruction performed using soft anchors according to the arthroscopic modified Broström technique (MBT) for the treatment of chronic ankle instability (CAI) and to evaluate the frequency of return to sports.

Patients and methods

A total of 14 patients with CAI (9 males, 5 females; mean age: 30.1±4.6 years; range, 22 to 38 years) who underwent the MBT with soft anchors between January 2015 and December 2019 were retrospectively analyzed. Ankle function was evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale and Karlsson Ankle Function Score (Karlsson/Peterson, K/D score), while pain was evaluated using the Visual Analog Scale (VAS) after a minimum follow-up of 12 months.

Results

The mean follow-up was 23.6±7.7 months. The mean overall AOFAS score was 74.0±2.6 preoperatively, which improved to 96.2±1.9 in the postoperative period (p=0.001). The mean pre- and postoperative K/P scores were 72.4±3.1 (range, 68 to 78) and 95.3±2.2 (range, 92 to 98), respectively (p=0.001). The mean preoperative VAS score was 2.4±0.9 (range, 1 to 4) and showed a significant improvement to 0.6±0.5 (range, 0 to 1) in the postoperative period (p=0.001). Nine (64.3%) patients returned to sports activities after surgery at a mean period of 9±2.1 months.

Conclusion

In the treatment of CAI, arthroscopic MBT performed with soft anchors provides successful outcomes in short-term follow-up. In addition to being a minimally invasive technique, MBT is a reliable and safe approach with low complication rates and significant functional improvement. However, the low ratio of return to sports should be considered as a failure of this technique.

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

BACKGROUND

Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device.

RESULTS

A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (-4.94° vs -7.03°; P = .415).

CONCLUSION

Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

Knotless All-Inside Arthroscopic Modified Broström Procedure for Lateral Ankle Instability

One reported complication of the arthroscopic modified Broström operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Broström operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Broström operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

Evaluation of BMI With an All Inside Arthroscopic Broström Procedure for Chronic Lateral Ankle Instability: An Analysis of 113 Patients

The all inside arthroscopic Broström surgical procedure for chronic lateral ankle instability is a minimally invasive procedure that is an option surgeons have when treating their patients. There have not been any studies analyzing the integrity of the repair to patients who have an elevated body mass index (BMI) to determine if the strength of the repair is adequate. We retrospectively evaluated a total of 113 consecutive patients who underwent this procedure. Fifty-nine patients had a BMI ≥30 kg/m²; 54 had a BMI <30 kg/m². Unpaired t tests were performed to determine if a difference in American Orthopedic Foot and Ankle Society, visual analog scale, and Foot Function Index were encountered. Our findings indicate that there is no significant difference between patients with a BMI ≥30 kg/m² compared to a BMI <30 kg/m² who undergo an all-inside arthroscopic Broström procedure for chronic lateral ankle instability. This information may help surgeons decide what procedure options are available when treating chronic lateral ankle instability.

Arthroscopic ankle lateral ligament repair alone versus arthroscopic ankle lateral ligament repair with reinforcement by inferior extensor retinaculum

PURPOSE

This study aimed to compare the clinical outcomes and postoperative activities of arthroscopic ankle lateral ligament (ALL) repair alone with arthroscopic ALL repair and reinforcement by the inferior extensor retinaculum (IER) for chronic ankle instability (CAI).

MATERIALS AND METHODS

All patients who underwent arthroscopic repair for CAI between 2017 and 2019 were evaluated. The Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q), and duration between the surgery and walking without any support, jogging, and complete return to sports were evaluated and compared. The exclusion criteria were (1) follow-up period of < 1 year after surgery, (2) the presence of associated ankle lesions requiring treatment during the same operative procedure, including patients with subfibular ossicle bigger than 5 mm on radiographs, chondral or osteochondral defect, bony impingement, deltoid ligament tear, fibular tendon pathology, or posterior ankle impingement, and (3) patients who underwent revision surgery.

RESULTS

We identified 126 patients who underwent surgery for CAI and subsequently excluded 36 patients on account of a short follow-up period (< 1 year), additional surgery, and previous surgery. The remaining 90 eligible patients included arthroscopic ALL repair alone (group A, n = 44) and arthroscopic ALL repair with reinforcement by the inferior extensor retinaculum (group G, n = 46) groups. There was no significant difference in the postoperative activities nor in the preoperative or postoperative JSSF scale and SAFE-Q between the two groups. However, significant differences were seen in the mean surgical time (15.5 ± 8.1 vs 20.1 ± 7.6, P = 0.013).

CONCLUSION

This study showed no difference in clinical outcomes between the two groups. However, arthroscopic ALL repair with reinforcement by IER resulted in a longer surgical time than arthroscopic ALL repair alone.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Is generalized ligamentous laxity a contraindication for a modified Broström operation to treat chronic lateral ankle instability? A systematic review

BACKGROUND

To investigate whether generalized ligamentous laxity (GLL) really is a contraindication for use of the modified Broström operation to treat chronic lateral ankle instability (CLAI).

METHODS

Case series and cohort studies of the clinical outcomes of the use of the modified Broström operation to treat patients with CLAI and GLL were systematically reviewed and a meta-analysis conducted.

RESULTS

A total of 447 patients (458 ankles) from 2 case series and 3 cohort studies were systematically analyzed, with mean follow-up times that ranged from 12 to 108 months. Postoperative foot and ankle values analyzed included foot and ankle outcome scores, foot and ankle ability measurements, Karlsson-Peterson ankle scores, American orthopedic foot and ankle society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, anterior talar translations (ATT), talar tilt angles (TTA) and adverse events. Reliable postoperative ankle stability was achieved in CLAI patients with GLL in the 2 case series without major complications. Suture-tape augmentation combined with a modified Broström operation was employed in 1 case series, and the modified Broström operation was only performed in CLAI patients with GLL if the contralateral uninjured ankle showed normal TTA and ATT in another case series. In the 3 cohort studies, 2 reported poorer outcomes and a significantly greater failure rate in patients with GLL compared with those without GLL, and 1 reported equivalent clinical results. In the further pooled data analysis, there was a significant difference in the postoperative TTA value between the GLL and non-GLL groups (SMD: 0.885, 95% CI [0.599-1.171], P = 0.000; I² = 98%, P = 0.000). The incidence of postoperative recurrent instability was significantly higher in the GLL group (RR: 6.265, 95% CI [2.563-15.309], P = 0.000; I² = 0%, P = 0.985). Two studies reported the preoperative Beighton score in 7 ankles with postoperative recurrent instability, 6 of which had a preoperative Beighton score ≥7.

CONCLUSIONS

GLL may not be a contraindication to the modified Broström operation being used to treat CLAI. However, some augmentation operations may be combined with the classic modified Broström operation, especially for those patients with preoperative Beighton scores ≥7, or with abnormal ATT and TTA in the contralateral ankle. This assertion should be further confirmed by a prospective, large-sample cohort and control study focused on this special population who are at a higher risk of developing postoperative instability.

LEVEL OF CLINICAL EVIDENCE

Level 3.

Ligament stabilization improved clinical and radiographic outcomes for individuals with chronic ankle instability and medial ankle osteoarthritis

PURPOSE

Chronic ankle instability with a long symptom duration is often accompanied by medial compartment ankle osteoarthritis (OA). However, the outcomes of individuals after ligament stabilization have rarely been reported. The radiographic and clinical outcomes after ligament stabilization in individuals with chronic ankle instability and medial compartment OA were investigated.

METHODS

The study investigated 27 ankles with chronic ankle instability and medial compartment OA that underwent lateral ankle ligament reconstruction from 2007 to 2015 with a follow-up period of at least 1 year. Ligament stabilization was performed via either the modified Broström procedure (MBP) or lateral ankle reconstruction (LAR) using semitendinosus tendon allografts.

RESULTS

The median instability duration was 60 (range 12-480) months, and the median follow-up period was 39 (range 12-108) months. The preoperative Takakura ankle OA stage was predominantly stage I (20 patients (74.1%)), followed by stage II (five patients (18.5%)). Ankle MRI (20 ankles) revealed medial cartilage denudation in three cases (15%), cartilage thinning in nine cases (45%), osteophyte formation in ten cases (50%), and loose body formation in six cases (30%). According to the arthroscopic results, the modified Outerbridge grade was two in nine cases and four in ten cases, so these grades were the most common (37.5% and 41.7%, respectively). The MBP was performed in 14 patients, and LAR was performed in 13 patients (52% and 48%, respectively); the bone marrow stimulation procedure was performed in 15 patients (55%). The visual analogue scale score decreased from 6.0 (SD 1.6) preoperatively to 1.8 (SD 1.6) postoperatively (p = 0.000). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 61.9 (SD 14.2) to 89.7 (SD 6.2), and the Karlsson-Peterson score improved from 54.7 (SD 13.9) to 88.3 (SD 9.0) (p = 0.000). There were no serious complications, and all patients were satisfied.

CONCLUSIONS

Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement.

LEVEL OF EVIDENCE

IV.

Evaluation of Stress Radiographs Taken Before and After Spinal Anesthesia in Patients With Chronic Ankle Instability

Stress radiography is known as an important diagnostic tool for confirming mechanical instability in patients with chronic ankle instability. However, there are no reports on how muscle guarding caused by the stress applied on the ankle during stress radiography affects test outcomes. Thus, this study aimed to analyze the effects of muscle guarding caused by stress radiography on outcomes by performing stress radiography before and after anesthesia. This is a prospective study involving 32 patients who were diagnosed with chronic ankle instability through patient history, physical examination, and magnetic resonance imaging studies. Varus and anterior drawer stress radiographs were taken before and after anesthesia in the operating room, and the findings were compared. On the post-anesthesia stress radiographs of the affected ankle, talar tilt and talar anterior translation were significantly increased by 2.55° ± 2.64° and 1.54 ± 2.03 mm, respectively (mean ± standard deviation; p < .05). These parameters were also significantly increased by 2.08° ± 2.62° and 1.27 ± 1.37 mm, p < .05, on the post-anesthesia radiographs of the unaffected ankle. Before anesthesia, 26 of 32 patients had positive stress radiographs, but 31 patients had positive results after anesthesia. Talar tilt and talar anterior translation significantly increased after anesthesia. Therefore, in CAI patients, efforts to reduce muscle guarding should be made before stress radiographs are taken. Moreover, when interpreting results, it should be noted that muscle guarding might have reduced the measurements of stress radiographs, leading to diagnostic false negatives.

Revision Surgery for Failed Lateral Ankle Stabilization

Although most primary lateral ankle ligament repairs have a high success rate, as with any surgery, failures and the need for revision can occur. Nonanatomic lateral ankle ligament repairs have fallen out of favor because of the increased stiffness and resultant change in mechanics of the functioning tendon that is normally used. Allograft anatomic lateral ankle ligament reconstruction for revision surgery has gained popularity over the last few years. This article discusses the factors that can lead to failure and the revision technique.

Diagnosis and Operation Results for Chronic Lateral Ankle Instability with Subtle Cavovarus Deformity and a Peek-A-Boo Heel Sign

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly (p=0.001), and instability did not recur. Radiographically, all stress parameters improved significantly (p=0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287).

Early Versus Delayed Mobilization Postoperative Protocols for Lateral Ankle Ligament Repair: A Systematic Review and Meta-analysis

Background:

The majority of patients with an acute lateral ankle ligamentous injury are successfully treated nonoperatively with functional rehabilitation; however, a small proportion of these patients experience persistent chronic instability and may require surgical intervention. Delayed primary repair of the ruptured ligaments is most commonly indicated for these patients. Optimal rehabilitation after lateral ankle ligament repair remains unknown, as surgeons vary in how they balance protection of the surgical repair site with immobilization against the need for ankle joint mobilization to restore optimal postoperative ankle range of motion.

Purpose:

To compare early and delayed mobilization (EM and DM, respectively) postoperative protocols in patients undergoing primary lateral ankle ligament repair to determine optimal evidence-based rehabilitation recommendations.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a meta-analysis using the PubMed/Ovid MEDLINE database was performed (October 11, 1947 to October 16, 2017), searching for articles involving lateral ankle ligament repair. Postoperative protocols were reviewed and divided into 2 categories: EM (within 3 weeks of surgery) and DM (more than 3 weeks post surgery). Return to sport (RTS), outcome scores (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot scale and Karlsson score), radiographic outcomes (talar tilt and anterior drawer), and complications of both populations were recorded and statistically analyzed.

Results:

A total of 28 of 1574 studies met the criteria for the final analysis, comprising 1457 patients undergoing primary lateral ankle ligament repair. The postoperative AOFAS score was significantly greater in the EM versus DM group (98.8 vs 91.9, respectively; P < .001), as was the postoperative Karlsson score (92.2 vs 90.0, respectively; P < .001). However, the EM group had significantly greater postoperative laxity on both the anterior drawer test (6.3 vs 3.9 mm, respectively; P < .001) and talar tilt test (5.1° vs 4.5°, respectively; P < .001). Also, the DM group had significantly lower rates of overall complications (3.1% vs 11.4%, respectively; P < .001) and skin wound complications (1.3% vs 3.8%, respectively; P = .005). RTS was not significantly different between groups (P = .100).

Conclusion:

Patients with EM postoperative protocols demonstrated improved functional outcomes; however, the EM group had increased objective laxity and a higher complication rate. Additional randomized studies are needed to definitively evaluate early versus delayed rehabilitation protocol timetables to optimize functional outcomes without compromising long-term stability.

Hamstring Autograft for Lateral Ligament Stabilization

PURPOSE OF REVIEW

This paper seeks to review the current literature and trends regarding use of hamstring autograft for lateral ankle instability.

RECENT FINDINGS

Reconstruction of the lateral ankle ligaments using hamstring autograft has been found to be an effective method to treat ankle instability in terms of patient-reported outcomes and objective measures. Biomechanically, reconstruction has been shown to be stronger (load to failure) when compared with the Broström procedure. Clinical studies have demonstrated non-inferiority when compared with the Broström procedure, with one synthetic reconstruction technique demonstrating superior outcomes. Reconstruction of the lateral ankle ligaments using hamstring autograft is especially useful in patients who are at high risk of failure (insufficient soft tissue available for repair, ligamentous laxity, previous failed ligament repair, ossicle > 1 cm, or in the heavier, high-demand athletes).

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

BACKGROUND

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

PURPOSE/HYPOTHESIS

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

STUDY DESIGN

Controlled laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Modified Broström Repair With and Without Augmentation Using Suture Tape for Chronic Lateral Ankle Instability

Objective

To compare the clinical and radiological outcome between the modified Broström repair with augmentation using suture tape (MBA) and the modified Broström repair (MB) for patients with chronic lateral ankle instability.

Methods

A retrospective study was performed in Ningbo No. 6 Hospital. The study included 53 patients who underwent surgical treatment from March 2014 to July 2016 and were followed for 2 years. A total of 25 patients underwent modified Broström repair with augmentation using suture tape, and 28 patients were treated with modified Broström repair. Patients were evaluated using the American Orthopedic Foot and Ankle Scale (AOFAS) hindfoot scale, the Foot and Ankle Ability Measure (FAAM) score, range of motion (ROM), and the visual analogue scale (VAS). The talar tilt angle (TTA) and anterior talar translation (ATT) were used to evaluate the mechanical stability. All radiological outcomes were measured by two orthopaedic surgeons, with the measurements repeated 3 days later.

Results

The mean age of the patients was 26.6 ± 17.8 years in the MBA group and 28.1 ± 19.4 years in the MB group, and no statistical difference in preoperative data was found between two groups. There were significant differences before and after the operation within the groups. Both groups achieved satisfactory outcomes, and significant improvements (VAS, FAAM, AOFAS, TTA, and ATT) were observed between the 1‐year follow‐up and final follow‐up (P < 0.05). The MBA group showed significant improvement in the FAAM Sport (87.1 ± 5.4 vs 78.2 ± 12.0, P = 0.001) and total scores (93.1 ± 2.3 vs 90.5 ± 5.1, P = 0.027) at the final follow‐up compared with the MB group, and for the other outcomes, there were no significant differences between the two groups.

Conclusion

The modified Broström repair with augmentation using suture tap for chronic lateral ankle instability achieves a better outcome; however, further research is necessary.

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 repair of chronic lateral ankle instability]

OBJECTIVE

Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies.

INDICATIONS

Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability.

CONTRAINDICATIONS

Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome.

SURGICAL TECHNIQUE

Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using a suture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing and short leg cast for 2 weeks, then 4 weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months.

RESULTS

Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to a significant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3 temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2 temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported a significantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.

A comparison of the "All-Inside" arthroscopic Broström procedure with the traditional open modified Broström-Gould technique: A review of 62 patients

BACKGROUND

The open Broström-Gould lateral ankle stabilization procedure has been the gold standard for primary lateral ankle stabilization. A new minimally invasive all-inside arthroscopic technique has been described for the correction of lateral ankle instability.

METHODS

We performed a review of patients who underwent lateral ankle stabilization by either the traditional open Broström-Gould (BG) or the All-Inside Bröstrom (AIB) technique to compare and identify any discrepancies between functional and/or patient satisfaction outcomes. A total of 62 patients underwent a lateral ankle stabilization. Of those 62 patients, 32 received a traditional open Broström-Gould procedure and 30 patients underwent an All-Inside Bröstrom type procedure. The two groups were compared preoperatively with AOFAS ankle-hindfoot scoring system and Visual Analog Score (VAS) for pain. Postoperatively, AOFAS, Karlsson Peterson and VAS scores were compared.

RESULTS

The mean preoperative VAS pain score for the open Broström-Gould was 7.28, the All-Inside Broström was 8.18. The mean postoperative VAS pain score for the open Broström-Gould was 1.2, the All-Inside Broström was 1.5. The mean preoperative AOFAS score for the Broström-Gould was 35.44, the All-Inside Broström was 35.07. The mean postoperative AOFAS score for the open Broström-Gould was 93.53, the All-Inside Broström was 95.33. The mean postoperative Karlsson Peterson score for the open Broström-Gould was 93.41, the All-Inside Broström was 91.80. The mean time to weight bearing for the Broström-Gould was 22 days, the All-Inside Broström was 12 days.

CONCLUSION

There were no statistically significant differences identified in any of the functional or patient satisfaction outcome scores using either technique. This review suggests the minimally invasive arthroscopic technique using bone anchors for lateral ankle stabilization may be comparable to the traditional open Broström-Gould with the added advantage of earlier time to weight bearing.

Clinical Outcomes of the Modified Broström Technique in the Management of Chronic Ankle Instability After Early, Intermediate, and Delayed Presentation

The modified Broström technique (MBT) is considered the reference standard for surgical management of ankle instability, with good short-term outcomes. However, limited evidence is available regarding outcomes for delayed presentations of instability. We report our outcomes for patients who underwent ligament repair using the MBT, from a single-surgeon retrospective study of consecutive patients. The minimum postoperative follow-up period was 6 months during a 5-year study period. The patients were retrospectively divided into 3 groups according to the delay in presentation: group 1, 6 months to 2 years; group 2, 2 to 4 years; and group 3, >4 years. We collected data on patient demographics, injury pattern, and intraoperative surgeon findings. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (AHS) was used to evaluate patient outcomes and satisfaction with surgery. Twenty-six patients were treated with MBT. The mean follow-up period was 36.9 (range 6-42) months. Twenty-five (96.2%) patients had unilateral injuries, and 1 (3.85%) had bilateral repairs. Of the 26 patients, 21 (80.8%) completed the AOFAS-AHS, with a mean score of 87.4 (range 12 to 100). The mean interval from injury to surgery was 47.9 months. The results were excellent in 15 (71.4%), good in 3 (14.3%), fair in 1 (4.8%), and poor in 2 (9.5%) using the AOFAS-AHS. We found no significant difference in the overall AOFAS-AHS score or postoperative satisfaction among the groups (p > .05). All patients had a stable ankle joint at their final follow-up visit. In conclusion, patients with persistent or chronic ankle instability have good clinical outcomes and satisfaction after the MBT, irrespective of the time from injury to presentation.

A chronic sinus tract infection developing after suture anchoring of the ankle: A case report

RATIONALE

Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor.

PATIENT CONCERNS

A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps.

DIAGNOSIS

A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus.

INTERVENTIONS

We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast.

OUTCOMES

The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up.

LESSONS

To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Postoperative Outcome of the Modified Broström Procedure in the Active Duty Military Population: A Retrospective Cohort Study

Ankle sprains are common injuries and typically treated conservatively. Chronic ankle instability, however, can require surgery when nonoperative measures fail. We evaluated the clinical outcomes of an active duty population in a retrospective study of patients who had undergone a modified Broström procedure at our facility from January 2010 through April 2014 by a single surgeon. The electronic medical records and Army E-profile database were reviewed to determine whether the patients had returned to active duty and whether they had any permanent postoperative lower extremity activity restrictions. A total of 127 patients met the inclusion criteria and had undergone the modified Broström procedure during the study period; 34 (26.8%) separated from the military postoperatively. Of these 34 patients, 23 (18.1%) were unfit for reasons related to their ankle and 11 (8.7%) required military separation for reasons unrelated to their ankle. Thus, 93 patients (73.2%) were able to remain on active duty after undergoing the Broström procedure. Of the 93 patients able to remain on active duty, 38 (40.9%) required activity modifications and 55 (59.1%) were able to return to full duty. Chronic ankle instability in active duty patients can be severely limiting. The modified Broström procedure can provide significant improvement in symptoms and allow patients to remain on active duty. In our high-demand population, ~73% of patients were able to remain on active duty after their injury and subsequent surgery, 60% of whom returned to their previous level of duty without any physical restrictions.

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

BACKGROUND

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

STUDY DESIGN

Controlled laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

X-shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure

PURPOSE

The inferior extensor retinaculum (IER) is an aponeurotic structure located in the anterior aspect of the ankle. According to the literature, it can be used to reinforce a repair of the anterior talofibular ligament in ankle instability. Despite its usual description as an Y-shaped structure, it is still unclear which part of the retinaculum is used for this purpose, or if it is instead the crural fascia that is being used. The purpose of this study is to define the anatomical characteristics of the IER to better understand its role in the Broström-Gould procedure.

METHODS

Twenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded.

RESULTS

Seventeen (81%) of the IER in this study had an X-shaped morphology, with the presence of an additional oblique superolateral band. This band, by far the thinnest of the retinaculum, is supposed to be used to reinforce the repair of the anterior talofibular ligament. The intermediate dorsal cutaneous nerve (lateral branch of the superficial peroneal nerve) was found to cross the retinaculum in all cases.

CONCLUSIONS

The IER is most commonly seen as an X-shaped structure, but the fact that the oblique superolateral band is a thin band of tissue probably indicates that it may not add significant strength to ankle stability. Furthermore, the close relationship of the retinaculum with the superficial peroneal nerve is another factor to consider before deciding to perform a Broström-Gould procedure. These anatomical findings advise against the use of the Gould augmentation.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review

BACKGROUND

Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Broström-Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies.

METHODS

A systematic literature review using PubMed/Medline databases was performed (July 1972-July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed.

RESULTS

The total ankles treated with an open Broström ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months-27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60-100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months-14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44-100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases.

CONCLUSIONS

The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.

A Modified Broström Repair with Transosseous Fixation for Chronic Ankle Instability: A Midterm Followup Study in Soldiers

BACKGROUND

Various surgical techniques are available to reduce chronic instability of the lateral ankle ligament complex. The most effective method for these procedures remains controversial. This report presents a surgical technique that is similar to the Broström procedure and uses a modified, nonaugmented repair technique.

MATERIALS AND METHODS

38 soldiers with a history of chronic lateral ankle instability and poor ankle function underwent plication of the anterior talofibular ligament-lateral capsule complex with transosseous fixation of the calcaneofibular ligament through a fibular bone tunnel between 2004 and 2007. This study included 33 men and 5 women with a mean age of 25.6 years (range 18-36 years) at the time of surgery. Each patient was confirmed to have a history of chronic lateral ankle instability after an inversion injury, and symptoms had been noted for at least 1 year. The patients were followed up with stress radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot functional score, and the Sefton assessment system. The mean followup period was 77.6 months (range 66-89 months).

RESULTS

At the last evaluation, the talar tilt reduced from an average of 13.9° ± 2.4° before surgery to 3.8° ± 1.8° after surgery, and anterior drawer displacement reduced from 9.6 ± 2.9 mm to 2.3 ± 1.6 mm. The mean AOFAS ankle-hindfoot scale score for functional stability increased from 71.6 ± 4.0 points preoperatively to 95.6 ± 4.0 points postoperatively. As evaluated by the Sefton assessment system, 36 patients (95%) reported an excellent or good functional outcome. All patients resumed normal daily activities and active military duty after the surgery.

CONCLUSION

The procedure described here could be considered a viable alternative option to anatomic reconstruction such as the modified Broström procedure and might be appropriate for the general population.

Comparison of Outcomes in Patients With Generalized Ligamentous Laxity and Without Generalized Laxity in the Arthroscopic Modified Broström Operation for Chronic Lateral Ankle Instability

BACKGROUND

The arthroscopic modified Broström operation (MBO) has been frequently used to treat chronic lateral ankle instability (CLAI). However, no reports comparing the clinical outcomes between patients with or without generalized ligamentous laxity (laxity or no laxity, respectively) currently exist. The purpose of this study was to compare the clinical outcomes of the 2 groups with CLAI.

METHODS

Between January 2013 and November 2015, arthroscopic MBO was performed on 99 patients with CLAI. Patients were divided into 2 groups: the laxity group (24 ankles) and no laxity group (75 ankles). Generalized ligamentous laxity was defined as a Beighton score of 4 or more points. Evaluation tools included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot ankle score, a pain visual analog scale (VAS), and talar tilt angle.

RESULTS

The change in talar tilt angle from preoperative to 12 months postoperative was significantly greater in the laxity group (-6.9 ± 5.2) compared with the no-laxity group (-4.2 ± 4.2) ( P = .03). The final follow-up AOFAS hindfoot ankle score and pain VAS in both groups showed improvement compared with the preoperative values.

CONCLUSION

All groups achieved successful clinical and radiological final follow-up outcomes. Arthroscopic MBO should be considered a reasonable method in patients who have chronic lateral ankle instability, regardless of generalized ligamentous laxity.

LEVEL OF EVIDENCE

III, comparative study.

Modified Broström Procedure Using Distal Fibular Periosteal Flap Augmentation vs Anatomic Reconstruction Using a Free Tendon Allograft in Patients Who Are Not Candidates for Standard Repair

BACKGROUND

The modified Broström procedure (MBP) is widely accepted as the primary operative treatment for chronic lateral ankle instability (CLAI). However, the MBP does not produce good clinical results in all patients, and anatomic reconstruction using a free tendon graft may be considered in those patients. The purpose of this study was to evaluate the efficacy of the MBP using distal fibular periosteal flap augmentation for CLAI in patients who were not candidates for standard repair.

METHODS

Thirty-eight patients (39 ankles) who underwent surgery for CLAI were retrospectively analyzed. The patients were divided into 2 groups: an anatomic lateral ligament reconstruction group (reconstruction group) consisting of 17 ankles and an MBP group using distal fibular periosteal flap augmentation (augmentation group) consisting of 22 ankles. Preoperative and postoperative clinical evaluations were performed using the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS), and Karlsson-Peterson (Karlsson) scores.

RESULTS

The mean VAS, AOFAS, and Karlsson scores significantly improved from 4.0 to 1.8, 54.7 to 92.9, and 46.4 to 92.7, respectively, in the reconstruction group ( P < .001, P < .001, P < .001), and from 4.1 to 1.5, 60.1 to 94.9, and 52.6 to 94.1, respectively, in the augmentation group ( P < .001, P < .001, P < .001). There were no significant differences in the mean postoperative AOFAS and Karlsson scores between the groups ( P = .214, P = .299).

CONCLUSION

The MBP using distal fibular periosteal flap augmentation was also an effective option for CLAI in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity.

LEVEL OF EVIDENCE

Level III, comparative series.

Avoiding Tommy John Surgery: What Are the Alternatives?

The number of ulnar collateral ligament (UCL) reconstructions being performed has risen sharply in recent years, most notably in the young amateur athlete. While successful outcomes have been reported with reconstruction, the surgery and the associated rehabilitation timeline may be difficult for the nonelite athlete to incur. Return-to-play expectations, along with level of competition, should help guide surgeons in exploring management options. While reconstruction remains a mainstay, focused research exploring nonreconstructive options has expanded. This review discusses the clinical approach to those with UCL injury, including current support for rehabilitation, biologic strategies, and available repair or augmentation alternatives.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

therapeutic case series, level IV.

Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL

PURPOSE

Current methods of anterior talofibular ligament (ATFL) reconstruction fail to restore the stability of the native ATFL. Therefore, augmented anatomic ATFL reconstruction gained popularity in patients with attenuated tissue and additional stress on the lateral ankle ligament complex. The aim of the present study was to evaluate the biomechanical stability of the InternalBrace (Arthrex Inc., Naples, FL, USA), a tape augmentation designed to augment the traditional Broström procedure.

METHODS

Twelve (12) fresh-frozen human anatomic lower leg specimens were randomized into two groups: a native ATFL (ATFL) and a tape augmentation group (IB). Dual-energy X-ray absorptiometry (DEXA) scans were carried out to determine bone mineral density (BMD) of the specimens. The ligaments were stressed by internally rotating the tibia against the inverted fixated hindfoot. Torque at failure (Nm) and angle at failure (°) were recorded.

RESULTS

The ATFL group failed at an angle of 33 ± 10°. In the IB group, construct failure occurred at an angle of 46 ± 16°. Failure torque reached 8.3 ± 4.5 Nm in the ATFL group, whereas the IB group achieved 11.2 ± 7.1 Nm. There was no correlation between angle at ATFL or IB construct failure or torque at failure, respectively, and BMD for both groups.

CONCLUSION

This study reveals that tape augmentation for ATFL reconstruction shows similar biomechanical stability compared to an intact native ATFL in terms of torque at failure and angle at failure. BMD did not influence the construct stability. Tape augmentation proved an enhanced initial stability in ATFL reconstruction which may allow for an accelerated rehabilitation process.

LEVEL OF EVIDENCE

II.