Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics?

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.

Analysis of Return to Play After Modified Broström Lateral Ankle Ligament Reconstruction

Background:

Despite marked improvements in stability after lateral ankle ligament repair, many patients do not return to their preinjury activity level. There are few studies addressing athletes’ assessment of their ability to return to play after lateral ankle ligament reconstruction for recurrent instability.

Purpose:

To determine the rate of return to the preinjury activity level among physically active patients after the modified Broström procedure (MBP) for recurrent lateral ankle instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were patients who had undergone a primary MBP by a single surgeon over a 6-year period and had a minimum 24 months of follow-up. A telephone questionnaire was conducted to ascertain the patient’s ability to return to sport and/or work activity at final follow-up. Activity levels were evaluated utilizing the Tegner activity score. Outcome scores and other measured variables were compared between patients who returned to their preinjury level and those who did not. The reasons for failing to return were also documented.

Results:

Of the 59 patients who met the inclusion criteria, 41 (69%; 20 men and 21 women) participated in the telephone interview. Results indicated that 22 (54%) returned to their prior level of activity (returners). The mean age of returners was 27.2 years; for nonreturners, the mean age was 27.1 years. Most patients (36/41; 88%) were satisfied with surgery and the overall outcome. Of the 19 nonreturners, 7 (37%) noted ankle-related reasons for not returning (pain: 57%; residual instability: 29%; decreased range of motion: 14%), and 12 (63%) cited non–ankle-related reasons. The mean preinjury and postoperative Tegner score for returners was 6.8. Moreover, 7 of 14 (50%) high-level athletes with preinjury Tegner scores ≥8 returned to their preinjury activity level. For high-level athletes who did not return to their previous level, the mean postoperative Tegner score was 6.6, and only 1 (7%) cited an ankle-related reason for not returning.

Conclusion:

A high patient satisfaction rate was reported after the MBP for recurrent lateral ankle instability. The majority of patients who did not return to their preinjury level cited a non–ankle-related factor as the reason for not returning to sport. This was especially true for the higher level athletes.

Anatomical Tenodesis Reconstruction Using Free Split Peroneal Brevis Tendon for Severe Chronic Lateral Ankle Instability

Many operative procedures have been reported for the management of chronic lateral ankle instability, and anatomical reconstructions are an excellent option. However, if the remnants of the ligaments are considerably damaged, anatomical reconstructions using such remnants can be difficult. In cases such as these, tenodesis stabilization may be required. However, tenodesis stabilization often restricts the range of ankle movement. The purpose of this study was to determine the effectiveness of a new procedure that we developed to mitigate the problems associated with tenodesis stabilization procedures. We installed grafts in the original anatomical position by devising a system for positioning the drill holes in the bones so that our procedure did not restrict the range of ankle movement. A retrospective review of 37 patients (13 men, 24 women) with a mean age of 30.2 (range, 16-66) years was performed at an average of 69 (range, 47-77) months after the surgery. The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved significantly from 65.6 (range, 47-77) points preoperatively to 98.0 (range, 87-100) points postoperatively (P < 0.001). With the number of subjects available, no significant differences were detected between the postoperative mean ranges of movement of the ankle and subtalar joints and those of the preoperative ankle. Patients who underwent anatomical tenodesis reconstructions with a free split peroneal brevis tendon showed good outcomes after a 69-month follow-up period.

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

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

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

The Location of the Fibular Tunnel for Anatomically Accurate Reconstruction of the Lateral Ankle Ligament: A Cadaveric Study

We aimed to describe the location of fibular footprint of each anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), as well as their common origin in relation to bony landmarks of the fibula in order to determine the location of the fibular tunnel. In 105 ankle specimens, the center of the footprints of the ATFL and CFL (cATFL and cCFL, respectively) and the intersection point of their origin (intATFL-CFL) were investigated, and the distances from selected bony landmarks (the articular tip (AT) and the inferior tip (IT) of the fibula) were measured. Forty-two (40%) specimens had single-bundle ATFL, and 63 (60%) had double-bundle patterns. The distance between intATFL-CFL and IT was 12.0 ± 2.5 mm, and a significant difference was observed between the two groups (p = 0.001). Moreover, the ratio of the intATFL-CFL location based on the anterior fibular border for all cadavers was 0.386. The present study suggests a reference ratio that can help surgeons locate the fibular tunnel for a more anatomically accurate reconstruction of the lateral ankle ligament. Also, it may be necessary to make a difference in the location of the fibular tunnel according to the number of ATFL bundles during surgery.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases

INTRODUCTION

Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results.

HYPOTHESIS

We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately.

MATERIALS AND METHODS

Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs.

RESULTS

The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability.

DISCUSSION

Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination.

LEVEL OF EVIDENCE

IV, Case-series.

Revision of Surgical Lateral Ankle Ligament Stabilization

Ankle sprains continue to be among the most common musculoskeletal injuries, most of which never require surgical treatment. Surgical treatment has traditionally been successful for those patients whose symptoms do not improve with nonoperative care. However, recurrent instability, although rare, can occur early or late after a stabilization procedure, as the result of an acute traumatic event or chronic repetitive minor injury. A complete workup of patients with recurrent ankle instability should be completed before revision surgery and should include evaluation for generalized joint hypermobility as well as anatomic variations, such as hindfoot varus, first ray plantarflexion, and midfoot cavus.

Arthroscopic Treatment of Ankle Instability - Allograft/Autograft Reconstruction

Inversion ankle sprains represent one of the most common traumatic injuries in the active sports population. Although most respond well to conservative treatment, some hide important lesions. Lateral ankle ligament injuries occur in more than 80% of all ankle sprains, with one-third of these developing chronic ankle instability (CAI). Lateral ankle ligament repair or reconstruction procedures aim to restore normal ankle anatomy and function in patients with CAI. Arthroscopic reconstruction techniques allow the surgeon to reach surgery objectives with minimal soft tissue injury. When the indications and surgical steps are respected, this arthroscopic technique seems to be safe and reproducible.

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.

Surgical Treatment of Chronic Lateral Ankle Instability Using an Inferior Extensor Retinaculum Flap: A Retrospective Study

Chronic lateral ankle instability causes significant problems with physical activity. The purpose of the present study was to evaluate the results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap. A consecutive series of 38 patients were included with a minimum follow-up duration of 2 years. The functional results were assessed using the Karlsson and American Orthopaedic Foot and Ankle Society scale scores. The pre- and postoperative radiologic assessment was performed using stress radiographs to measure varus tilt and anterior drawer tests. All 38 patients were followed up for 2.5 to 7.2 years, and 35 patients were satisfied. The American Orthopaedic Foot and Ankle Society scale score had improved significantly from 57 (range 20 to 70) points preoperatively to 95 (range 80 to 100) points postoperatively (p < .0001), and 35 patients believed their ankle was more stable after surgery. The patients had returned to their previous sports activities an average of 4.7 (range 2 to 12) months after surgery. On the stress radiographs, the mean talar tilt angle had improved significantly from 15.2° (range 6° to 26°) preoperatively to 3.8° (range 1° to 8°) at the final follow-up visit (p < .001), and the mean anterior talar had improved significantly from 13.2 (range 8 to 18) mm preoperatively to 4 (range 4 to 7) mm at the final follow-up visit (p < .002). Regarding the prognostic factors, a link was found between the functional result and residual radiologic laxity measured on the stress radiographs. Reconstruction of the lateral ligaments for chronic ankle instability combining capsuloligamentous retensioning and reinforcement with an extensor retinaculum flap resulted in successful outcomes, excellent ankle stability, and preservation of ankle joint mobility. This technique addressed both lateral ankle and subtalar instability by developing an extraarticular interosseous ligament.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up

INTRODUCTION

A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ.

HYPOTHESIS

The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair.

MATERIALS AND METHODS

A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected.

RESULTS

Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair.

CONCLUSION

Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair.

STUDY DESIGN

Review of the literature; level of proof IV.

Anatomic validation of the lateral malleolus as a cutaneous marker for the distal insertion of the calcaneofibular ligament

PURPOSE

An anatomic study was performed to confirm whether the lateral malleolus could serve as a simple and reproducible anatomic reference for the distal insertion of the calcaneofibular ligament (CFL).

METHODS

Dissection was performed after placement of a Kirschner wire to simulate the calcaneal tunnel for the distal insertion of the CFL. The skin was penetrated 1 cm distal and posterior to the tip of the lateral malleolus. The main information recorded was the distance from the Kirschner wire to the centre of the distal insertion of the CFL. Other elements were noted (characteristics of the CFL, distance between the distal insertion of the CFL-peroneal tubercle, nerve or tendon injuries).

RESULTS

Thirty ankles were dissected. The mean distance from the Kirschner wire to the centre of the distal insertion of the CFL was 2.4 ± 1.8 mm. Only one case of peroneal injury was noted. The sural nerve was usually located a mean 1.8 ± 1.1 mm from the Kirschner wire. The posterior tibial vascular pedicle was a mean 27.8 ± 3.5 mm from the point of exit of the Kirschner wire.

CONCLUSION

Using the lateral malleolus as the cutaneous reference for the distal insertion of the CFL seems to be more reliable than the pure arthroscopic technique. This study describes a percutaneous technique to obtain a calcaneal tunnel for distal insertion of the CFL. The sural nerve is at the greatest risk of injury with this technique and requires careful subcutaneous incision to prevent injury. This new percutaneous technique is less invasive than a purely arthroscopic technique and more accurately identifies the location of the tunnel. It can be used to do calcaneal tunnel in clinical practice during anatomic ligament reconstruction for chronic ankle instability.

Arthroscopic Lateral Ligament Repair Through Two Portals in Chronic Ankle Instability

Objectives:

Injury to the lateral ligament complex of the ankle is one of the most common sports-related injury.

Usually lateral ankle evolves with excellent clinical recovery with non surgical treatment, however, near about 30% develop a lateral chronic instability sequela.

Several open and arthroscopic surgical techniques have been described to treat this medical condition.

Material and Methods:

Of the 22 patients who were treated; 18 males and 4 females, and aged from 17-42 years (mean 28 years).

All patients presented a history of more than three ankle sprains in the last two years and presented positive anterior drawer and talar tilt test of the ankle in the physical examination.

We perform an anterior arthroscopy of the ankle in order to treat asociated disease and then we performed “All inside¨ lateral ligament repair through two portals (anteromedial and anterolateral) using an anchor knotless suture.

Results:

Clinical outcome evaluations were performed at a mean follow up of 25 months. (R: 17-31).

Overall results has been shown by means of the American Orthopaedic Foot and Ankle Society (AOFAS). Mean AOFAS scores improved from 63 points (range 52–77) preoperatively to 90 points (range 73–100) at final follow up.

No recurrences of ankle instability were found in the cases presented.

Conclusion:

Several surgical procedures have been described during the last years in order to treat chronic ankle instability. ¨All inside¨ lateral ligament reconstruction presents lower local morbidity than open procedures with few complications. Moreover, it is a reproductible technique, with high clinical success rate, few complications and relatively quick return to sports activities. A high knowledge of the anatomic landmarks should be essential to avoid unwated injuries.

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.

The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability

BACKGROUND

Numerous biomechanical studies of the lateral ankle ligaments have been reported; however, the isolated function of the calcaneofibular ligament has not been clarified. We hypothesize that the calcaneofibular ligament would stabilize the ankle joint complex under multidirectional loading, and that the in situ force in the calcaneofibular ligament would change in each flexed position.

METHODS

Using seven fresh frozen cadaveric lower extremities, the motions and forces of the intact ankle under multidirectional loading were recorded using a 6-degree-of-freedom robotic system. On repeating these intact ankle joint complex motions after the calcaneofibular ligament transection, the in situ force in the calcaneofibular ligament and the contribution of the calcaneofibular ligament to ankle joint complex stability were calculated. Finally, the motions of the calcaneofibular ligament-transected ankle joint complex were recorded.

FINDINGS

Under an inversion load, significant increases of inversion angle were observed in all the flexed positions following calcaneofibular ligament transection, and the calcaneofibular ligament accounted for 50%-70% of ankle joint complex stability during inversion. The in situ forces in the calcaneofibular ligament under an anterior force, inversion moment, and external rotation moment were larger in the dorsiflexed position than in the plantarflexed position.

INTERPRETATION

The calcaneofibular ligament plays a role in stabilizing the ankle joint complex to multidirectional loads and the role differs with load directions. The in situ force of the calcaneofibular ligament is larger at the dorsiflexed position. This ligament provides the primary restraint to the inversion ankle stability.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments: A technical simplification

Anatomical reconstruction of the lateral ankle ligaments has become a pivotal component of the treatment strategy for chronic ankle instability. The recently described arthroscopic version of this procedure is indispensable to ensure that concomitant lesions are appropriately managed, yet remains technically demanding. Here, we describe a simplified variant involving percutaneous creation of the calcaneal tunnel for the distal attachment of the calcaneo-fibular ligament. The rationale for this technical stratagem was provided by a preliminary cadaver study that demonstrated a correlation between the lateral malleolus and the distal footprint of the calcaneo-fibular ligament. The main objectives are simplification of the operative technique and decreased injury to tissues whose function is crucial to the recovery of proprioception.

[Treatment of lateral ankle joint instability. Open or arthroscopic?]

Chronic ankle joint instability often necessitates operative treatment. Operative treatment methods are classified into non-anatomical tenodesis, anatomical reconstruction and direct repair. In addition to open approaches, arthroscopic techniques are increasingly becoming established. This article describes the various operative treatment procedures, their advantages and disadvantages and in particular the arthroscopic feasibility.

Radiographic monitoring of the distal insertion of the calcaneofibular ligament in anatomical reconstructions of ankle instabilities: A preliminary cadaveric study

BACKGROUND

The purpose of the study therefore was to determine radiographic landmarks that support the identification of the insertion site of the distal calcaneofibular ligament (CFL) in anatomic ankle ligament reconstructions.

METHODS

In 10 lower limb cadaver specimens the midpoint of the distal CFL insertion was dissected and marked with a nail inserted orthogonally. On a standardized lateral radiograph in neutral ankle position a horizontal tangent was aligned to the deepest visible concavity of the tarsal sinus and one vertical tangent to the farthest posterior convexity of the talus. Additionally, a line was drawn from the radiographically marked distal CFL to the fibular insertion of the CFL to determine the CFL-fibular angle.

RESULTS

In relation to the radiographic tangents intersection the mean deviation of the depicted CFL nails was 2.2mm [SD ± 1.1 mm] leading to an angular, circular to slightly oval 6 mm insertion. The scatter-plot of the marked positions convened along a line from the supposed fibular CFL insertion to the intersection in all cases. The mean CFL-fibular angle was 131.7° [SD ± 3.16°].

CONCLUSIONS

Determining a virtual intersection between a horizontal tangent aligned to the deepest visible concavity of the tarsal sinus and one vertical tangent aligned to the farthest posterior convexity of the talus on a standardized lateral radiograph in neutral ankle position supports an anatomic insertion of the distal calcaneofibular ligament most probably.

Minimally invasive reconstruction of the lateral ankle ligaments using semitendinosus autograft or tendon allograft

BACKGROUND

The purpose of the study was to retrospectively compare the therapeutic effect between semitendinosus autograft and tendon allograft for lateral ankle ligaments reconstruction.

METHODS

From September 2006 to June 2011, 68 patients (41 males, 27 females) with chronic ankle instability underwent anatomical reconstruction of the lateral ligaments using semitendinosus autograft (autograft group, 32 patients) or tendon allograft (allograft group, 36 patients) via a minimally invasive approach. All patients were followed up for at least 12 months. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and stress tests were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded.

RESULTS

Compared with allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the mean time to heal was significantly shorter (11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group. Although the mean AOFAS score was significantly increased at the final follow-up in the autograft group (95.1 ± 7.5 vs 62.3 ± 8.2, P = .0001) and allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001), no significant difference in AOFAS was found between these 2 groups. Similarly, there was no significant difference in talar tilt or shift between autograft and allograft groups. In addition, no patients complained of weakness or disability at the donor site in the autograft group, while incisional swelling was observed in 4 patients in the allograft group, which was resolved via dressing change, oral use of indomethacin or dexamethasone.

CONCLUSION

Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach was safe and effective for ankle instability with a relatively short time for healing and minimal donor site problems.

LEVEL OF EVIDENCE

Level III, comparative case series.

Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft

Lateral ankle sprains are common; if conservative treatment fails and chronic instability develops, stabilization surgery is indicated. Numerous surgical procedures have been described, but those that most closely reproduce normal ankle lateral ligament anatomy and kinematics have been shown to have the best outcomes. Arthroscopy is a common adjunct to open ligament surgery, but it is traditionally only used to improve the diagnosis and the management of any associated intra-articular lesions. The stabilization itself is performed open because standard anterior ankle arthroscopy provides only partial visualization of the anterior talofibular ligament from above and the calcaneofibular ligament attachments cannot be seen at all. However, lateral ankle endoscopy can provide a view of this area that is superior to open surgery. We have developed a technique of ankle endoscopy that enables anatomic positioning of the repair or fixation of the graft. In this article we describe a safe and reproducible arthroscopic anatomic reconstruction of the lateral ligaments of the ankle using a gracilis autograft. The aim of this procedure is to obtain a more physiological reconstruction while maintaining all the advantages of an arthroscopic approach.

Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review

Many studies investigated the contributing factors of chronic ankle instability, but a consensus has not yet been obtained. The objective of this critical review is to provide recent scientific evidence on chronic ankle instability, including the epidemiology and pathology of lateral ankle sprain as well as the causative factors of chronic ankle instability. We searched MEDLINE from 1964 to December 2013 using the terms ankle, sprain, ligament, injury, chronic, functional, mechanical, and instability. Lateral ankle sprain shows a very high recurrence rate and causes considerable economic loss due to medical care, prevention, and secondary disability. During the acute phase, patients with ankle sprain demonstrate symptoms such as pain, range of motion deficit, postural control deficit, and muscle weakness, and these symptoms may persist, leading to chronic ankle instability. Although some agreement regarding the effects of chronic ankle instability with deficits in postural control and/or concentric eversion strength exists, the cause of chronic ankle instability remains controversial.

LEVELS OF EVIDENCE

Therapeutic Level IV: Review of Level IV studies.

Qualitative and Quantitative Anatomic Investigation of the Lateral Ankle Ligaments for Surgical Reconstruction Procedures

BACKGROUND

Lateral ankle sprains are common sports injuries that may require surgery for chronic lateral ankle instability. Anatomic repair or reconstruction is desired, yet there is a scarcity of quantitative information regarding the origins and insertions of the lateral ligaments related to surgically pertinent osseous landmarks.

METHODS

Fourteen ankle specimens were dissected to isolate the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament. A three-dimensional coordinate measurement device was used to determine the origins, insertions, footprint areas, orientations, and distances from osseous landmarks.

RESULTS

A single-banded anterior talofibular ligament was identified in seven of the fourteen specimens, and a double-banded anterior talofibular ligament was identified in the remaining seven. The single-banded anterior talofibular ligament originated an average of 13.8 mm (95% confidence interval [CI], 12.3 to 15.3) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 17.8 mm (95% CI, 16.3 to 19.3) superior to the apex of the lateral talar process along the anterior border of the talar lateral articular facet. The calcaneofibular ligament originated an average of 5.3 mm (95% CI, 4.2 to 6.5) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 16.3 mm (95% CI, 14.5 to 18.1) from the posterior point of the peroneal tubercle. The posterior talofibular ligament was the largest ligament and originated an average of 4.8 mm (95% CI, 3.7 to 5.9) superior to the inferior tip of the lateral malleolus in the digital fossa to insert an average of 13.2 mm (95% CI, 11.5 to 14.9) from the talar posterolateral tubercle. The cervical ligament originated on the superior part of the calcaneus and inserted at a point that was approximately 50% of the talar neck anteroposterior distance.

CONCLUSIONS

Consistent distances from the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament footprint centers to osseous landmarks were identified.

CLINICAL RELEVANCE

Footprint center distances from surgically relevant osseous landmarks identified in this study can be used during reconstructive surgery of the lateral ankle ligaments and may result in more anatomically accurate placement of the reconstructed ligaments.

Reconstruction of compound loss of lateral malleolus and lateral ankle ligaments with double-bundle Achilles tendon-bone allograft

Open ankle fracture, including compound loss of the lateral malleolus, lateral ankle ligaments, and overlying skin, is a severe injury and can result in ankle instability and permanent disability. Treatment of this injury is challenging and requires bone grafting and soft tissue reconstruction. In the present report, we describe a unique reconstruction technique for compound loss of the lateral malleolus, lateral ankle ligaments, and the overlying skin using a double-bundle Achilles tendon-bone allograft combined with a reverse sural fasciocutaneous flap. The patient obtained a stable ankle with nearly full range of motion and displayed satisfactory function during the follow-up period.

Is deltoid and lateral ligament reconstruction necessary in varus and valgus ankle osteoarthritis, and how should these procedures be performed?

Varus and valgus ankle deformities represent a challenge to the foot and ankle surgeons. The presence of degenerative changes of the tibiotalar joint articular surfaces introduces an additional layer of complexity. Reconstruction of such deformities requires a customized approach to each patient. Surgical intervention often requires joint-sparing realignment, arthroplasty, and/or arthrodesis, depending on the severity of deformity and the joint surface integrity. The ligamentous stability of the ankle plays an essential role in the preservation and optimization of function. This article reviews the role of deltoid and lateral ligament reconstruction in the treatment of varus and valgus ankle osteoarthritis.

Proximity of arthroscopic ankle stabilization procedures to surrounding structures: an anatomic study

PURPOSE

To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk.

METHODS

Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged.

RESULTS

Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity.

CONCLUSIONS

Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction.

CLINICAL RELEVANCE

Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

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

BACKGROUND

Lateral ankle instability leads to an increased risk of tibiotalar joint osteoarthritis. Previous studies have found abnormal tibiotalar joint motions with lateral ankle instability that may contribute to this increased incidence of osteoarthritis, including increased anterior translation and internal rotation of the talus under weightbearing loading. Surgical repairs for lateral ankle instability have shown good clinical results, but the effects of repair on in vivo ankle motion are not well understood.

HYPOTHESIS

The modified Broström-Gould lateral ligament reconstruction decreases anterior translation and internal rotation of the talus under in vivo weightbearing loading conditions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven patients underwent modified Broström-Gould repair for unilateral lateral ankle instability. Ankle joint kinematics as a function of increasing body weight was studied with magnetic resonance imaging and biplanar fluoroscopy. Tibiotalar kinematics was measured in unstable ankles preoperatively and postoperatively at a mean follow-up of 12 months as well as in the uninjured contralateral ankles of the same patients.

RESULTS

Surgical repair resulted in statistically significant decreases (expressed as mean ± standard error of the mean) in anterior translation of the talus (0.9 ± 0.3 mm; P = .018) at 100% body weight and internal rotation of the talus at 75% (2.6° ± 0.8°; P = .019) and 100% (2.7° ± 0.8°; P = .013) body weight compared with ankle kinematics measured before repair. No statistically significant differences were detected between repaired ankles and contralateral normal ankles.

CONCLUSION

The modified Broström-Gould repair improved the abnormal joint motion observed in patients with lateral ankle instability, decreasing anterior translation and internal rotation of the talus.

CLINICAL RELEVANCE

Altered kinematics may contribute to the tibiotalar joint degeneration that occurs with chronic lateral ankle instability. The findings of the current study support the efficacy of this repair in improving the abnormal ankle motion observed in these patients.

Autologous split peroneus longus lateral ankle stabilization

Lateral ankle instability is a common clinical entity, and a variety of surgical procedures are available for stabilization after conservative management fails. Herein the authors reviewed outcomes after performing autologous split peroneus longus lateral ankle stabilization, using a previously described surgical technique to anatomically recreate the anterior talofibular and calcaneofibular ligaments. Twenty-five consecutive patients from 2 surgeons' practices underwent reconstruction between March 2007 and January 2011 with a minimum follow-up of 12 (range 12 to 51) months (mean 29.5 months). Follow-up interviews demonstrated 92.0% good or excellent outcomes with only 8.0% rating the outcome as fair and none as poor; 92.0% had no recurrent sprains or difficulty going up or down hills; 88.0% related no difficulty with uneven ground. The authors conclude that the autologous split peroneus longus lateral ankle stabilization results in a stable ankle with a low rate of complications and high patient satisfaction.

Anatomical reconstruction of the lateral ligaments using Gracillis tendon in chronic ankle instability; a new technique

BACKGROUND

Many surgical technique have been described to assess the outcome of anatomical reconstruction of the lateral ligaments using Gracillis tendon. This technique aims to restore the stability of the ankle by reconstruction of the talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using the Gracillis tendon.

METHODS

From January 2004 to February 2008; inclusive, 16 patients; 11 male and 5 female, underwent an anatomic reconstruction of the lateral ankle ligament for chronic ankle instability. Their ages ranged from 18 to 29 giving a mean age of 25 years. Patients were then subjected to radiologic and clinical assessments for a period of at least 33.5 months. For pain scoring the Americans Orthopaedic Foot and Ankle Society (AOFAS) scores were used; whilst subjective symptom was evaluated using the Olerud and Molander ankle scoring system.

RESULTS

All patients returned for the final evaluation and subjective excellent or good results were recorded on self-assessment, pain scores, AOFAS and Karissons scores. Additionally Olerud and Molander ankle scoring was also done. During the final follow-up, the mean post-operative AOFAS score was 96 (range 80-100), the Visual analog score was 6 (range 0-4), Karissons score was 94.7 (range 80-100) and last but not least Olerud and Molander score was 87.5 (range 70-100). It was noted that the ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was reduced from a mean of 12-4° (p<0.0001) and the anterior drawer was reduced from a mean of 11-4mm (p<0.001) by the ankle ligament reconstruction.

CONCLUSION

Anatomical reconstruction of the lateral ligaments of chronic ankle instability using Gracillis tendon graft resulted in successful results, excellent ankle stability, significant reduction in pain and negligible loss of ankle and hind foot motion.

The characteristics of the mechanoreceptors of the hip with arthrosis

Mechanoreceptors have been extensively studied in different joints and distinct signals that convey proprioceptive information to the cortex. Several clinical reports have established a link between the number of mechanoreceptors and a deficient proprioceptive system; however, little or no literature suggest concentration of mechanoreceptors might be affected by hip arthrosis. The purpose of this study is first to determine the existence of mechanoreceptors and free nerve endings in the hip joint and to distinguish between their conditions: those with arthrosis and without arthrosis. Samples of 45 male hips were analyzed: 30 taken from patients with arthrosis that were submitted to total arthroplasty and 15 taken from male cadavers without arthrosis. The patients' ages ranged from 38 to75 years (average 56.5) and the cadavers' ages ranged from 21 to 50 years (average 35.5). The capsule, labrum, and femoral head ligament tissues were obtained during the arthroplasty procedure from 30 patients with arthrosis and from 15 male cadavers. The tissue was cut into fragments of around 3 mm. Each fragment was then immediately stained with gold chloride 1% solution and divided into sections of 6 μm thickness. The Mann-Whitney test was used for two groups and the ANOVA, Friedman and Kruskal-Wallis tests for more than two groups. Results show the mechanoreceptors (Pacini, Ruffini and Golgi corpuscles) and free nerve endings are present in the capsule, femoral head ligament, and labrum of the hip joint. When all the densities of the nerve endings were examined with regard to those with arthrosis and those without arthrosis, the mechanoreceptors of cadavers without arthrosis were found to be more pronounced and an increase in free nerve endings could be observed (p = 0.0082). Further studies, especially electrophysiological studies, need to be carried out to clarify the functions of the mechanoreceptors in the joints.

Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow-up

BACKGROUND

Lateral ankle sprains account for 85% of ankle lesions.

HYPOTHESIS

Combined open and arthroscopic procedures could improve the diagnosis and management of intra-articular lesions and allow surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty consecutive patients underwent ankle arthroscopy for recurrent (2 or more episodes) lateral ankle instability unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was confirmed at imaging (plain radiographs and magnetic resonance imaging [MRI]) and arthroscopic assessment. All patients underwent arthroscopic Broström-Gould repair for management of lateral ankle instability; secondary lesions were also managed. Postoperatively, the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to assess the functional status; clinical examination and conventional radiographs were performed in all patients.

RESULTS

Thirty-eight patients were reviewed at an average postoperative follow-up of 9.8 years. The mean AOFAS score was 90 (range, 44-100) at the last follow-up. No significantly different outcomes were found in patients who had undergone microfractures for management of grade III to IV cartilage lesions compared with patients with no cartilage lesions. Postoperative AOFAS scores were graded as excellent and good in almost all patients (94.7%). Concerning failure rate, 2 patients (5.3%) reported a low AOFAS score: one patient underwent soft tissue removal for anterior impingement, and one received simultaneous medial ankle instability repair.

CONCLUSION

The arthroscopic Broström-Gould-assisted technique could be a viable alternative to the gold-standard Broström-Gould procedure for anatomic repair of chronic lateral ankle instability and management of intra-articular lesions. Prospective randomized controlled trials are needed.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, conservative or surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010.

SELECTION CRITERIA

All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).

AUTHORS' CONCLUSIONS

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

Results of anatomic lateral ankle ligament reconstruction with tendon allograft

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p < 0.01). The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively. The technique described restores mechanical stability in patients with chronic lateral ankle instability and may be considered in a select group of patients.

In vivo cartilage contact strains in patients with lateral ankle instability

Damage to the anterior talofibular ligament (ATFL) and cacaneofibular ligament (CFL) during an ankle sprain may be linked to the development of osteoarthritis. Although altered tibiotalar kinematics have been demonstrated, the effects of lateral ankle instability (LAI) on in vivo cartilage strains have not been described. We hypothesized that peak cartilage strains increase, and the location is shifted in patients with ATFL injuries. We used 3-D MRI models and biplanar fluoroscopy to evaluate in vivo cartilage contact strains in seven patients with unilateral LAI. Subjects had chronic unilateral ATFL injury or combined ATFL and CFL injury, and were evaluated with increasing load while stepping onto a force plate. Peak cartilage strain and the location of the peak strain were measured using the contralateral normal ankle as a control. Ankles with LAI demonstrated significantly increased peak strain when compared with ATFL-intact controls. For example, at 100% body weight, peak strain was 29+/-8% on the injured side compared to 21+/-5% on the intact side. The position of peak strain on the injured ankle also showed significant anterior translation and medial translation. At 100% body weight, the location of peak strain in the injured ankle translated anteriorly by 15.5+/-7.1mm and medially by 12.9+/-4.3mm relative to the intact ankle. These changes correspond to the region of clinically observed osteoarthritis. Chronic LAI, therefore, may contribute to the development of tibiotalar cartilage degeneration due to altered cartilage strains.

Lateral ligament repair and reconstruction restore neither contact mechanics of the ankle joint nor motion patterns of the hindfoot

BACKGROUND

Ankle sprains may damage both the lateral ligaments of the hindfoot and the osteochondral tissue of the ankle joint. When nonoperative treatment fails, operative approaches are indicated to restore both native motion patterns at the hindfoot and ankle joint contact mechanics. The goal of the present study was to determine the effect of lateral ligament injury, repair, and reconstruction on ankle joint contact mechanics and hindfoot motion patterns.

METHODS

Eight cadaveric specimens were tested with use of robotic technology to apply combined compressive (200-N) and inversion (4.5-Nm) loads to the hindfoot at 0° and 20° of plantar flexion. Contact mechanics at the ankle joint were simultaneously measured. A repeated-measures experiment was designed with use of the intact condition as control, with the other conditions including sectioned anterior talofibular and calcaneofibular ligaments, the Broström and Broström-Gould repairs, and graft reconstruction.

RESULTS

Ligament sectioning decreased contact area and caused a medial and anterior shift in the center of pressure with inversion loads relative to those with the intact condition. There were no significant differences in inversion or coupled axial rotation with inversion between the Broström repair and the intact condition; however, medial translation of the center of pressure remained elevated after the Broström repair relative to the intact condition. The Gould modification of the Broström procedure provided additional support to the hindfoot relative to the Broström repair, reducing inversion and axial rotation with inversion beyond that of intact ligaments. There were no significant differences in center-of-pressure excursion patterns between the Broström-Gould repair and the intact ligament condition, but this repair increased contact area beyond that with the ligaments intact. Graft reconstruction more closely restored inversion motion than did the Broström-Gould repair at 20° of plantar flexion but limited coupled axial rotation. Graft reconstruction also increased contact areas beyond the lateral ligament-deficient conditions but altered center-of-pressure excursion patterns relative to the intact condition.

CONCLUSIONS

No lateral ankle ligament reconstruction completely restored native contact mechanics of the ankle joint and hindfoot motion patterns.

An anatomic and autologous lateral ankle stabilization

A new technique for stabilization of the lateral ankle ligaments is presented. The procedure uses a split peroneus longus tendon to recreate the calcaneofibular and anterior talofibular ligaments. The new ligaments follow a precise anatomic course that replicates the pathway of the original ligaments. The procedure also capitalizes on interference screw technology so that accurate ligament tension can be obtained. This technique is most useful for severe ligamentous insufficiency involving both the calcaneofibular and anterior talofibular ligaments. Biomechanical rationale for the use of peroneus longus is also discussed.

Metacarpophalangeal collateral ligament reconstruction using small intestinal submucosa in an equine model

Xenogeneic porcine small intestinal submucosa (SIS) is a natural, biodegradable matrix that has been successfully used as a scaffold for repair of tissue defects. The goal of this study was to compare a collateral ligament transection surgically reconstructed with an anchored SIS ligament to a sham-operated control procedure for the correction of joint laxity using an equine model. Ten metacarpophalangeal joints from 10 horses had complete transection of the lateral collateral ligament. In 6 horses, the collateral ligament was reconstructed with a multilaminate strip of SIS anchored with screws into bone tunnels proximal and distal to the joint. The sham controls had similar screws, but no SIS placed. Clinical compatibility and effectiveness were evaluated with lameness, incisional quality, and joint range of motion, circumference and laxity. Ligament structure and strength was quantified with serial high resolution ultrasound, histology, and mechanical testing at 8 weeks. Surgical repair with SIS eliminated joint laxity at surgery. SIS-treated joints had significantly less laxity than sham treatment at 8 weeks (p < 0.001). SIS-treated ligaments demonstrated a progressive increase in repair tissue density and fiber alignment that by week 8 were significantly greater than sham-treated ligament (p < 0.03). SIS-repaired ligament tended to have greater peak stress to failure than sham-treatment (p < 0.07). Cellularity within the ligament repair tissue and inflammation within the bone tunnel was significantly greater in the SIS-treated limbs (p < 0.017). Within the first 8 weeks of healing, SIS implanted to reinforce collateral ligament injury was biocompatible in the joint environment, restored initial loss of joint stability, and accelerated early repair tissue quality. SIS ligament reconstruction might provide benefit to early ligament healing and assist early joint stability associated with ligament injury.

Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle

We performed a retrospective study to assess the long-term outcome of non-augmented anatomical direct repair of the lateral ankle ligaments, as originally described by Duquennoy et al, for the treatment of chronic lateral instability of the ankle. This procedure aims to restore stability by the re-insertion and tightening of the original talofibular and calcaneofibular ligaments without division of the ligament. We examined the outcome in terms of the post-operative quality of life, the function of the joint and the development of osteoarthritis.

Between 1985 and 2002, 23 patients (11 males, 12 females) with a mean age of 32 years (15 to 58) who had undergone this procedure completed the Short-Form 36 assessment of quality of life and the Olerud and Molander Ankle score for the subjective evaluation of symptoms. Clinical re-evaluation, including examination of the ankle and the completion of the American Orthopaedic Foot and Ankle Society questionnaire was performed on 21 patients after a mean follow-up of 13 years (3 to 22.2). At the final follow-up radiographs of both ankles were taken to assess the development of osteoarthritis.

The mean total Short-Form 36 and Olerud and Molander Ankle scores in 23 patients at final follow-up were 79.6 points (37 to 100) and 81.6 points (40 to 100), respectively. The mean total post-operative American Orthopaedic Foot and Ankle Society score in 21 patients was 89.7 points (72 to 100). We found a significant post-operative reduction in talar tilt and anterior drawer sign (chi-squared test, p < 0.001). The functional outcome of the procedure was excellent in ten patients (48%), good in seven (33%) and fair in four (19%). The results in terms of ankle function and stability did not deteriorate with time and there was little restriction in movement.

This procedure is simple and effective with a very low rate of complications.

Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability

We describe an arthroscopic technique by which to reconstruct both the calcaneofibular ligament and anterior talofibular ligament anatomically. The ankle joint is examined through the anteromedial portal and a lateral portal close to the talar insertion of the anterior talofibular ligament. The subtalar joint is examined through the anterolateral portal and the middle portal. Associated intra-articular pathology (e.g., osteochondral defect) is evaluated and addressed. The calcaneofibular ligament is an extracapsular structure that can be examined arthroscopically through the anterolateral portal in the extra-articular plane. The peroneal tendon sheath is stripped with a small periosteal elevator through the middle subtalar portal, and the calcaneal insertion of the calcaneofibular ligament is identified. The plantaris tendon is identified and freed through multiple small wounds at the medial calf, and the tendon is cut proximally and retrieved to its calcaneal insertion. A calcaneal bone tunnel (tunnel 1) is created between the plantaris tendon and the calcaneofibular ligament insertions by use of a 3.5-mm drill bit. The tendon graft is then looped onto a suture, and the suture is passed through the tunnel to the calcaneofibular ligament insertion and retrieved to the middle subtalar portal. Through the anterolateral subtalar portal, the fibular insertion of the calcaneofibular ligament is identified. Another bone tunnel is created from this point to the posterior edge of the fibula (tunnel 2) with a 3.5-mm drill through the middle subtalar portal. The fibular insertion of the anterior talofibular ligament is identified on ankle arthroscopy. Tunnel 3 is created from this point to the exit point of tunnel 2 through the lateral ankle portal. The tendon graft is retrieved to the lateral ankle joints through the second and third tunnels and is pierced through the lateral ankle capsule and course from intracapsular to extracapsular. The tendon graft loop is anchored to the insertion point of the anterior talofibular ligament by a 4.0-mm cancellous screw with a spiked washer. The tendon graft is tensioned by pulling the free end of the tendon graft while tightening the screw. The free end of the tendon graft and the stay stitch are sutured to surrounding soft tissue or anchored with another 4.0-mm cancellous screw and spiked washer. The procedure is then completed, and a short leg cast is applied. The patient is advised to perform non-weight-bearing walking for 6 weeks.

Chronic lateral instability: arthroscopic findings and long-term results

BACKGROUND

A wide variety of procedures have been described to treat chronic lateral ankle instability. Nonanatomic procedures sacrifice normal tissue and can restrict motion. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments, supplemented by reefing of the exstensor retinaculum (modified Broström procedure) provides good long-term stability with minimal drawbacks.

METHODS

Twenty-one patients had arthroscopic evaluation followed by the Gould modification of the Broström procedure. All patients filled out a detailed questionnaire, including the American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Score, Modified Weber Score, and Hamilton Score at an average of 60 months after surgery. All patients were re-examined, and 14 had stress radiographs for comparison with the preoperative films.

RESULTS

Ninety-five percent of the patients (20 of 21) had associated intra-articular problems. The mean score for the Modified Weber Score was 96; for the Ankle/Hindfoot Score, 97; and for the Hamilton score, 100% good and excellent results. All 14 patients recorded a side-to-side difference of less than 3 degrees on their postoperative stress radiographs.

CONCLUSIONS

A high percentage of patients with lateral ankle instability have intra-articular pathology. Excellent results can be expected in patients with ankle instability who undergo arthroscopic treatment of associated intra-articular pathology and the modified Broström procedure.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, both conservative and surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer.

AUTHORS' CONCLUSIONS

In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft

Many techniques have been described for surgical management of lateral ankle instability. Anatomic repair and nonanatomic reconstruction have higher recurrence rates, and may be complicated by ankle stiffness. Anatomic reconstruction should be considered in stabilization for deficiencies of the lateral ankle ligament complex, as the initial construct is stronger while maintaining normal ankle mechanics.