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

Anatomic Variations of the Calcaneofibular Ligament

BACKGROUND

The lateral ankle joint comprises the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The purpose of this study was to propose a classification of CFL morphology.

METHODS

The material comprised 120 paired lower limbs from human cadavers (30 male, 30 female), mean age 62.3 years. The morphology was carefully assessed, and morphometric measurements were performed.

RESULTS

A 4-part method for anatomic classification can be suggested based on our study. Type 1 (48.3%), the most common type, was characterized by a bandlike morphology. Type 2 (9.2%) was characterized by a Y-shaped band, and type 3 (21.7%) by a V-shaped band. Type 4 (20.8%) was characterized by the presence of 2 or 3 bands. Type 2 and 4 were divided into further subtypes based on origin footprint.

CONCLUSION

The aim of our study was to describe variations of calcaneofibular ligament. Our proposed 4-part classification may be of value in clinical practice in future recognition of CFL injuries and in its repair or reconstruction.

CLINICAL RELEVANCE

The anatomy of the CFL plays an important role in stability of the ankle. Greater recognition of anatomical variation may help improve reconstructive options for patients with chronic lateral ankle instability.

Arthroscopic modified Broström may improve function while anatomic reconstructions could enhance stability for chronic lateral ankle instability: A network meta-analysis

PURPOSE

The purpose of this systematic review and network meta-analysis was to compare the efficacy of different surgical treatments, including open and arthroscopic modified Broström procedures (MB), anatomical reconstructions, and suture tape augmentations (STA), for chronic lateral ankle instability (CLAI).

METHODS

We conducted a systematic search for comparative studies that included adult patients with CLAI who underwent open MB, arthroscopic MB, reconstruction with autografts or allografts, and STA. We used a random-effects model to present the NMA results, with mean differences and 95 % confidence intervals (CI) for continuous measures and relative ratios with 95 % CI for dichotomous variables. Surface under the cumulative ranking curve analysis (SUCRA) was used for treatment ranking.

RESULTS

The results, based on surface under the cumulative ranking curve analysis, showed that arthroscopic MB likely improves functional outcomes the most as measured by change in American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. Anatomical graft reconstructions with allografts or autografts demonstrated greater reduction in anterior talar translation (ATT) and talar tilt angle (TTA). Arthroscopic MB and STA were associated with fewer complications.

CONCLUSIONS

Arthroscopic MB may be associated with better functional outcomes, while anatomical reconstructions appear to provide greater improvements in stability for CLAI. Additionally, arthroscopic techniques seem to have lower complication risks compared to open procedures. These potential differences in outcomes and risks between techniques could help guide surgical decision-making.

Comparison of Direct Repair Versus Anatomic Graft Reconstruction of the Anterior Talofibular Ligament: A Biomechanical Cadaveric Study

The goal of our study is to compare the stability of the anatomic reconstruction of the anterior talofibular ligament (ATFL) with direct repair of the ATFL, in a cadaver model. We performed the following techniques in 18 cadaveric ankles: the intact ATFL was cut, after which a direct repair using 2 anchors was performed. The repair was sectioned, and anatomic reconstruction was then performed with a tendon autograft. We measured angular displacement in 3 anatomic planes (axial, coronal, sagittal) for each situation in response to the anterior drawer test (ADT), talar tilt test (TTT) and pivot test (PT), using a specifically constructed arthrometer. The sectioned ATFL was inferior to the intact ATFL in the axial plane with the ADT (p = .012), in the axial plane with the PT (p = .001) and in the axial and coronal planes with the TTT (p = .013 and p = .016, respectively). Direct anatomic repair was inferior to the intact ATFL in the axial plane upon the PT (p = .009). No differences could be found between anatomic graft reconstructions and the intact ATFL with any manoeuver, nor when comparing anatomic graft reconstruction and direct repair with 2 anchors. We were able to conclude that anatomic graft reconstruction of the ATFL reproduces angular stability of the native ligament in a cadaver model. While we could not detect if anatomic graft reconstruction was superior to direct repair, the latter proved to be less stable in the axial plane upon internal rotation (pivot test) versus the intact ATFL.

Chronic Lateral Ankle Instability: Can We Get Even Better with Surgical Treatment?

Lateral ligament attenuation may occur after repetitive ankle sprains, creating instability. Management of chronic ankle instability requires a comprehensive approach to mechanical and functional instability. Surgical treatment, however, is indicated when conservative treatment is not effective. Ankle ligament reconstruction is the most common surgical procedure to resolve mechanical instability. Anatomic open Broström-Gould reconstruction is the gold standard for repairing affected lateral ligaments and returning athletes to sports. Arthroscopy may also be beneficial for identifying associated injuries. In severe and long-standing instability, reconstruction with tendon augmentation could be necessary.

Lateral ankle instability - repair/ reconstruct what's new

Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.

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

INTRODUCTION AND IMPORTANCE

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

Chronic Lateral Ankle Instability Treated With Tendon Allografting: A Preliminary Comparison of Arthroscopic and Open Anatomic Ligament Reconstruction

Background:

Roughly 30% of patients with chronic lateral ankle instability (CLAI) have long-lasting painful instability requiring surgical intervention. Ligament reconstruction with the traditional open method and using tendon allografts can provide sufficient mechanical stability for severe CLAI. Arthroscopic ligament reconstruction with tendon allograft has recently been introduced to treat CLAI.

Purpose:

In this study, we describe an arthroscopic ligament reconstruction procedure involving the use of the tendon allograft for patients with CLAI, and we compare the efficacy of this procedure with open ligament reconstruction with tendon allograft.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We enrolled 10 patients (4 men and 6 women) with CLAI (mean age, 37.3 years; range, 16-57 years) who underwent arthroscopic ligament reconstruction with tendon allografting between November 2017 and June 2019. The control group consisted of 10 patients who received open tendon allograft reconstruction. Preoperative and 2-year postoperative functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale (AOFAS), Karlsson Ankle Functional Score (KAFS), pain visual analog scale (VAS), 12-Item Short Form Health Survey (SF-12), and Tegner activity score (TAS).

Results:

The mean operative time was 118 and 110 minutes in the arthroscopic and open groups, respectively. At 2-year follow-up, scores on the AOFAS improved significantly compared with preoperatively, from 71.3 to 96.4 (P = .006) in the arthroscopic group, and from 68.6 to 96.7 (P = .005) in the open group. The postoperative AOFAS, VAS, KAFS, and SF-12 scores did not differ significantly between the 2 groups; however, the TAS score was significantly higher in the arthroscopic reconstruction group compared with in the open group (7 vs 6.1, respectively; P = .01).

Conclusion:

Arthroscopic ligament reconstruction with tendon allografting resulted in sufficient ankle stability and no donor-site morbidity. This procedure can yield similar functional outcomes to open reconstruction technique and may be an option for the management of CLAI.

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.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quantitative Evaluation of Ankle Instability Using a Capacitance-Type Strain Sensor

BACKGROUND

Manual evaluation is an important method for assessing ankle instability, but it is not quantitative. Capacitance-type sensors can be used to measure the distance on the basis of the capacitance value. We applied the sensor to the noninvasive device for measuring ankle instability and showed its utility.

METHODS

First, 5 ankles embalmed by Thiel's method were used in an experiment using a cadaver. The capacitance-type sensor was fixed alongside the anterior talofibular ligament (ATFL) of a specially made brace, and the anterior drawer test was performed. The test had been performed for the intact ankle, with the ATFL transected and with both the ATFL and calcaneofibular ligament (CFL) transected. The anterior drawer distance was calculated by the sensor. Intra- and interinvestigator reliability were also analyzed.Next, as a clinical study, a brace with a sensor was fitted to 22 ankles of 20 patients with a history of ankle sprain. An anterior drawer test at a load of 150 N was conducted using a Telos stress device. The anterior drawer distances measured by the sensor and based on radiographic images were then compared.

RESULTS

The mean anterior drawer distances were 3.7 ± 1.0 mm for the intact cadavers, 6.1 ± 1.6 mm with the ATFL transected (P < .001), and 7.9 ± 1.8 mm with the ATFL and CFL transected (P < .001). The intrainvestigator intraclass correlation coefficients (ICCs) were 0.862 to 0.939, and the interinvestigator ICC was 0.815. In the experiments on patients, the mean anterior drawer distance measured by the sensor was 2.9 ± 0.9 mm, and it was 2.7 ± 0.9 mm for the radiographic images. The correlation coefficient between the sensor and the radiographic images was 0.843.

CONCLUSION

We quantitatively evaluated anterior drawer laxity using a capacitance-type sensor and found it had high reproducibility and strongly correlated with stress radiography measurements in patients with ankle instability. Capacitance-type sensors can be used for the safe, simple, and accurate evaluation of ankle instability.

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.

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.

Early Versus Delayed Mobilization Post-Operative Protocols for Primary Lateral Ankle Ligament Reconstruction: A Systematic Review and Meta-Analysis

Introduction

Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization, which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review was to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature.

Methods

Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947 – 1/28/2020). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical, and non-English language were excluded. Protocols were reviewed and divided into two categories: early mobilization (within three weeks of surgery) and delayed mobilization (after three weeks of surgery). Functional outcome scores (American Orthopedic Foot and Ankle Society Score (AOFAS), Karlsson scores), radiographic measurements (anterior drawer, talar tilt), and complications were evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models.

Results

After our search, twelve out of 1,574 studies met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group (28.0 (5.5) vs. 26.3 (0.0), respectively; p < 0.001), although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high.

Conclusions

While there are some conflicting results, the findings indicated the timing of post-operative mobilization made no difference in functional outcomes or post-operative stability for patients undergoing lateral ankle ligament reconstruction. Because heterogeneity was high, future studies are needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity

PURPOSE

Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks.

METHODS

The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed.

RESULTS

For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares.

CONCLUSION

Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

Using arthroscopy combined with fluoroscopic technique for accurate location of the bone tunnel entrance in chronic ankle instability treatment

Background

Minimally invasive reconstruction techniques are used for anatomical ligament construction of the lateral collateral ligament complex of the ankle, but the two key elements, the bone tunnel and the appropriate graft tension, for the identification of the anatomic location during the surgery are not clearly stated.

Methods

The patients with chronic ankle instability who received arthroscopic anatomic lateral ligament complex reconstruction were retrospectively analyzed. The anatomical location of the bone tunnel was performed under arthroscopy combined with fluoroscopy for accurate location of the bone tunnel entrance. The graft tension and routing were controlled under arthroscopic visualization. The clinical outcomes were assessed using the Karlsson-Peterson score, Sefton articular stability scale, and Visual Analogue Scale (VAS). The complications were recorded during the follow-up.

Results

A total of 18 patients were enrolled in this study. The mean follow-up was 33.33 ± 3.69 (range from 24 to 36) months. No patient had recurrence of ankle instability after the operation. According to the Sefton articular stability scale, 94.5% of the patients had excellent/good function. The mean value of the anterior drawer tests and the talar tilt angle examination were decreased. The mean of the Karlsson-Peterson score and the Visual Analogue Scale(VAS) score were both improved significantly.

Conclusions

The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopy combined with the fluoroscopic technique could improve the clinical functions, satisfaction, and reduced pain of patients.

Clinical Outcomes and Return to Sport After Minimally Invasive Reconstruction of the Lateral Ligament Complex with Semitendinosus Tendon Autograft in Chronic Lateral Ankle Instability

BACKGROUND

Ankle sprains are common, affecting especially the lateral ligament complex of the ankle, often leading to chronic symptoms and instability. Many procedures have been described for chronic ankle instability. This study analyzes clinical outcomes and return to sport in patients who underwent minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus tendon autograft.

METHODS

Twenty-three patients (mean age, 33.9 years) with grade 3 lesions of both the anterior talofibular and calcaneofibular ligaments underwent minimally invasive reconstruction of the anterior talofibular and calcaneofibular ligaments with an ipsilateral semitendinosus tendon autograft. They were retrospectively reviewed, and return to sport was evaluated with the Halasi ankle activity scale.

RESULTS

Mean follow-up was 30 months (range, 26-53 months). The mean American Orthopaedic Foot and Ankle Society score increased from 68.6 to 95.3. The average visual analog scale score decreased from 3.6 to 1.3. The Halasi score changed from 5.0 to 5.1. Except for the Halasi score, the differences were significant (P < .001). Nineteen patients judged the received treatment as excellent, 2 as good. No revision procedures were performed. No major complications were reported.

CONCLUSIONS

This study confirms good clinical and sport outcomes after minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus autograft.

Intra-articular opening osteotomy combined with lateral ligament reconstruction for varus ankle arthritis

Background

Takakura 3B ankle arthritis is featured as obliteration of ankle space with subchondral bone contact. Among these patients, some have medial distal tibial platform erosion. It is hard to treat this kind of patients. The purpose of this study was to evaluate the therapeutic outcomes of intra-articular opening osteotomy combined with lateral ligament reconstruction for Takakura 3B ankle arthritis with medial distal tibial platform erosion.

Methods

From September 2009 to May 2016, 17 patients with Takakura 3B ankle arthritis were reviewed, including 3 male and 14 female patients. All underwent the operation of intra-articular opening osteotomy combined with lateral ligament reconstruction. All patients were available for analysis. The main outcome measurements included TT angle, AOFAS score, VAS score, SF-36 scale, and AOS scale.

Results

All patients were followed for a mean follow-up of 87.2 months (range, 49 to 129 months). The VAS scale improved from 5.5 ± 1.6 to 2.3 ± 1.9. The mean AOFAS score improved from 47.7 ± 15.7 to 75.8 ± 12.0. The SF-36 scale improved from 41.6 ± 14.0 to 67.7 ± 14.6. The AOS improved from 60.9 ± 13.9 to 28.2 ± 17.7. The TT angle improved from 14.3 ± 5.0° to 5.3 ± 4.0°. The TAS and TLS changed from 83.4 ± 2.6° and 77.5 ± 2.3° to 90.7 ± 2.3° and 78.6 ± 2.2°. However, the LTAS was not corrected significantly.

Conclusion

Intra-articular opening osteotomy combined with lateral ligament reconstruction is an effective method to treat varus ankle arthritis with medial distal tibial platform erosion.

Chronic Lateral Ankle Instability: Surgical Management

Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Open anatomic reconstruction is an effective method of stabilization. Ankle arthroscopy is a recommended to address intra-articular disorder before stabilization. An anatomic approach provides full range of motion, stability, and return to sport and activity. Allograft or suture tape augmentation can be useful for patients with generalized ligamentous laxity, patients with high body mass index, and elite athletes. Allograft reconstruction may be especially useful in revision procedures. Arthroscopic approach to lateral ankle ligament stabilization may provide good outcomes, with long-term data still limited.

A modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction: medium-term clinical and radiologic results comparable with open reconstruction

BACKGROUND

The aim of this study was to compare clinical and radiologic outcomes of a modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction with traditional open reconstruction.

METHODS

From January 2012 and March 2016, 60 eligible patients with chronic lateral ankle instability (CLAI) received all arthroscopic remnant-preserving reconstruction or open reconstruction of the anterior talofibular ligament and calcaneofibular ligament using semitendinosus autograft. They were divided into the arthroscopic group (n = 28) and the open group (n = 32). The American Orthopaedic Foot and Ankle Society (AOFAS),visual analog scale (VAS), and Karlsson scores and ankle range of motion (ROM) were used to evaluate clinical outcomes pre-operatively and at six and 12 months and the final follow-up of at least 24 months post-operatively, with SF-36 physical component summary (PCS) and mental component summary (MCS) scores evaluated for quality of life, and the anterior talar translation and talar tilt measurements for radiologic outcomes.

RESULTS

There was no difference in pre-operative demographics between two groups (P > 0.05). At the final follow-up, the AOFAS, VAS, Karlsson, SF-36 PCS, and MCS scores improved significantly in both groups (P < 0.05). However, no significant difference was found in AOFAS (91.9 ± 6.8 vs 91.1 ± 5.5), VAS (2.7 ± 1.7 vs 2.5 ± 1.6), Karlsson (95.3 ± 6.7 vs 94.8 ± 6.5), SF-36 PCS (53.2 ± 6.1 vs 52.9 ± 5.7), and MCS scores (55.7 ± 5.8 vs 54.2 ± 5.4) between the two groups (P > 0.05). There was no significant difference in post-operative operated/non-operated ankle ROM between two groups (P > 0.05). No significant difference was observed in talar tilt angle (7.6 ± 4.1° vs 6.8 ± 3.6°) and anterior talar translation (5.8 ± 1.7 mm vs 5.7 ± 1.5 mm) between the two groups at the final follow-up (P > 0.05), although these two variables improved significantly in both groups (P < 0.05). No severe complications were encountered in both groups during the follow-up period.

CONCLUSIONS

The modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction could produce excellent clinical and radiologic outcomes comparable with open reconstruction.

Outcomes After Anatomic Lateral Ankle Ligament Reconstruction Using Allograft Tendon for Chronic Ankle Instability: A Systematic Review and Meta-analysis

The purpose of this study was to systematically review the current evidence in the literature to ascertain whether the anatomic ankle ligament reconstruction procedure with allograft resulted in improved patient outcomes after ≥2 years of follow-up. A literature search of Medline, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Clinical studies investigating anatomic lateral ankle ligament reconstruction procedures for chronic ankle instability with a mean of >2 years' follow-up were included. Means were calculated for population size, age, follow-up duration, and postoperative Tegner scores. Pooled estimates were calculated for postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion, return to sports, risk of postoperative instability, and complications. Six clinical trials with 153 patients were included. The pooled estimated mean for the postoperative AOFAS score was 89.4 points (95% confidence interval [CI], 86.0 to 92.9; I² = 88.7%). The pooled proportion of patients who returned to sports after surgery was 80% (95% CI 57.0% to 100%; I² = 88.7%). The pooled total risk of recurrent instability after surgery was 6% (95% CI 1% to 12%; I² = 0%). No rejection was reported. Anatomic lateral ankle ligament reconstruction procedure results in significant improvements in patient function and outcome scores, with low rates of recurrent instability.

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).

Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability

PURPOSE

The aim of the study was to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. The hypothesis of the presented study is that suture-tape augmentation technique has comparable clinical and radiological outcomes with arthroscopic Broström repair technique.

METHODS

Sixty-one consecutive patients with chronic ankle instability were operated between 2012 and 2016 randomized to 2 groups. First group was composed of 31 patients whom were operated using an arthroscopic Broström repair technique (ABR) and second group was composed of 30 Patients whom were operated using arthroscopic lateral ligaments augmentation using suture-tape internal bracing (AST). At the end of total follow-up time, all patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiological evaluation was performed using anterior drawer and varus stress radiographs with standard Telos device in 150 N. Talar tilt angles and anterior talar translation were measured both preoperatively, 1 year postoperatively and at the final follow-up.

RESULTS

Preoperative total FAOS scores for ABR and AST groups were 66.2 ± 12 and 67.1 ± 11, respectively. Postoperative Total FAOS scores for ABR and AST groups were 90.6 ± 5.2 and 91.5 ± 7.7, respectively. There was no statistical difference in between 2 groups both pre- and postoperatively (n.s). According to FAAM, sports activity scores of ABR and AST groups were 84.9 ± 14 and 90.4 ± 12 at the final follow-up, which showed that AST group was significantly superior (p = 0.02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Mean operation time for AST and ABR groups were 35.2 min and 48.6 min, respectively, which shows statistically significantly difference (p < 0.05). There was no significant difference in recurrence rate of instability between to operation techniques (n.s).

CONCLUSIONS

Arthroscopic lateral ligament augmentation using suture tape shows comparable clinical outcomes to arthroscopic Broström repair in the treatment of chronic ankle instability at intermediate-term follow-up time. Arthroscopic lateral ligament augmentation using suture tape has a significant superiority in the terms of less operation time and no need for cast or brace immediate after surgery which allows early rehabilitation. It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life.

LEVEL OF EVIDENCE

II.

Evaluation modalities for the anatomical repair of chronic ankle instability

PURPOSE

Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment.

METHODS

Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018.

RESULTS

One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies.

CONCLUSIONS

There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data.

LEVEL OF EVIDENCE

Level IV, review of level I, II, III and IV studies.

Lateral ankle ligament anatomic reconstruction for chronic ankle instability: Allograft or autograft? A systematic review

BACKGROUND

To investigate if there is any evidence in favour of autograft or allograft use for anatomic reconstruction of lateral ankle ligaments in patients with symptomatic chronic ankle instability.

METHODS

A literature search was performed in PubMed MEDLINE, Cochrane Library, EMBASE and Google Scholar databases, over the years 1994-2017, to identify the studies presenting clinical results of anatomic lateral ankle ligaments reconstruction using various combinations of the keywords "lateral ankle ligaments reconstruction", "anatomic reconstruction", "chronic ankle instability", "allograft", "autograft". The surgical procedure was considered anatomic if consistent with the description of lateral ankle ligaments made by Burks and Morgan in 1994.

RESULTS

Among the 89 papers matching the search terms, only 12 could be included in which 357 anatomic lateral ankle ligaments reconstructions were performed. One was a comparative case series (level of evidence III - LOE III) while other papers were retrospective case series (LOE IV), the mean Modified Coleman Methodology Score (MCMS) was fair: 56.7 (SD±5.2). Due to the low level of evidence of the available literature only a qualitative analysis was performed. The limited evidence from the studies analysed suggests that there is no difference in graft survivorship, graft-dependent variables, patient's satisfaction, clinical outcome measures and radiographic results between allograft and autograft.

CONCLUSIONS

Given the low number of studies, their poor methodology score and their low level of evidence it is not possible to determine if allograft is better or safer than autograft.

LEVEL OF EVIDENCE

Level IV, review paper of level III and level IV studies.

The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study

PURPOSE

The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints METHODS: An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position.

RESULTS

Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30 mm each. Footprint morphometrics were heterogenous amongst the different CFL variants.

CONCLUSION

The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

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.

Medial Open-Wedge Supramalleolar Osteotomy for Patients with Takakura 3B Ankle Osteoarthritis: A Mid- to Long-Term Study

It is controversial whether supramalleolar osteotomy is suitable for Takakura Stage 3B osteoarthritis or not. The aim of this study was to evaluate the outcomes of supramalleolar osteotomy in patients with Takakura 3B osteoarthritis. From February 2008 to August 2013, supramalleolar osteotomy was performed in 21 patients matching the inclusion criteria. The mean patient age at operation was 53.7±5.8 years (range: 39 to 61 years). The mean duration of follow-up was 87.7±19.5 months (range: 61 to 125 months). The radiologic evaluation included the tibial articular surface (TAS) angle, tibial lateral surface (TLS) angle, and talar tilt (TT) angle. Functional assessment was performed with use of the AOFAS, VAS, SF-36, and AOS. All patients were followed. TAS angle improved from 82.8±2.4 to 90.3±2.3. TLS angle changed from 77.5±2.8 to 79.4±2.7. The preoperative TT angle and postoperative TT angle were 13.4±3.6 to 4.8±3.6, respectively. For functional evaluation, the preoperative VAS and AOFAS-AH scores were 5.7±1.3 and 48.0±15.8, while the postoperative VAS and AOFAS-AH scores were 2.5±1.9 and 74.8±11.5. The mean SF-36 scale improved from 41.2±13.1 to 66.7±14.9. The AOS score improved from 61.4±12.5 to 27.5±17.8. 1 patient underwent total ankle replacement 3 years postoperatively. 4 patients remained stage 3B including the TAR one. 4 improved to stage 3A, 11 improved to stage 2, and 2 improved to stage 1. Supramalleolar osteotomy combined with auxiliary procedures can restore the malalignment of ankle joint and modify the abnormal stress distribution so as to achieve functional improvement and improve radiographic stages.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.

A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability

BACKGROUND

Although various minimally invasive procedures for chronic ankle instability are increasingly being used, a question regarding whether these procedures can be a viable alternative of the modified Broström procedure remains controversial. This study was conducted to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients.

METHODS

Sixty female patients with chronic lateral ankle instability were randomly assigned and underwent surgical treatments by one surgeon. Twenty-eight patients with suture-tape augmentation and 27 modified Broström procedures were followed ≥2 years and analysed in this comparative study. The clinical evaluation included the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and stress radiographs. Medical expense related with operation was analysed to evaluate the cost-effectiveness.

RESULTS

There were no statistically significant differences in the clinical outcomes between two procedures based on FAOS, FAAM, recurrence rate of instability, and stress radiographs. Total medical expense was approximately 1.3 times more in the suture-tape group (P<0.001), despite shorter operation time.

CONCLUSIONS

Lateral ankle ligaments augmentation using suture-tape showed the similar clinical outcomes but low cost-effectiveness, as compared to modified Broström repair for young female patients with chronic ankle instability.

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.

Supramalleolar Osteotomy Combined With an Intra-articular Osteotomy for the Reconstruction of Malunited Medial Impacted Ankle Fractures

BACKGROUND:

Malunion of a medial impacted ankle fracture may cause varus ankle deformity. This retrospective study examined the use of supramalleolar osteotomy combined with an intra-articular osteotomy in patients with malunited medial impacted ankle fractures.

METHODS:

Twenty-four patients with malunited medial impacted ankle fracture were treated between January 2011 and December 2014. Using Weber's classification, 10 had type A fractures and 14 had type B, and with the AO classification, 20 had 44A2 and 4 had 44B3. All of these patients had varus ankle deformity. Supramalleolar osteotomy combined with an intra-articular osteotomy was performed. The visual analog scale (VAS) for pain during daily activities, the Olerud and Molander Scale and the modified Takakura classification stage were used to determine the clinical outcomes and a radiographic analysis was performed.

RESULTS:

The radiographic parameters, including the tibial ankle surface (TAS) angle and talar tilt angle (TTA), showed significant differences between the preoperative and follow-up assessments. The mean tibial lateral surface (TLS) did not show a significant change. The average Olerud and Molander Scale score improved significantly from 56.4 ± 6.21 preoperatively to 77.0 ± 6.11 at the latest follow-up ( P < .01). The mean VAS decreased significantly from 6.7 ± 0.8 preoperatively to 3.1 ± 0.6 at the latest follow-up ( P < .01). No significant difference in the modified Takakura classification stage was observed between the preoperative assessment and the last follow-up.

CONCLUSIONS:

The use of a supramalleolar osteotomy combined with an intra-articular osteotomy was an effective option for the treatment of malunited medial impacted ankle fractures associated with varus ankle deformity.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

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.

Surgical management of chronic lateral ankle instability: a meta-analysis

Background

A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods

We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results

Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups.

One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains.

Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle.

Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time.

One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique.

One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions

There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0870-6) contains supplementary material, which is available to authorized users.

Surgical Procedures for Chronic Lateral Ankle Instability

Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.

Clinical and magnetic resonance imaging assessment of anatomical lateral ankle ligament reconstruction: comparison of tendon allograft and autograft

PURPOSE

To compare the results of anatomical lateral ankle ligament (LAL) reconstruction with tendon allograft and autograft using clinical scores and ultrashort echo time (UTE) sequence of MRI.

METHODS

A total of 26 patients with LAL reconstruction were recruited in this study, including 16 using semitendinosus allografts and 10 using semitendinosus autograft. All of them were diagnosed as chronic ankle instability and accepted anatomic reconstruction. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, and radiological evaluation using MRI UTE scanning were extracted from each patient. The comparative analysis of the clinical assessments and UTE-T2* values were performed between the patients using autografts and allografts.

RESULTS

For the allograft group, the mean AOFAS score improved from 69.9 ± 13.3 to 94.8 ± 5.4 (P = 0.000), and the mean Karlsson score improved from 70.3 ± 12.2 to 93.8 ± 5.6 (P = 0.000). For the autograft group, the mean AOFAS score improved from 68.4 ± 10.0 to 94.7 ± 5.0 (P = 0.000), and the mean Karlsson score improved from 64.5 ± 14.4 to 95.0 ± 5.8 (P = 0.000). No significant differences were found between the allograft and autograft neither before (AOFAS P = 0.756, Karlsson P = 0.285) nor after (AOFAS P = 0.957, Karlsson P = 0.574) surgery. While the UTE T2* values in allograft were higher than those of autograft group both in anterior talofibular ligament (8.3 ± 1.0 vs 7.6 ± 1.1 P = 0.027) and intra-tunnel graft (7.8 ± 0.6 vs 7.2 ± 0.8 P = 0.045).

CONCLUSION

Both allograft and autograft reconstructions could get an ideal patient satisfaction and clinical functional outcomes at the follow-up. Higher T2* values were found in allograft group which indicated that autograft had some superiorities in respect of revascularization process, collagen structure, water content, and tendon properties.

Hamstring Autograft for Foot and Ankle Applications

BACKGROUND

Hamstring tendon autografts may be used for foot and ankle surgeries, although reports on their effectiveness and morbidity in the foot and ankle literature are limited. We studied a cohort of patients who underwent hamstring harvest for foot and ankle applications, hypothesizing that morbidity to the knee would be limited.

METHODS

We studied a cohort of patients who underwent hamstring autograft for foot or ankle applications by a fellowship-trained sports and foot and ankle surgeon since 2011. Thirty-seven patients underwent isokinetic strength testing using a dynamometer an average of 38 months postoperatively. The average patient age was 45 ± 16 (range, 18-78) years, and 54% were women. Peak flexion and extension torque as well as flexion and extension torque at 30, 70, and 90 degrees of flexion were collected at 2 different testing speeds, 180 and 300 degrees/s. t tests were used for all comparisons.

RESULTS

At follow-up, 32 patients (86%) reported no pain at the harvest site; the remaining 5 patients reported mild to moderate symptoms. No patients were dissatisfied, and all would recommend the surgery to someone else. Flexion strength at higher degrees of flexion was significantly lower compared with extension strength as well as compared with flexion strength at lower degrees of flexion, when testing was performed at lower speed ( P < 0.05).

CONCLUSIONS

When used for foot and ankle surgery, hamstring autografts resulted in high patient satisfaction with minimal donor site morbidity. While knee flexion strength was decreased at higher degrees of flexion, this finding did not appear to be clinically significant.

LEVEL OF EVIDENCE

Level IV, case series.

Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques

PURPOSE

To determine the best surgical treatment for chronic ankle instability (CAI) a systematic review was performed to compare the functional outcomes between various surgical stabilization methods.

METHODS

A systematic search was performed from 1950 up to April 2016 using PubMed, EMBASE, Medline and the Cochrane Library. Inclusion criteria were a minimum age of 18 years, persistent lateral ankle instability, treatment by some form of surgical stabilization, described functional outcome measures. Exclusion criteria were case reports, (systematic) reviews, articles not published in English, description of only acute instability or only conservative treatment, medial ankle instability and concomitant injuries, deformities or previous surgical treatment for ankle instability. After inclusion, studies were critically appraised using the Modified Coleman Methodology Score.

RESULTS

The search resulted in a total of 19 articles, including 882 patients, which were included in this review. The Modified Coleman Methodology Score ranged from 30 to 73 points on a scale from 0 to 90 points. The AOFAS and Karlsson Score were the most commonly used patient-reported outcome measures to assess functional outcome after surgery. Anatomic repair showed the highest post-operative scores [AOFAS 93.8 (SD ± 2.7; n = 119); Karlsson 95.1 (SD ± 3.6, n = 121)], compared to anatomic reconstruction [AOFAS 90.2 (SD ± 10.9, n = 128); Karlsson 90.1 (SD ± 7.8, n = 35)] and tenodesis [AOFAS 86.5 (SD ± 12.0, n = 10); Karlsson 85.3 (SD ± 2.5, n = 39)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SD ± 6.8, n = 128); Karlsson 51.6 (SD ± 5.5, n = 35) compared to anatomic repair [AOFAS 31.8 (SD ± 5.3, n = 119); Karlsson 40.9 (SD ± 2.9, n = 121)] and tenodesis [AOFAS 19.5 (SD ± 13.7, n = 10); Karlsson 29.4 (SD ± 6.3, n = 39)] (p < 0.005).

CONCLUSION

Anatomic reconstruction and anatomic repair provide better functional outcome after surgical treatment of patients with CAI compared to tenodesis reconstruction. These results further discourage the use of tenodesis reconstruction and other non-anatomic surgical techniques. Future studies may be required to indicate potential value of tenodesis reconstruction when used as a salvage procedure. Not optimal, but the latter still provides an increase in functional outcome post-operatively. Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. This has to be kept in mind when choosing between reconstruction and repair in the treatment of CAI.

LEVEL OF EVIDENCE

IV.

A new minimally invasive method for anatomic reconstruction of the lateral ankle ligaments with a Tightrope system

BACKGROUND

Several minimally invasive anatomic reconstruction techniques of the lateral ligaments have been introduced for the treatment of chronic lateral ankle instability. However, these strategies may not always follow accurate ligament anatomic attachments, especially in the construction of the fibular bone tunnels.

OBJECTIVES

This study reported a new percutaneous technique for reconstruction of the ligaments of lateral ankle anatomically with a Tightrope system.

METHODS

From April 2016 to August 2016, 25 ankles of 24 patients with chronic ankle instability underwent our new percutaneous anatomic reconstruction of the lateral ligaments with a Tightrope system. The operation was performed through several small incisions. The fibular tunnel was made obliquely from the anteromedial side of lateral malleolus tip towards retro-malleolar cortex. The graft was fixed in the tunnel with the help of a Tightrope system. The calcaneal tunnel and talar tunnel were made as our previous method. The mean final follow-up was 12.2 months (range 10-14). Visual Analogue Scale for pain, American Orthopaedic Foot and Ankle Society score, and patients' subjective satisfaction were used to measure clinical outcomes. Preoperative and postoperative stress tests were performed and radiographic parameters were measured.

RESULTS

The Visual Analogue Scale decreased from 3.0 ± 1.4 to 1.3 ± 0.8 at the last follow-up (p < 0.01). The American Orthopaedic Foot and Ankle Society score was improved from 70.2 ± 5.4 preoperatively to 92.4 ± 5.3 at the final follow-up (p < 0.01). Radiologically, the mean anterior talar displacement was 13.1 ± 2.7 mm preoperatively versus 5.6 ± 1.3 mm at last follow-up (p < 0.01),and the mean varus talar tilt angle was 15.0° ± 2.4° preoperatively versus 5.6° ± 1.9° at the last follow-up (p < 0.01). Patients were satisfied ('excellent' or 'good') in 23 ankles (92%). Two patients reported residual instability but less apprehension than the preoperative condition.

CONCLUSIONS

Percutaneous anatomic reconstruction of the lateral ligaments of the ankle with a Tightrope system is an anatomic and effective procedure for the treatment of chronic lateral ankle instability.

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.

Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study

PURPOSE

The purpose of this study was to determine the clinical utility of three bony tubercles: fibular obscure tubercle, talar obscure tubercle and tuberculum ligamenti calcaneofibularis, to serve as anatomical landmarks for defining the precise location of the origins and insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL).

METHODS

Twelve lower extremity cadaveric specimens were procured. The detectability of the tubercles was tested using palpation and fluoroscopy with subsequent confirmation after dissection. If the tubercles were present, then distances from the identified tubercles to the footprint centres and the intersection of the ATFL and CFL were measured to allow precise localization of the ATFL and CFL origin and intersection sites. Further, if the tubercles were not detectable, then an attempt to provide an alternative means of localizing ATFL and CFL origin and insertion sites was made by measuring distances between alternative landmarks and other important structures. All the measurements were performed by two researchers, and the results were averaged.

RESULTS

The fibular obscure tubercle existed and was detectable in all specimens. It was located 1.3 mm proximal to the articular tip of the fibula, 2.7 mm to the intersection of the ATFL and CFL, 3.7 mm distal to the ATFL and 4.9 mm proximal to the CFL origins. The talar obscure tubercle existed 58 % of specimens and was detectable in 57 %. The talar obscure tubercle was located 1.4 mm to the ATFL. The ATFL insertion point was located 60 % of the distance from the inferolateral corner to the anterolateral corner of the of talar body along the anterior border of the talar lateral articular facet. The tuberculum ligamenti calcaneofibularis existed in 33 % of specimens and was detectable in 8 %. The CFL inserted 17 mm on a perpendicular projected line distal from the subtalar joint.

CONCLUSIONS

The fibular obscure tubercle was clinically relevant and reliable bony landmark of the ATFL and CFL origin location. However, the talar obscure tubercle was less reliable and the tuberculum ligamenti calcaneofibularis was rarely available and as such alternative landmarks for the ATFL and CFL insertion location should be utilized. The present study describes the utility of clinically relevant bony landmarks that may assist in identifying the origins and insertions of the ATFL and CFL to facilitate minimally invasive ankle stabilization surgery.

Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review

PURPOSE

To gain a better understanding of the precise anatomy of the lateral ligaments of the ankle through a systematic review of published cadaveric studies in order to improve anatomical minimally invasive surgery (MIS) for treatment of chronic ankle instability (CAI).

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, Cochrane databases and Web of Science on June 2015 with the two search concepts: "lateral ligament of the ankle" and "anatomy". Anatomical studies that reported gross anatomy of the anterior talar fibular ligament (ATFL) and calcaneal fibular ligament (CFL) in English were included to assess the morphology and origins and insertions of the ligaments. All records found in the literature search were screened by title and abstract. Potentially relevant articles were selected for full-text review. Each of the identified articles was reviewed and included in qualitative synthesis. The following data were abstracted from the included articles: authors, date of publication, sample size, mean age, the length and the width of the each ligament, number of bundle of the ATFL and the location and the footprint of the origins and insertions for the ATFL and CFL.

RESULTS

Sixteen studies were identified indicating the length of the ATFL and CFL was 12-24.8 and 18.5-35.8 mm, respectively, while the width was 5-11.1 and 4.6-7.6 mm, respectively. Fibular origins of the ATFL and CFL were located on the anterior border of distal fibula at a distance of 10-13.8 and 5.3-8.5 mm proximal to the tip of the fibula, respectively. The talar insertion of the ATFL was located 14.2-18.1 mm to the subtalar joint or 11.3-14.8 mm to the anterolateral corner of the talar body. The calcaneal insertion of the CFL was located 12.1-13 mm to the subtalar joint or 13.2-27.1 mm to the peroneal tubercle on the lateral wall of calcaneus.

CONCLUSION

Systematic review of the literature of the research for the ATFL and CFL has identified the morphology of the ligaments and their location of origins and insertions. This is the best available data about the ATFL and CFL which will facilitate more precise anatomical MIS for treatment of CAI.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Osteochondral autograft transplantation with biplanar distal tibial osteotomy for patients with concomitant large osteochondral lesion of the talus and varus ankle malalignment

Background

Osteochondral lesions of the talus (OLTs) are amongst the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (>10 mm), Osteochondral autograft transplantation is usually recommended. This article highlights biplanar distal tibial osteotomy as an approach and management for patients with concomitant large OLTs and varus ankle malalignment.

Methods

From January 2012 to July 2014, 13 patients (6 male and 7 female) underwent surgery in our faculty and their average age was 55.4 (ranging from 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, followed by an osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight-bearing X-rays were conducted and used for the measurement of radiographic parameters such as the tibial articular surface (TAS) and tibial lateral surface (TLS) angles. Ankle function of the subjects was evaluated according to the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot score (AOFAS-AH) questionnaires and Visual Analog Scale (VAS).

Results

11 patients completed the follow-up over a mean period of 21.2 months. The average area of talar lesion was 135.9 mm² while the average depth was 11.4 mm. The mean time for osseous union was 8.5 weeks. Donor site morbidity was not recorded in any of the cases. The mean AOFAS-AH and VAS improved from 53 to 90 points (p < 0.05) and 6.7 to 1.9 points (p < 0.05) respectively. The mean TAS angle improved from 83.1 to 90.3° (p < 0.05).

Conclusions

Biplanar distal tibial osteotomy with the combination of osteochondral autograft transplantation could be used to address patients with concomitant large OLTs and varus ankle malalignment as this technique provides excellent visualization of the talar defect, favorable biomechanical environment for the ankle joint with high rate of good and excellent results.

Minimally invasive surgical treatment for chronic ankle instability: a systematic review

PURPOSE

The purpose of this study was to determine the evidence-based support for the treatment for chronic ankle instability (CAI) using minimally invasive surgery (MIS) techniques.

METHODS

A systematic comprehensive review of the literature was performed on 4 September 2015 using PubMed, EMBASE, Cochrane databases and Web of Science along with the two search concepts: lateral ligament of the ankle (patients) and minimally invasive surgical procedure (intervention). Articles of clinical study on MIS for CAI were included in this review and classified into four MIS categories (arthroscopic repair, non-arthroscopic minimally invasive repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction) based on the adopted surgical procedure. Included articles were reviewed and assigned a classification according to the research method quality of evidence (Level I-V evidence). Analysis of these studies was then conducted to provide a grade of recommendation for each MIS category.

RESULTS

The systematic literature review generated 430 articles, and 33 articles met our inclusion criteria. The highest recommendation was Grade C (poor-quality evidence) to support the use of the arthroscopic repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction. Insufficient evidence was currently available to make any recommendation (Grade I) for non-arthroscopic minimally invasive repair category.

CONCLUSIONS

Despite recent increases in publications on MIS for the treatment for CAI, there was currently poor quality of evidence that was insufficient to allow a high grade of recommendation to support the use of the MIS. This paper should stimulate those surgeons performing higher quality studies in the form of prospective and preferably randomized comparative studies that will be necessary to allow better recommendations for the treatment for CAI with MIS. The present study showed thorough evidence-based recommendation for the clinical use of the MIS based on the comprehensive review of the literature.

LEVEL OF EVIDENCE

Systematic review, Level IV.