Outcomes of the Modified Broström Procedure Augmented With Suture-Tape for Ankle Instability in Patients With Generalized Ligamentous Laxity

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity

BACKGROUND

To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL).

METHODS

From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0.

RESULTS

The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up.

CONCLUSION

Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Augmentation of the medial collateral ligament using suture tape reduces the recurrence after corrective surgery for severe hallux valgus

BACKGROUND

The severity of hallux valgus (HV) deformity is associated with recurrence after corrective surgery because of the degenerative change of the medial capsule including the medial collateral ligament (MCL) at the metatarsophalangeal joint. This study aimed to assess the effectiveness of the MCL augmentation using a suture tape anchor of the recurrence of HV and to evaluate the histological changes of the medial joint capsule in HV patients.

METHODS

Thirty-four feet with severe hallux valgus were included and divided into 2 groups. Seventeen feet had the MCL reconstruction using suture tape anchor with a combination of the corrective osteotomy as the suture tape group (mean age, 64.0 years), and other seventeen feet had the corrective osteotomy without MCL reconstruction as the control group (mean age, 62.0 years). HV angle (HVA) and intermetatarsal angle (IMA) on the weight-bearing radiograms and the Japanese Society for Surgery of the Foot (JSSF) score in both groups were compared at the final follow-up. The medial capsule was harvested from other 20 feet with HV and the relationship between the severity of HV and the histological findings was analyzed.

RESULTS

HVA, IMA, and JSSF scores in both groups were significantly improved from preoperatively to the final follow-up (P < 0.01). At the final follow-up, HVA in the suture tape group (9.2°) was significantly smaller than that in the control (15.4°) (P < 0.01). There were no significant differences in the IMA and the JSSF score at the final follow-up between both groups. Histological scores in HV with ≥40° HVA was significantly worse than those in <40°.

CONCLUSION

The medial joint capsule in severe HV deformity showed the degenerative change and the MCL reconstruction using suture tape combined with osteotomy provides a strong medial constraint to prevent the recurrence of the deformity in severe hallux valgus.

LEVEL OF CLINICAL EVIDENCE

3.

Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study

PURPOSE

The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint.

METHODS

Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up.

RESULTS

Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications.

CONCLUSIONS

Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical Outcomes and Return to Preinjury Sports After Anatomic Reconstruction With a Gracilis Autograft Versus the Modified Broström Procedure in Patients With Generalized Joint Laxity

Background

Generalized joint laxity (GJL) is a risk factor for inferior outcomes after the modified Broström procedure for chronic lateral ankle instability, while anatomic reconstruction with tendons is more inclined to be recommended. However, whether anatomic reconstruction could achieve better results than the modified Broström procedure in patients with GJL is unknown.

Purpose

To compare clinical outcomes and return to sports between anatomic reconstruction and the modified Broström procedure in patients with GJL.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with GJL (Beighton score ≥4) who underwent either the modified Broström procedure or anatomic reconstruction with gracilis autografts between 2017 and 2020 were reviewed. Included were 19 patients who underwent anatomic reconstruction (reconstruction group) and 49 patients who underwent the modified Broström procedure (MBP group). Clinical outcomes were compared using the Foot and Ankle Outcome Score (FAOS) and the Karlsson score. The rates of return to preinjury level in high-demand sports, sprain recurrence, and range of motion between the 2 groups were also compared.

Results

The mean follow-up duration was 38.3 months in the reconstruction group and 43.7 months in the MBP group. The FAOS and Karlsson scores improved significantly after surgery in both groups (P < .001 for all), with the reconstruction group having significantly higher postoperative FAOS-Sports scores (87.9 ± 8.9 vs 80.5 ± 11.6; P = .015) and Karlsson scores (86.9 ± 6.1 vs 82 ± 8.4; P = .025) than the MBP group. The rate of return to preinjury high-demand sports was higher in the reconstruction group than in the MBP group (73.3% vs 38.9%; P = .034). The MBP group had a significantly higher rate of sprain recurrence (22.4% vs 0%; P = .027). More patients reported dorsiflexion restriction in the reconstruction group (n = 4; 21.1%) than in the MBP group (n = 1; 2%) (P = .019); nonetheless, there was no noticeable effect on daily life and sports.

Conclusion

Better clinical outcomes, less sprain recurrence, and a higher rate of return to preinjury high-demand sports were found after anatomic reconstruction with free tendons compared with the modified Broström procedure in patients with GJL. Anatomic tendon reconstruction can be recommended for such patients, especially those participating in high-demand sports.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years

BACKGROUND

An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation.

METHODS

Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used.

RESULTS

Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability.

CONCLUSION

At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone.

LEVEL OF EVIDENCE

Level II, retrospective cohort study.

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Evaluation of Spin in the Clinical Literature of Suture Tape Augmentation for Ankle Instability

Background

Spin is defined as the use of specific reporting strategies to highlight the beneficial effect of a treatment despite nonsignificant results. The presence of spin in peer-reviewed literature can negatively impact clinical and research practices. The purpose of this study was to identify the quantity and types of spin present in primary studies and systematic reviews using suture tape augmentation for ankle instability as a model.

Methods

This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each abstract was assessed for the presence of the 15 most common types of spin. Extracted data included study title, authors, publication year, journal, level of evidence, study design, funding, reported adherence to PRISMA guidelines, and PROSPERO registration. Full texts of systematic reviews were used in the assessment of study quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

Results

Nineteen studies were included in the final sample. At least 1 type of spin was identified in each study except one (18 of 19, 94.7%). The most common type of spin observed was type 3 ("selective reporting or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention") (6 of 19, 31.6%), The second most reported category of spin was type 4 ("the conclusion claims safety based on non-statistically significant results with a wide confidence interval") (4 of 19, 21.1%). Among systematic reviews, we identified type 5 ("the conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") in 4 out of 6 (66.7%) of the articles that were included. No significant associations were found between study characteristics and type of spin.

Conclusion

In this exploration of the introduction of a new technology, we identified spin to be highly present in the abstracts of primary studies and systematic reviews concerning suture tape augmentation for ankle instability. Steps should be taken by scientific journals to ensure that spin is minimized in the abstract to accurately reflect the quality of the intervention.

Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review

BACKGROUND

"Failure" is a term that is frequently used to describe an unfavorable outcome for patients who undergo surgical treatment for lateral ankle instability (LAI). A standard definition of failure for the surgical treatment of ankle instability has not been established by clinicians and researchers.

PURPOSE

To identify the definitions of ankle instability treatment failure that are currently in the literature and to work toward the standardization of the definition.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of MEDLINE, SPORTDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for LAI and included information about surgical failure. Studies with level of evidence 1 to 4 were included in this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinions were excluded. The included studies were then reviewed for definitions of failure of any surgical procedure that was performed to correct LAI.

RESULTS

Of the 1200 studies found, 3.5% (42/1200) published between 1984 and 2021 met the inclusion criteria and were analyzed. After reviewing the data, we found numerous definitions were reported in the literature for LAI surgical failure. The most common was recurrent instability (40% [17/42]), followed by rerupture (19% [8/42]). For the original surgical procedure, the anatomic Broström-Gould technique was used most frequently (57% [24/42]). The failure rate of the Broström-Gould technique ranged from 1.1% to 45.2% depending on the definition of failure.

CONCLUSION

There were multiple definitions of failure for the surgical treatment of LAI, which is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. This definition should include specific, objective physical examination findings that eliminate the ambiguity surrounding failure.

Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue

PURPOSE

Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants.

METHODS

64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test.

RESULT

Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found.

CONCLUSION

Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

Modified Brostrom-Gould surgical procedure for chronic lateral ankle instability compared with other operations: a systematic review and meta-analysis

Background

This study performed a randomized trial data meta-analysis to assess The Modified Brostrom-Gould (MBG) for proven chronic lateral ankle instability (CLAI).

Methods

All published randomized clinical trials comparing MBG and other operations were found by searching the Cochrane Library, EMBASE, and PubMed databases. The Review Manager 5.4 software was used to compare the two groups regarding postoperative functional score, ankle stability, and complications. Risk Ratio (RR) and Mean Differences (MD) were used in meta-analyses.

Results

8 experiments are suitable for it, 426 patients were enrolled, and 222 patients underwent other operations surgery. Among the six outcome indicators, in terms of FAOS scores, the other operations group has an advantage, 6.53 points higher than MBG; others show no significant differences.

Conclusions

Based on this meta-analysis, the authors believe that other surgical groups can achieve better outcomes than MBG in some aspects of CLAI treatment.

The Influence of Suture-Tape Augmentation on Biological Healing of the Anterior Talofibular Ligament in Chronic Ankle Instability: A Quantitative Analysis Using MRI

While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL.

Comparison of Modified Broström Procedure with or without Suture Tape Augmentation Technique for the Chronic Lateral Ankle Instability

Purpose

To compare the clinical outcomes of the modified Broström repair (MBR) with or without suture tape augmentation (STA) for managing the chronic lateral ankle instability.

Methods

72 patients with chronic lateral ankle instability treated at our hospital from January 2018 to July 2019 were included, with 37 patients receiving the MBR and 35 treated by the MBR with STA. The clinical efficacy of the two techniques was assessed in terms of VAS, AOFAS, and Karlsson scores and by physical examination in follow-ups.

Results

In all 72 patients, operations were successful, and the patients were followed up for 29.3 months on average (range, 24-43 months). There were no significant differences in preoperative pain, AOFAS, and Karlsson scores between the two groups. Compared with preoperative findings, all the functional scores were significantly improved in both groups 3 months after the operation and at the last follow-up. Three months after the operation, the STA group had significantly lower VAS and higher AOFAS scores than the isolated MBR group, suggesting that patients in the STA group suffered less pain and achieved better functional improvement. However, the VAS and functional scores at the last follow-up and the Karlsson score at 3 months postoperatively showed no intragroup difference in both groups.

Conclusion

MBR with or without STA could achieve good results for the treatment of chronic lateral ankle instability. Compared with the widely used MBR, combining with STA may be more effective in promoting rehabilitation in early term.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review

Background:

There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle.

Purpose:

To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed.

Results:

There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I² = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, –3.73 to 6.21]; I² = 66%; P = .63), talar tilt angle improvement (MD, –0.07 [95% CI, –0.68 to 0.54]; I² = 0%; P = .42), or anterior talar translation improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I² = 0%; P = .77).

Conclusion:

Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

A quantitative evaluation of the individual components contributing to the functional ankle instability in patients with modified Broström procedure

Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. A total of 46 patients (46 ankles) underwent the MBP for chronic ankle instability were eligible for this study and were followed for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a 6-meter hop test, and a cross 3-meter hop test. The error in joint-position sense significantly improved from a mean 4.3º to 2.8º (p < .001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm (p = .024). Balance retention time significantly improved from a mean 4.7 seconds to 6.4 seconds (p < .001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively (p = .031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense (p < .001), 86.9% in peroneal strength (p = .012), and 74.4% in postural control (p < .001) with significant side-to-side differences. Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively.

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.

Biomechanical Comparison of Modified Adams-Berger and DX technique in DRUJ Reconstruction

Background  Adams-Berger ligamentoplasty is a widely accepted reconstruction for unrepairable triangular fibrocartilage complex (TFCC) injuries with instability. Failure of the reconstruction and recurrent instability is still a clinical problem. Internal brace augmentation of tendon grafts is gaining more popularity, but use in the distal radioulnar joint (DRUJ) is not yet published. Questions/Purposes  The purpose of this study was to compare a novel anatomical DRUJ reconstruction with a modified Adams-Berger reconstruction to answer which technique stabilize better the DRUJ and which has enough stabilizing effect to allow early mobilization. Methods  Nine matched pairs of cadaveric upper extremities were used. The dorsopalmar translations in the DRUJ that occurred with 50 N load were measured before and after detachment of the TFCC from the ulna and after ligament reconstruction with either modified Adams-Berger procedure or DX Swivelock technique. Internal brace augmented palmaris longus tendon grafts were used in all reconstruction. Results  In the Adams-Berger group, the injured and the reconstructed displacements were significantly higher than the native, while in the DX group both the native and the reconstructed displacements were significantly lower than the injured. The mean (standard deviation) change of translations was 0.46 (1.94) mm after Adams-Berger and 2.51 (1.31) mm after DX reconstruction, implying significant better stabilizing effect of the latter. Conclusions  DX Swivelock reconstruction showed better time zero stabilizing effect compared with Adams-Berger procedure, regaining almost normal stability of the DRUJ.

Lack of Definition of Chronic Ankle Instability With Arthrometer-Assisted Ankle Joint Stress Testing: A Systematic Review of In Vivo Studies

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability.

The changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure for chronic ankle instability

Purpose: Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. Methods: A total of 46 patients (46 ankles) who underwent the MBP for chronic ankle instability were eligible for this study and were followed up for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a six-meter hop test, and a cross three-meter hop test. Results: The error in joint-position sense significantly improved from a mean 4.3° to 2.8° (p < 0.001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm (p = 0.024). Balance retention time significantly improved from a mean 4.7 s to 6.4 s (p < 0.001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively (p = 0.031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense (p < 0.001), 86.9% in peroneal strength (p = 0.012), and 74.4% in postural control (p < 0.001), with significant side-to-side differences. Conclusion: Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively. Level of Evidence: Level IV (prospective case series).

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Clinical and Functional Results of Broström-Gould Procedure With Suture Tape Augmentation: An Evaluation Using Three Scales

The mechanical superiority of suture tape augmentation associated with the Broström-Gould procedure for treating lateral ankle instability has been reported. This study aimed to describe functional results using the visual analog scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) scale, and Short Form of Quality of Life Survey (SF-36) in patients with ankle lateral instability who underwent the modified Broström-Gould repair and suture tape augmentation and to determine the recurrence of injury and the impact on the perception of its stability. This retrospective cohort study included patients with lateral ankle instability treated using the modified Broström-Gould procedure and suture tape augmentation from December 2015 to July 2018 with a 6- to 36-month follow-up. Clinical and functional results were evaluated using the 3 aforementioned scales. p ≤ 0.05 was considered statistically significant. Twenty-eight patients were included, 18 (64%) males and 10 (36%) females (mean ± standard deviation age of 33.25 ± 12.73). The mean pre- and postoperative VAS scores were 6 ± 1.18 and 0.53 ± 0.92, respectively. The average pre- and postoperative AOFAS scores were 65.89 ± 15.08 and 94.60 ± 6.88, respectively; results were excellent (91 to 100) in 18 (64%) patients and good (81 to 90) in 10 (36%). Three patients experienced recurrence of injury treated with physical therapy, and their progress was satisfactory; stability perception was maintained. Excellent clinical and functional results were demonstrated in our study using suture tape augmentation in the modified Broström-Gould procedure, which probably protects against the recurrence of lateral ankle instability.

Traditional Modified Broström vs Suture Tape Ligament Augmentation

BACKGROUND

The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB.

METHODS

Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm.

RESULTS

Average RTPAL was 17.5 weeks after MB and 13.3 weeks after ST (P < .001). At 26 weeks, 12.5% of patients in the MB group and 3.6% of patients in the ST group had not managed RTPAL (P = .14). The complication rate was 8.5% in the MB group vs 1.7% in the ST group (P = .12). Four patients in the MB group failed to complete the ARP vs 1 in the ST group (P = .144).

CONCLUSION

Results from this multicenter, prospective, randomized trial suggest that ST augmentation allows for earlier RTPAL than MB alone. ST augmentation may support successful accelerated rehabilitation and did not result in increased complications or morbidity.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

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.

Evaluation of the uninjured anterior talofibular ligament by ultrasound for assessing generalized joint hypermobility

BACKGROUND

Most clinicians use the Beighton score to assess generalized joint hypermobility (GJH) when deciding on the treatment of chronic lateral ankle instability (CLAI). The purpose of the study was to evaluate anterior talofibular ligament (ATFL) status by ultrasound and correlate these values with Beighton scores and the manual anterior drawer test (ADT).

METHODS

The participants were divided into two groups, those without GJH (24 ankles) and with GJH (20 ankles). For the investigation of ATFL, resting and stress ultrasonography was performed to assess the length, height (degree of loosening) and thickness. Beighton scores, manual ADT grades and ultrasound parameters of participants with and without GJH were compared. The correlation coefficients among those values were analyzed.

RESULTS

The mean ATFL length, resting height, stress height and mean difference in height between resting and stress ATFL were all significantly different between the two groups (P < .05). The resting and stress ATFL length, height, and difference in height between resting and stress ATFL showed a positive linear relationship with Beighton scores and manual ADT grades (P < .05).

CONCLUSIONS

The ATFL stress ultrasound parameters showed significant differences between participants with high and low Beighton scores and were correlated with Beighton scores and manual ADT grades.

LEVEL OF EVIDENCE

Cross-sectional cohort study; Level of evidence IV.

Do Mid-term Outcomes of Lateral Ankle Stabilization Procedures Differ Between Military and Civilian Populations?

BACKGROUND

Ankle instability is common and previous studies have documented greater than 85% good-to-excellent outcomes based upon both patient-reported outcome measures and subjective evaluation of ability to return to previous activity levels after lateral ankle stabilization in the civilian population. However, patient-reported outcomes and performance may differ in the military population. The military oftentimes requires servicemembers to navigate uneven terrain and ladderwells, which can stress ankles differently than in their civilian counterparts. There has been limited evidence regarding patient outcomes after lateral ankle stabilization within a military population and its elucidation is important in optimizing outcomes for our servicemembers. Furthermore, the potential benefit of fibular periosteum augmentation with lateral ankle stabilization procedures in a military population has not been described. The results of using this extra tissue to reinforce the repair are important in determining whether its routine incorporation is indicated in the military.

QUESTIONS/PURPOSES

In an active-duty military population, we asked: (1) What proportion of patients who underwent lateral ankle stabilization using anatomic repair techniques with or without fibular periosteum augmentation achieved good-to-excellent outcomes based on the Foot and Ankle Disability Index (FADI) score at a minimum follow-up interval of 2 years? (2) Was the proportion of patients who achieved a good-to-excellent FADI score higher among those treated with fibular periosteum augmentation than those treated without? (3) Did the likelihood of achieving a good-to-excellent outcome after lateral ankle stabilization vary based on whether the procedure was performed by a fellowship-trained sports or foot and ankle orthopaedic surgeon versus a podiatrist?

METHODS

Between 2007 and 2017, 15 surgeons (six orthopaedic surgeons and nine podiatrists) performed 502 lateral ankle stabilizations. We excluded 4% (18 of 502) of patients because they were not active-duty at the time of surgery, and we excluded 12% (56 of 502) of lateral ankle stabilizations because they were performed as part of other potentially confounding foot or ankle procedures. We considered 60% (303 of 502) as lost to follow-up because the patients could not be contacted at least 2 years after surgery, they declined to participate, or they did not fully answer the questionnaires. This left 125 patients for analysis. Of those, 79% (99 of 125) had a procedure with fibular periosteum augmentation and 21% (26 of 125) had a procedure without augmentation. During the study period, five fellowship-trained orthopaedic foot and ankle surgeons and two podiatrists always used fibular periosteum augmentation. Orthopaedic surgeons performed 75% (94 of 125) of the procedures, and the other 25% (31 of 125) were performed by podiatrists. Whether a servicemember was treated by one specialty or the other was simply based upon whom they were referred to for care. Orthopaedic surgeons tended to perform procedures with augmentation (five with versus one without) and podiatrists tended to perform procedures without augmentation (two with versus seven without). To help account for this confounding factor, we performed separate analyses for procedures performed with versus without augmentation in addition to procedures performed by orthopaedic surgeons versus podiatrists. We retrospectively contacted each patient to obtain their self-reported overall result, FADI outcome score, and postoperative military capabilities. The minimum follow-up duration was 2 years; overall mean follow-up duration was 7 years. The fibular periosteum augmentation group mean follow-up was 7 ± 4 years and without augmentation was 6 ± 3 years. The orthopaedic surgeons group mean follow-up was 7 ± 3 years and the podiatrists group was 7 ± 3 years. We obtained postoperative FADI scores via phone interview along with data regarding the patients' postoperative military capabilities, but did not have preoperative FADI scores.

RESULTS

Pooling both surgical treatments, 67% (84 of 125) of the patients reported good-to-excellent results and 33% (41 of 125) reported very poor-to-fair results. We found no difference in the proportion of patients treated with fibular periosteal augmentation who achieved a good or excellent score on the FADI than was observed among the patients treated without periosteal augmentation (68% [67 of 99] versus 65% [17 of 26]; odds ratio 1 [95% CI 0 to 2]; p = 0.81). The proportion of patients who achieved a good or excellent score on the FADI did not differ depending on whether the procedure was performed by an orthopaedic surgeon or a podiatric surgeon (66% [62 of 94] versus 71% [22 of 31]; OR 1 [95% CI 1 to 2]; p = 0.66).

CONCLUSION

The patient-reported outcome scores after lateral ankle stabilization in our study of military servicemembers at a minimum of 2 years and a mean of 7 years were far lower than have been reported in studies on civilians. Indeed, our findings may represent a best-case scenario because more patients were lost to follow-up than were accounted for, and in general, surgical results among missing patients are poorer than among those who return for follow-up. Variability in the addition of fibular periosteum augmentation and whether an orthopaedic surgeon or podiatrist performed the procedure did not account for these findings. With one third of patients reporting very-poor-to-fair results after these reconstructions, and many patients lost to follow-up, we recommend surgeons counsel their servicemember patients accordingly before surgery. Specifically, that there is a one third chance they will need permanent restrictions or have to leave the military postoperatively; analogously, we believe that our findings may apply to similarly active patients outside the military, and we question whether these procedures may not be serving such patients as well as previously believed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF CLINICAL EVIDENCE

Level 3.

Arthroscopic Internal Brace Augmentation With Arthroscopic Modified Broström Operation for Chronic Ankle Instability

Lateral ankle sprains are very common injuries that sometimes lead to chronic lateral ankle instability. The modified Broström operation is the gold standard procedure for treatment of chronic lateral ankle instability. Currently, this operation is performed arthroscopically. Broström repair depends on the quality of the remnant ligament. In cases with an insufficient remnant ligament, Gould augmentation or reconstruction using the gracilis tendon is generally performed. Recently, tape augmentation (internal brace) also has been used to support an insufficient ligament. This article introduces arthroscopic tape augmentation with arthroscopic modified Broström operation. This technique consists of creation of a talar anchor hole and fibular anchor hole, reattachment of the remnant ligament to the fibula with tape, and tape fixation to the talus. This technique uses only one knotless anchor screwed to the fibula for both the modified Broström operation and fixation of the tape. This technique is relatively simple and produces similar results as an open procedure.

A systematic review of the "Logsplitter" injury: how much do we know?

BACKGROUND

As an emerging proposed type of ankle joint injury, the concept of logsplitter injury is a unified overview of the high-energy ankle fracture and dislocation accompanied by distal tibiofibular syndesmosis separation and displacement. Since the concept of logsplitter injury is still relatively novel, there is no uniform standard for its clinical classification, diagnosis and treatment currently. Thus, we reviewed previous literatures here to provide certain references for its better clinical diagnosis and treatment in future.

METHODS

The available literatures from January 1985 to June 2020 in five medical databases were searched and analyzed. The original articles that evaluated the outcomes of patients treated surgically for the logsplitter injury were included. The detailed data were then extracted from each research, including the researchers, type of study, level of evidence, type of center research, groups, number of patients, gender, age, causes of injury, time from injury to surgery, operative time, intraoperative blood loss, length of follow-up, postoperative complications and clinical outcomes. The overall search procedures were performed by the two independent reviewers.

RESULTS

Seven pieces of researches (199 patients) were eligible for inclusion. All researches were either retrospective or prospective study, and all but one was single center study. Falling from height ranked first in the causes of injury (52.8%), and followed by the traffic accidents (29.6%). Clinical outcomes were all measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the mean AOFAS score at the final follow-up was 77.9 points.

CONCLUSIONS

None of the definitive consensuses exists on how logsplitter injury should be diagnosed and surgically managed. In light of the novel concept, short presentation time and numerous postoperative complications, the logsplitter injury has not been well understood by most surgeons currently, and its overall situation still needs to be supported by a larger sample size of multicenter research in the future.

[Arthroscopic reinforced reconstruction of anterior cruciate ligament with autologous hamstring tendon and anchor suture band]

OBJECTIVE

To investigate the effectiveness of arthroscopic reinforced reconstruction of anterior cruciate ligament (ACL) with autologous hamstring tendon combined with anchor suture band.

METHODS

Between February 2016 and March 2018, 60 patients who were to be treated with arthroscopic ACL reconstruction and met the selection criteria were selected in the study. Among them, 30 cases were reconstructed with autologous hamstring tendon combined with anchor suture band (trial group), and 30 cases were reconstructed with simple autologous hamstring tendon (control group). There was no significant difference in gender, age, disease duration, cause of injury, injury side, and preoperative Lysholm score, Tegner score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). After reconstruction, the patients in the trial group were allowed to start knee flexion and extension activities early without wearing an adjustable brace, while the patients in the control group were required to wear an adjustable brace for 12 weeks. The knee joint function (Lysholm score, Tegner score, IKDC score) and stability (Lachman test and pivot shift test) were compared between the two groups after operation.

RESULTS

There was no significant difference in graft diameter between the two groups ( t=1.061, P=0.115). Compared with the control group, the operation time of the trial group was significantly different ( t=4.924, P=0.000). All incisions healed primarily. In the control group, the intramuscular venous thrombosis occurred in 2 cases after operation. Both groups were followed up 18 months. The Lysholm score, Tegner score, and IKDC score of the two groups at each time point after operation were significantly higher than those before operation ( P<0.05); the above scores in the trial group were significantly higher than those in the control group at 3, 6, and 9 months after operation ( P<0.05); there was no significant difference between the two groups at 18 months after operation ( P>0.05). There was no significant difference in Lachman test results between the two groups at each time point after operation ( P>0.05). There was a significant difference in pivot shift test results at 6 months after operation between the two groups ( P<0.05); but there was no significant difference at other time points ( P>0.05).

CONCLUSION

The effectiveness of ACL reinforcedreconstruction with autologous hamstring tendon combined with anchor suture band is satisfactory. Compared with using autologous hamstring tendon alone, it has better initial strength and joint stability, and is more conducive to early postoperative functional exercise and functional recovery of knee joint.

Evolution in Surgical Management of Ankle Instability in Athletes

Recent concepts are changing the management of ankle instability. These include concurrent medial and lateral instabilities, use of ankle arthroscopy, use of suture anchors, all-arthroscopic stabilization, synthetic augmentation, and early postoperative rehabilitation. Medial sided injuries occur in up to 72% of the lateral ankle sprains, and concomitant repair may provide greater stability. Suture anchors are equally as strong as transosseous tunnels, and the technique is simple, reproducible, and may decrease complications, but anchors do increase costs. Synthetic augmentation demonstrates greater strength than Broström alone in cadaver-based biomechanical testing. Although clinical studies of synthetic augmentation have demonstrated equivocal stability and pain compared with Broström alone, synthetic augmentation may expedite rehabilitation. All-arthroscopic ankle stabilization is gaining popularity with increasing publications. Early findings demonstrate comparable biomechanical and clinical data compared with open techniques. Early postoperative weight-bearing within 2 weeks seems to be safe and may shorten time to return to play. Surgeons may consider using these novel techniques in the management of lateral ankle instability.

No Differences in Clinical Outcomes of Suture Tape Augmented Repair Versus Broström Repair Surgery for Chronic Lateral Ankle Instability

Background

Suture tape (ST) augmented repair, an alternative to traditional Broström repair (BR), may protect the repaired anterior talofibular ligament during ligament healing. No systematic review of cohort studies has been conducted to compare traditional BR with ST-augmented repair for chronic lateral ankle instability.

Purpose

To review the current evidence in the literature to ascertain whether ST-augmented repair is superior to traditional BR in managing chronic lateral ankle instability.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was performed to identify relevant articles published in PubMed, Embase, and Cochrane Library databases in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included cohort studies comparing the efficacy of BR and ST-augmented repair procedures in terms of incidence of instability recurrence, functional scores, talar tilt angle (TTA), anterior talar translation (ATT), and complication rate. Methodological quality was assessed using the Jadad scale for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies.

Results

A total of 4 clinical trials with 254 patients were included. No significant differences were detected between BR and ST-augmented repair procedures in terms of incidence of recurrent instability, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Foot and Ankle Ability Measure, TTA, ATT, or complication rate. The ST group appeared to have a shorter operation time compared with the BR group.

Conclusion

No significant differences were found between ST-augmented repair and BR surgery regarding incidence of recurrent instability, functional outcome scores, or complication rates. Although technically challenging, the ST-augmented repair procedure appears to be a safe and fast option.

Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation

Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair. Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears. Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0-57.5° and 0-71°, respectively, for chronic tears and 2.2-53.9° and 0-71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications. Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

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.

In vivo assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study

AIMS

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

MATERIALS AND METHODS

A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).

RESULTS

At eight weeks, FiberTape alone or FiberTape-augmented autograft demonstrated increased biomechanical stability compared with autograft regarding ultimate load to failure (p = 0.035), elongation (p = 0.006), and energy absorption (p = 0.022). FiberTape-grafted samples also demonstrated increased bone mineral density in the bone tunnel (p = 0.039). Histological evaluation showed integration of all grafts in the bone tunnels by new bone formation, and limited signs of inflammation overall. A lack of prolonged inflammation in all samples was confirmed by quantification of inflammation biomarkers. However, no regeneration of ligament-like tissue was observed along the suture tape materials. Except for one autograft failure, no adverse events were detected.

CONCLUSION

Our results indicate that FiberTape increases the biomechanical performance of intra-articular ligament reconstructions in a verified rabbit model at eight weeks. Within this period, FiberTape did not adversely affect bone tunnel healing or invoke a prolonged elevation in inflammation. Cite this article: Bone Joint J 2019;101-B:1238-1247.

Flexible Fixation in Foot and Ankle Surgery

Flexible fixation has been described and utilized in various aspects of foot and ankle surgery over the past several decades. In regards to ankle surgery, flexible fixation devices have been used for stabilization of the ankle syndesmosis and augmentation of lateral collateral ankle ligament repair. In the foot, flexible fixation devices have been incorporated into hallux valgus or varus correction, Lisfranc injury repair, and more recently spring ligament repair augmentation. This article reviews the various applications for flexible fixation in foot and ankle surgery, as well as evidence-based literature on surgical applications and clinical outcomes.

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.

Correlation Between Joint-Position Sense, Peroneal Strength, Postural Control, and Functional Performance Ability in Patients With Chronic Lateral Ankle Instability

BACKGROUND

The first aim of this study was to evaluate the side-to-side difference of joint-position sense, peroneal strength, postural control, and functional performance ability in patients with chronic lateral ankle instability. The second aim was to identify the correlation between various components contributing to the functional ankle instability (FAI).

METHODS

Thirty-five patients to be scheduled for the modified Broström procedure for chronic ankle instability were analyzed. Joint-position sense and peroneal strength were measured with an isokinetic dynamometer. Postural control ability was evaluated using the modified Romberg test. The functional performance test consisted of the 1-leg hop test, 6-meter hop test, and cross 3-m hop test. Spearman's correlation coefficient (r) was calculated to determine the linear association between the individual components of the FAI.

RESULTS

Except for the 6-m and cross 3-m hop tests, most examination tools for the FAI demonstrated significant side-to-side differences compared with the unaffected ankle. Spearman's correlation analysis revealed that individual components (joint-position sense, peroneal strength, postural control, and functional performance ability) of the FAI were significantly associated with one another, except between peroneal strength and postural control ability (r = 0.21, P = .195).

CONCLUSION

Joint-position sense, peroneal strength, postural control ability, and 1-leg hop test demonstrated significant side-to-side differences in patients with chronic lateral ankle instability. Individual components contributing to the FAI were significantly correlated with one another, except between peroneal strength and postural control ability. Postural control evaluation using the modified Romberg test could substitute for dynamometer testing, with convenience and economic advantage.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Lateral Ankle Sprain and Chronic Ankle Instability

A select 10-30% of patients with recurrent lateral ankle sprains develop chronic ankle instability (CAI). Patients with chronic ankle instability describe a history of the ankle “giving way” with or without pathological laxity on examination. Evaluation includes history, identification of predisposing risk factors for recurrent sprains, and the combination of clinical tests (eg, laxity tests) with imaging to establish the diagnosis. There are a variety of nonoperative strategies to address chronic ankle instability, which include rehabilitation and taping or bracing to prevent future sprains. Patients who fail conservative treatment are candidates for surgery. The anatomic approaches (eg, modified Broström) are preferred to nonanatomic procedures since they recreate the ankle’s biomechanics and natural course of the attenuated ligaments. There is a growing interest in minimally invasive procedures via ankle arthroscopy that also address the associated intra-articular disorders. This article provides a review of chronic lateral ankle instability consisting of relevant anatomy, associated disorders, evaluation, treatment methods, and complications.

Effect of Lateral Ligament Augmentation Using Suture-Tape on Functional Ankle Instability

BACKGROUND:

Although lateral ligament augmentation using suture-tape has been effective for restoration of mechanical ankle stability, few data are available regarding changes of peroneal strength, proprioception, and postural control. The aim of this study was to determine effects of suture-tape augmentation on functional ankle instability (FAI).

METHODS:

Twenty-four patients who underwent suture-tape augmentation were eligible and were followed more than 2 years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test.

RESULTS:

CAIT and FAAM (average of daily and sports activity scores) significantly improved to average 27.2 points and 86.7 points, respectively, at final follow-up. Peak torque for eversion in 60 degrees/s angular velocity significantly improved to 10.6 Nm at final follow-up. Deficit ratio of peak torque for eversion significantly improved from mean 39.5% to 20.9%, and significant side-to-side difference was revealed ( P < .001). There were no significant differences in joint position sense. A significant improvement in balance retention time was revealed at final follow-up, and the relative deficit ratio compared to the unaffected side was 30.9%.

CONCLUSIONS:

Patient-reported functional outcomes significantly improved after lateral ligament augmentation using suture-tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were not significant at the intermediate-term follow-up. In addition, there was no positive effect on proprioception of the ankle.

LEVEL OF EVIDENCE:

Level IV, prospective 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.

Functional Results of Open Broström Ankle Ligament Repair Augmented With a Suture Tape

BACKGROUND

The Broström procedure is the most commonly used lateral ligament repair for chronic instability, but there is concern about the strength of the repair and the risk of reinjury. Currently, the InternalBrace^TM ligament augmentation repair is an accepted augmentation method for management of a Broström procedure. Our hypothesis was that augmentation of the Broström repair with an InternalBrace^TM would allow accelerated rehabilitation and return to activity and would aid in stability of the repair without a tendency to stretch.

METHODS

Eighty-one patients with lateral ankle instability procedures repaired with a Broström and InternalBrace^TM augmentation were evaluated at a one-time postoperative visit between 6 and 24 months. Outcomes included demographics, surgical time, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Veterans Rand 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), satisfaction, and objective clinical measurements. Eighty-one patients were analyzed including 30 males and 51 females. Median age was 34 years (range, 18-62 years) with a median return for follow-up of 11.5 months (range, 6-27 months).

RESULTS

Average postoperative VAS and satisfaction were 0.8 ± 1.4 and 9.1 ± 1.6, respectively. Mean return to sport (n = 68) was 84.1 days. Average AOFAS Ankle-Hindfoot score was 94.3. A score of 90 or higher on the FAAM Sports subscale was seen in 79.0% of the subjects. The single-leg hop test (Limb Symmetry Index %) showed that 86.4% of patients returned to normal or near normal function. The tape measure method and ankle dorsiflexion comparisons showed a significant difference: 9.2 ± 3.3 cm (operative side) and 10.4 ± 3.7 cm (contralateral side) ( P = .034). Ankle plantar flexion comparison (goniometer) was 48.5 ± 11.5 degrees (operative side) and 49.7 ± 11.9 degrees (contralateral side), showing no difference ( P = .506).

CONCLUSION

These results suggest that InternalBrace^TM augmentation of a Broström procedure is a safe and efficacious procedure that produces favorable outcomes in patients in terms of preventing recurrent instability in the ankle in the short term.

LEVEL OF EVIDENCE

Level IV, case series.

Ultrasound-Guided Suture Tape Augmentation and Stabilization of the Medial Collateral Ligament

Management of medial collateral ligament (MCL) injuries usually consists of time and conservative management; however, patients are typically immobilized and need extensive time to return to sport. Although the MCL has been shown to have the ability to heal given time, surgical management is still sometimes needed to provide stability to the knee. Operative techniques vary in methodology, but are typically highly invasive and technically demanding. In the event of multiligamentous or severe injuries, reinforcing the MCL with an ultrahigh-strength, 2-mm-wide suture tape allows for early functional rehabilitation, permitting the native MCL tissue to heal and avoiding late reconstructions. This technical report details an ultrasound-guided technique for the percutaneous suture tape augmentation and stabilization of the MCL with or without repair. Ultrasound allows for anatomic percutaneous placement of the sockets, as opposed to landmark palpation guidance that has proven to be unreliable. This is a simple, quick procedure that provides instant stability to the MCL with or without operating on the ligament itself, allowing patients to return to activity faster with the reduced risk of reinjury due to less muscle atrophy and loss of function.