Arthroscopic-Assisted Versus All-Arthroscopic Ankle Stabilization Technique

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability

PURPOSE

Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique.

METHODS

All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared.

RESULTS

A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference.

CONCLUSION

Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients.

LEVEL OF EVIDENCE

Level III.

Improvement in clinical outcomes following arthroscopic all-inside medial lateral ligament reconstruction for rotational ankle instability

PURPOSE

Rotational ankle instability can be diagnosed in up to 18% of cases of chronic lateral ankle instability. It is characterised by an abnormal increase of talar rotation within the tibiofibular mortise, due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligament. The aim of this prospective observational study was to investigate the clinical outcomes following arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability.

METHODS

A prospective observational study of consecutive patients undergoing arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with minimum 6-month follow-up. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire. Secondary outcomes included the EQ-5D, European Foot and Ankle Society score and complications.

RESULTS

Between 2020 and 2023, 12 patients underwent primary arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with pre- and post-operative PROMs available for all 12 patients. The mean ± standard deviation age was 33.9 ± 7.2 years and the mean follow-up was 1.9 ± 1.2 (range: 0.5-3.8, interquartile range: 0.9-3.0) years. There was a significant improvement in all Manchester-Oxford Foot Questionnaire domain scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ-5D-5L Index, VAS and VAS Pain; however, these were not statistically significant. There was one complication-a superficial peroneal nerve injury which resolved with a corticosteroid injection.

CONCLUSION

The arthroscopic all-inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9-year follow-up.

LEVEL OF EVIDENCE

Level IV.

Results of Anatomical Arthroscopic Repair of Anterior Talofibular Ligament in Chronic Lateral Ankle Instability Patients

BACKGROUND

To assess the clinical and functional outcomes of all-inside arthroscopic anatomical repair of anterior talofibular ligament (ATFL) for management of chronic lateral ankle instability (CLAI) in a considerable number of patients during medium-term follow-up.

METHODS

A retrospective analytic study was performed on 100 patients with CLAI who presented between August 2015 and July 2020 (average age: 32.9 years; range: 16-54 years). All-inside arthroscopic ATFL direct repair was performed in all patients through 2 portals only with fixation using 2 knotless anchors. Associated intraarticular lesions were treated in the same procedure. Outcomes were assessed with pre- and postoperative visual analog scale (VAS), the ankle-hindfoot score of the American Orthopaedic Foot & Ankle Society (AOFAS), and the Karlsson Ankle Functional Score (KAFS).

RESULTS

All patients were followed for 24-48 months. At the final follow-up, ankle pain had improved significantly. Both the ankle anterior drawer test and the ankle varus stress tests were negative. There was no loss of ankle range of motion compared with preoperative measures, and all patients returned to normal gait. The mean VAS score decreased to 0.39 ± 0.63, the AOFAS score increased to 95.17 ± 4.7, and the KAFS score increased to 95 ± 4.07. All the follow-up indexes significantly improved compared to those before surgery.

CONCLUSION

At minimum 24-month follow-up, the all-inside arthroscopic ATFL repair used to treat CLAI was found to restore ankle stability and yield good clinical outcomes with a relatively low complication rate.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

The ATFL inferior fascicle, the CFL and the PTFL have a continuous footprint at the medial side of the fibula

PURPOSE

Knowledge of the complex anatomy of the lateral ankle ligaments is essential to understand its function, pathophysiology and treatment options. This study aimed to assess the lateral ligaments and their relationships through a 3D view achieved by digitally marking their footprints.

METHODS

Eleven fresh-frozen ankle specimens were dissected. The calcaneus, talus and fibula were separated, maintaining the lateral ligament footprints. Subsequently, each bone was assessed by a light scanner machine. Finally, all the scans were converted to 3D polygonal models. The footprint areas of the talus, calcaneus and fibula were selected, analysed and the surface area was quantified in cm2.

RESULTS

After scanning the bones, the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) footprints were continuous at the medial side of the fibula, corresponding to a continuous footprint with a mean area of 4.8 cm2 (± 0.7). The anterior talofibular ligament (ATFL) footprint on the talus consisted of 2 parts in 9 of the 11 feet, whilst there was a continuous insertion in the other 2 feet. The CFL insertion on the calcaneus was one single footprint in all cases.

CONCLUSION

The tridimensional analysis of the lateral ligaments of the ankle demonstrates that the ATFLif, CFL and PTFL have a continuous footprint at the medial side of the fibula in all analysed specimens. These data can assist the surgeon in interpreting the ligament injuries, improving the imaging assessment and guiding the surgeon to repair and reconstruct the ligaments in an anatomical position.

The lowest point of fibula (LPF) could be used as a reliable bony landmark for arthroscopic anchor placement of lateral ankle ligaments ----compared with open Broström procedure

BACKGROUND

Arthroscopic technique procedures was wide accepted for the treatment of chronic ankle instability (CAI). But little acknowledge was involved to the bony landmarks and anatomic features of different bundles of lateral ligaments under arthroscopic view.

METHODS

Sixty patients with acute or chronic lateral ankle ligaments injury (LAI) were collected prospectively, and divided randomly into two groups. In arthroscopic group, the bone tunnels were made on the LPF arthroscopically. And in open group, the bone tunnels were made on the Fibular obscure tubercle (FOT) in open procedure. The inferior bundle of ATFL and Arcuate fibre was also identified reference to the LPF and labeled by a PDS II suture penetration. Following that, The distances of the bone tunnels to the different bony markers were measured and compare between two groups. The penetrating locations of PDS II on the inferior bundle of ATFL and Arcuate fibre were also confirmed intraoperatively. And the safe angle of anchor implantation on the axial view was measured on postoperative CT scan.

RESULTS

The distances of bone tunnel to the fibular tip, the fibular insertion of anterior-inferior tibiofibular ligament (AITFL), and the FOT in arthroscopic and open locating groups were 4.9 ± 2.2 and 6.3 ± 2.2 mm, 13.5 ± 2.7 and 12.4 ± 1.1 mm, 5.8 ± 2.2 and 5.6 ± 1.0 mm, respectively. The distances of bone tunnels to the FOT and fibular tip on 3d-CT view was 4.4 ± 1.5 and 4.6 ± 0.9 mm, 14.4 ± 3.2 and 13.2 ± 1.8 mm in arthroscopic and open group, and there were no significant differences between two groups. The safe angle of arthroscopic anchor placement on the axial plan was ranged from 24.9 ± 6.3o to 58.1 ± 8.0o. The PDS II sutures penetrating on the inferior bundles of ATFL and the arciform fibres were also comfirmed successfully by open visualizaion.The average distance of penetration point to the horizontal line cross the fibular tip was 2.3 ± 2.7 mm (ranged from - 3.1 to 6.0 mm), and to the vertical line cross the FOT was 2.7 ± 2.7 mm (ranged from - 2.5 to 7.5 mm).

CONCLUSION

Take the lowest point of fibula under arthroscopy (LPF) as a bony reference, we could identify the iATFL under arthroscopic visualization. By this way, we could place the suture anchors properly to the fibular footprint and suture the iATFL fibres successfully.

Arthroscopic modified Broström procedure achieves faster return to sports than open procedure for chronic ankle instability

PURPOSE

To compare the clinical outcomes, rate of return to sports, postural control, and muscle strength between the arthroscopic and open modified Broström procedure for chronic lateral ankle instability (CLAI) patients.

METHODS

From September 2018 to April 2019, 70 patients diagnosed with CLAI were prospectively included with arthroscopic modified Broström procedure (n = 36) and open modified Broström procedure (n = 34). They were evaluated at five time points (preoperation and 3 months, 6 months, 1 year and 2 years postoperatively). The main results examined the rate of return to sports, American Orthopaedic Foot and Ankle Society Score (AOFAS), Foot and Ankle Ability Measure (FAAM), visual analogue scale (VAS), centre of pressure (COP) excursion velocity, time to boundary (TTB), plantar pressure, isokinetic muscle strength and complications.

RESULTS

Compared with the open group, the arthroscopic group demonstrated a significantly shorter period of return to the preinjury sport (13.2 ± 2.4 weeks vs. 18.7 ± 3.1 weeks, P = 0.023) and a higher early sport ratio (80.6 vs. 61.8%, P = 0.011) combined with better FAAM sports and AOFAS at 3 months and 6 months postoperatively and VAS at 3 months postoperatively. In addition, better anterior-posterior postural control stability, less time to peak force under lateral hindfoot and better dorsiflexion strength were shown in the arthroscopic group at 6 months postoperatively. No significant difference was found in clinical scores, posture control or muscle strength at the 1- or 2-year follow-up between the two groups.

CONCLUSIONS

Shorter period and higher rates of return to sport activities and better clinical scores, posture control and muscle strength were achieved in the arthroscopic group at 6 months postoperatively, and no clinical differences were found between arthroscopic and open modified Broström procedure 1 year or 2 years postoperatively. Arthroscopic modified Broström procedure is a reliable procedure for CLAI injuries with the demand for fast exercise recovery.

CLINICAL REGISTRATION

ChiCTR1900023999.

LEVEL OF EVIDENCE

II.

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

Background/aims

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

Methods

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

Results

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

Conclusion

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

Arthro-Broström with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques

Background

There is still some controversy about the augmentation of the inferior extensor retinaculum after arthroscopic anterior talofibular ligament repair. The aim of this study was to evaluate the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques for chronic lateral ankle instability.

Methods

Thirty-four cases with grade-2 or grade-3 chronic anterior talofibular ligament lesions who underwent the novel arthro-Broström procedure with endoscopic retinaculum augmentation using all-inside lasso-loop stitch techniques were assessed retrospectively. A total of 30 cases (30 ankles) were followed up for a mean of 26.67 ± 4.19 months (range, 24—36 months). four cases were excluded due to insufficient medical records or loss of follow-up reports. The Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were evaluated before surgery and at the final follow-up time. Also, the results of stress fluoroscopic tests and complications were recorded.

Results

At the final follow-up, the average of the Cumberland Ankle Instability Tool scores, The Karlsson-Peterson scores and Visual Analogue Scale scores were 86.63 ± 6.69 (range, 77—100), 90.17 ± 4.64 (range, 85—100) and 0.53 ± 0.63 (range, 0—2), respectively. Moreover, the results of stress fluoroscopic tests were improved significantly after surgery. Mild keloid formation and/or knot irritation were observed in four cases. No wound infections, nerve injuries and recurrent instability were recorded. Also, no stiffness or arthritis of the subtalar joint was encountered.

Conclusions

The arthro-Broström procedure combined with endoscopic retinaculum augmentation using all-inside lasso-loop techniques is reliable and safe due to the advantage of direct endoscopic visualization.

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Purpose

To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

Methods

The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

Conclusions

Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

Clinical Relevance

Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

Fully Intra-articular Lasso-Loop Stitch Technique for Arthroscopic Anterior Talofibular Ligament Repair

BACKGROUND

Arthroscopic techniques have gradually become popular for anterior talofibular ligament (ATFL) repair. However, the reliability of the repair and the risk of nerve injuries are of concern. The aim of this study was to evaluate the fully intra-articular lasso-loop stitch technique for arthroscopic ATFL repair.

METHODS

From October 2018 to December 2019, 43 cases with chronic lateral ankle instability were treated with this fully intra-articular lasso-loop stitch technique using the Arthro-Pierce instrument. The Karlsson-Peterson score, Cumberland Ankle Instability Tool (CAIT) score, visual analog scale (VAS) score, anterior drawer and talar tilt stress fluoroscopy were evaluated at the preoperative and final follow-up appointments, respectively. All surgical complications were also recorded.

RESULTS

A total of 39 cases were followed up for a mean of 28.23 ± 3.64 months (range, 23-34 months). At the final follow-up, the averages of the Karlsson-Peterson, CAIT and VAS scores were 90.26 ± 6.58, 88.56 ± 7.21 and 0.79 ± 1.06, respectively. During surgery, 2 cases were modified with augmentation of the inferior extensor retinaculum. No nerve injuries were encountered. Only 1 female complained about mild knot irritation. A 25-year-old solider required revision surgery due to an accidental injury.

CONCLUSION

We found the fully intra-articular lasso-loop stitch technique for ATFL repair using the Arthro-Pierce instrument to be reliable and safe with a sufficient and good-quality ligament remnant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

All-inside arthroscopic repair of the anterior talofibular ligament: a case series

INTRODUCTION

The all-inside arthroscopic repair of the anterior talofibular ligament (ATFL) is a technically challenging and still-recent procedure to treat chronic ankle instability (CAI). Favourable clinical outcomes have been shown from originator centers, but this is one of the first series from a non-originator centre. The purpose of the present study is to present the clinical and functional results of patients with CAI underwent arthroscopic all-inside ATFL repair.

METHODS

This is a series of cases of 18 consecutive patients who underwent the all-inside arthroscopic ATFL repair, for CAI, after the failure of conservative treatment performed for six months. The evaluation was made using the American Orthopaedic Foot and Ankle Score (AOFAS), visual analog pain scale (VAS), anterior drawer, and talar tilt tests.

RESULTS

All 18 patients were evaluated for a mean follow-up period of 12 months. There was an improvement in the AOFAS (p < 0.001), with the mean improving from 69.6 points to 98.1, standard deviation (SD) = 11.09, and in the mean VAS score (p < 0.001), from 5.0 to 0.5 points (SD = 0.78). All ankles were stable, as assessed by the anterior drawer test and talar tilt test. The only complication found was neurapraxia of the superficial fibular nerve in one patient (5%). All of the patients classified the treatment as good or excellent and returned to sports activities without limitations.

CONCLUSION

Treatment of CAI by the all-inside arthroscopic ATFL repair was able to restore ankle stability and showed good clinical results and high satisfaction rates.

Connecting fibers between ATFL's inferior fascicle and CFL transmit tension between both ligaments

PURPOSE

The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis.

METHODS

An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL.

RESULTS

A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD ± 0.34).

CONCLUSION

Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Editorial Commentary: Arthroscopic Treatment of Ankle Instability Is the Emerging Gold Standard

Arthroscopic techniques for the treatment of ankle instability are increasing. The possibility of treating concomitant ankle pathology and ankle instability in the same procedure with similar outcomes and minor complications is making foot and ankle surgeons rethink the role of the current gold standard technique, the open Broström-Gould procedure. The improvement of arthroscopic procedures in the ankle joint, as has happened before in other joints, is forcing the evolution of the classic open gold standard techniques toward an arthroscopic approach. A nondistraction and ankle dorsiflexion procedure is the key arthroscopic technique. The anterior talofibular ligament's superior fascicle, an intra-articular structure, is located on the floor of the lateral gutter, and distraction detrimentally narrows the view and access to this space.

Assessment of plantaris and peroneus tertius tendons as graft materials for ankle ligament reconstructions - A cadaveric biomechanical study

Both the plantaris tendon and the peroneus tertius tendon are used as auto- and allogenous graft materials to reconstruct the ankle ligament complex. However, it is unclear to what extent these graft materials resemble the load-deformation behavior of the ankle ligaments. A total of 34 human ankle ligaments and 35 tendons were assessed mechanically deploying a quasi-static tensile testing setup. Tendons were significantly stiffer (median elastic moduli: plantaris tendon = 465.7 MPa, peroneus tertius tendon = 338.5 MPa, medial ligament = 61.4 MPa, lateral ligament = 49.3 MPa; p ≤ 0.035), but more distensible (median strain at maximum force: plantaris tendon = 15.1%, peroneus tertius tendon = 15.3%, medial ligament = 9.3%, lateral ligament = 9.6%; p ≤ 0.008) and mechanically tougher (median ultimate tensile strength: plantaris tendon = 51.0 MPa, peroneus tertius tendon = 40.5 MPa, medial ligament = 4.1 MPa, lateral ligament = 3.5 MPa; p ≤ 0.033) when compared to medial and lateral ankle ligaments. The lateral ligaments of the right ankle were significantly tougher compared to the left side (p = 0.015). The elastic modulus of the medial ligament (r = 0.489, p = 0.045) and the peroneus tertius tendon (r = 0.517, p = 0.014) yielded an age-dependent increase. Both tendons seem biomechanically suitable graft materials to replace the medial and lateral ankle ligaments during physiological loading. The age-dependent increase in tissue elastic properties of the medial vs. lateral ankle ligaments, and differences in ultimate tensile strength between the lateral ligaments left vs. right, may reflect the complex asymmetric loading behavior of both ankle ligaments.

Does arthroscopic repair show superiority over open repair of lateral ankle ligament for chronic lateral ankle instability: a systematic review and meta-analysis

Background

There is still no definite consensus on whether arthroscopic repair shows superiority over open repair for chronic lateral ankle instability. We conducted a systematic review and meta-analysis of the current comparative studies to make a generalized analysis.

Methods

PubMed, Embase, and Web of Science databases were searched from inception to April 2020. Included studies were assessed by the level of evidence and quality of evidence (Cochrane Handbook or MINORS). The process of data extraction was conducted by two independent authors. The comparative results of clinical outcomes, stress radiographic outcomes, and complication rates between two groups were pooled. Statistical analysis was performed using STATA.

Results

Nine comparative studies for a total of 473 patients (250 arthroscopic repair, 223 open repair) were included. For the clinical outcomes, a significant difference was found in favor of arthroscopic repair with regard to AOFAS scores (MD 0.32, 95% CI 0.12 to 0.53, I² = 7.7%, P = .370) and VAS scores (MD − 0.30, 95% CI − 0.54 to − 0.05, I² = 48.3%, P = .102). No significant difference was found regarding to stress radiographic outcomes. Importantly, the total complication rate (RR 0.88, 95% CI 0.51 to 1.49, I² = 0%, P = .957) as well as nerve complication rate (RR 1.21, 95% CI 0.53 to 2.75, I² = 0%, P = .975) of arthroscopic repair group is not significantly different to that of open repair group.

Conclusions

Arthroscopic repair for lateral ankle instability shows excellent clinical results comparable to open repair. Especially, arthroscopic repair might alleviate more pain due to the minimally invasive procedure. Patients receiving arthroscopic repair do not result in a higher total complication rate and nerve injury rate.