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Dias S, Lewis TL, Alkhalfan Y, Ahluwalia R, Ray R. Current concepts in the surgical management of chronic ankle lateral ligament instability. J Orthop 2022; 33:87-94. [PMID: 35874042 PMCID: PMC9305620 DOI: 10.1016/j.jor.2022.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022] Open
Abstract
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.
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Affiliation(s)
- Shiluka Dias
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Thomas L. Lewis
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Raju Ahluwalia
- King's College Hospital MTC, London; King's College Hospital Diabetic Foot Unit & King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Robbie Ray
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, UK
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Ziaei Ziabari E, Lubberts B, Chiou D, Razi M, Haghpanahi M, Ashkani-Esfahani S, DiGiovanni CW. Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review. J Foot Ankle Surg 2021; 60:762-769. [PMID: 33712375 DOI: 10.1053/j.jfas.2020.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 02/03/2023]
Abstract
One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for "kinetic outcomes," "kinematic outcomes," "Broström procedure," and "lateral ligament repair." Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.
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Affiliation(s)
- Elaheh Ziaei Ziabari
- Research Fellow, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; PhD Candidate, School of Mechanical Engineering, Iran University of Science and Technology, Narmak, Tehran, Iran.
| | - Bart Lubberts
- Director, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Instructor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Foot & Ankle Service, Massachusetts General Hospital, Boston, MA
| | - Daniel Chiou
- Research Intern, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mohammad Razi
- Associate Professor of Orthopedic Surgery and President of Iranian Orthopaedic Association, Department of Orthopaedic Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Haghpanahi
- Professor of Biomechanical Engineering, School of Mechanical Engineering, Iran University of Science and Technology, Narmak, Tehran, Iran
| | - Soheil Ashkani-Esfahani
- Physician-Researcher, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Orthopaedic Surgery Research Fellow, Department of Orthopaedic Surgery, Foot & Ankle Service, Massachusetts General Hospital, Boston, MA
| | - Christopher W DiGiovanni
- Professor of Orthopaedic Surgery, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Chief of Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Foot & Ankle Service, Massachusetts General Hospital, Boston, MA; President-Elect, American Orthopaedic Foot and Ankle Society, Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, Boston, MA
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Guillo S, Odagiri H, van Rooij F, Bauer T, Hardy A. All-inside endoscopic anatomic reconstruction leads to satisfactory functional outcomes in patients with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc 2021; 29:1318-1324. [PMID: 32607815 DOI: 10.1007/s00167-020-06130-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Ankle sprain is a common injury that can be treated conservatively, though many injured patients do not seek treatment or are not adequately managed, both of which can lead to subsequent chronic ankle instability (CAI). The purpose of this study was to evaluate the functional scores and complication rates of an all-inside anatomic reconstruction technique to treat CAI at a minimum follow-up of 24 months. METHODS The authors retrospectively collected the records of 41 patients that underwent all-inside endoscopic anatomic reconstruction of the ATFL and CFL including demographics, complications, satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson score, and ankle activity score (AAS), at a minimum follow-up of 24 months. RESULTS The study cohort, comprised 34 patients aged 35.6 ± 10.8 years, were assessed at 48.7 ± 19.0 months. AOFAS scores improved from 60.3 ± 11.9 to 94.3 ± 6.2 postoperatively. Karlsson scores improved from 49.0 ± 10.9 to 87.2 ± 10.1 postoperatively. Thirty-three (97%) patients returned to the same AAS (5.6 ± 3.1) and rated their overall satisfaction ≥ 7. One patient (3%) was reoperated to treat a hematoma, while five patients (15%) were reoperated to remove the cortical fixation device that caused discomfort. CONCLUSION The novel all-inside endoscopic technique for anatomic reconstruction of the ATFL and CFL grants satisfactory functional outcomes at a minimum of 24 months, and the improvements in AOFAS and Karlsson scores compared favourably to those reported for other techniques in the literature. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Haruki Odagiri
- Clinique du Sport de Bordeaux-Merignac, Mérignac, France
| | | | - Thomas Bauer
- Ambroise Paré Hospital, Boulogne-Billancourt, France
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Chen C, Lu H, Hu J, Qiu X, Li X, Sun D, Qu J, Zhang T, Xu D. Anatomic reconstruction of anterior talofibular ligament with tibial tuberosity-patellar tendon autograft for chronic lateral ankle instability. J Orthop Surg (Hong Kong) 2019; 26:2309499018780874. [PMID: 29890893 DOI: 10.1177/2309499018780874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Anatomic repair of the anterior talofibular ligament (ATFL) is challenging when the local ligamentous tissue is severely attenuated. Anatomic reconstruction of the ATFL with tibial tuberosity-patellar tendon (TT-PT) autograft is a feasible choice that can avoid the complicated tendon-bone healing and restore ankle stability. MATERIALS AND METHODS From 2009 to 2015, 31 chronic lateral ankle instability (CLAI) patients (31 ankles), who had a serious injury on the ATFL only, were treated with anatomic reconstruction of ATFL with TT-PT. American orthopedic foot and ankle society ankle-hindfoot score (AHS), visual analog scale for pain score (VAS), Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion were used to evaluate the clinical outcomes before and after operation. Radiographically, talar tilt angles and anterior drawer were assessed in pre- and postoperative ankle stress views. RESULTS Among the 31 ankles, 17 ankles with single-bundle ATFL and 14 ankles with double-bundle ATFL were found at operation. At a mean follow-up of 42 months (24-82 months), all patients were satisfied with the procedure. Mean AHS significantly increased from 60.5 ± 8.2 to 93.5 ± 4.8. Mean Karlsson-Peterson score significantly increased from 55.2 ± 11.0 preoperatively to 91.2 ± 6.9 at final follow-up. Average VAS significantly decreased from 5.9 ± 1.6 preoperatively to 1.4 ± 1.0 at the latest follow-up. Mean Tegner activity level was 3.7 ± 0.9 before operation, compared with 7.0 ± 0.8 after operation. On stress radiographs, mean talar tilt angle was 17.0 ± 3.4° before operation and 3.8 ± 2.1° at the latest follow-up. In addition, mean anterior tibiotalar translation was 7.5 ± 2.2 mm before operation and 1.8 ± 1.1 mm at the latest follow-up. CONCLUSION Anatomic reconstruction of the ATFL using a TT-PT autograft allows bone-bone healing in talus and tendon-tendon/periosteum healing in fibula rather than requiring tendon-bone healing, which is an alternative choice for treating CLAI caused by single ATFL insufficiency.
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Affiliation(s)
- Can Chen
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Hongbin Lu
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jianzhong Hu
- 2 Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xuqiang Qiu
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiong Li
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Deyi Sun
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jin Qu
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Tao Zhang
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Daqi Xu
- 1 Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
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Hassan S, Thurston D, Sian T, Shah R, Aziz A, Kothari P. Clinical Outcomes of the Modified Broström Technique in the Management of Chronic Ankle Instability After Early, Intermediate, and Delayed Presentation. J Foot Ankle Surg 2018; 57:685-688. [PMID: 29655649 DOI: 10.1053/j.jfas.2017.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Indexed: 02/03/2023]
Abstract
The modified Broström technique (MBT) is considered the reference standard for surgical management of ankle instability, with good short-term outcomes. However, limited evidence is available regarding outcomes for delayed presentations of instability. We report our outcomes for patients who underwent ligament repair using the MBT, from a single-surgeon retrospective study of consecutive patients. The minimum postoperative follow-up period was 6 months during a 5-year study period. The patients were retrospectively divided into 3 groups according to the delay in presentation: group 1, 6 months to 2 years; group 2, 2 to 4 years; and group 3, >4 years. We collected data on patient demographics, injury pattern, and intraoperative surgeon findings. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (AHS) was used to evaluate patient outcomes and satisfaction with surgery. Twenty-six patients were treated with MBT. The mean follow-up period was 36.9 (range 6-42) months. Twenty-five (96.2%) patients had unilateral injuries, and 1 (3.85%) had bilateral repairs. Of the 26 patients, 21 (80.8%) completed the AOFAS-AHS, with a mean score of 87.4 (range 12 to 100). The mean interval from injury to surgery was 47.9 months. The results were excellent in 15 (71.4%), good in 3 (14.3%), fair in 1 (4.8%), and poor in 2 (9.5%) using the AOFAS-AHS. We found no significant difference in the overall AOFAS-AHS score or postoperative satisfaction among the groups (p > .05). All patients had a stable ankle joint at their final follow-up visit. In conclusion, patients with persistent or chronic ankle instability have good clinical outcomes and satisfaction after the MBT, irrespective of the time from injury to presentation.
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Affiliation(s)
- Sami Hassan
- Orthopaedic Registrar, Department of Trauma and Orthopaedics, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom.
| | - Daniel Thurston
- Surgical Trainee, Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham, United Kingdom
| | - Tanvir Sian
- Surgical Trainee, Department of Trauma and Orthopaedics, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom
| | - Rohi Shah
- Surgical Trainee, Department of Trauma and Orthopaedics, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom
| | - Abdul Aziz
- Surgical Trainee, Department of Trauma and Orthopaedics, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom
| | - Paresh Kothari
- Consultant Foot and Ankle Surgeon, Department of Trauma and Orthopaedics, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom
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Behandlung der lateralen Instabilität des oberen Sprunggelenks. ARTHROSKOPIE 2018. [DOI: 10.1007/s00142-017-0158-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Noailles T, Lopes R, Padiolleau G, Gouin F, Brilhault J. Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up. Foot Ankle Surg 2018; 24:80-85. [PMID: 29409255 DOI: 10.1016/j.fas.2016.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 07/11/2016] [Accepted: 10/27/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ. HYPOTHESIS The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair. MATERIALS AND METHODS A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected. RESULTS Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair. CONCLUSION Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair. STUDY DESIGN Review of the literature; level of proof IV.
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Affiliation(s)
- Thibaut Noailles
- Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44000 Nantes, France.
| | - Ronny Lopes
- Clinique Brétéché, 3 rue de la Béraudière, 44000 Nantes, France
| | - Giovanni Padiolleau
- Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44000 Nantes, France
| | - François Gouin
- Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44000 Nantes, France
| | - Jean Brilhault
- Université F. Rabelais & C.H.R.U Tours, 1 Hôpital Trousseau, 37044 Tours Cedex 09, France.
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Ahn HW, Lee KB. Comparison of the Modified Broström Procedure for Chronic Lateral Ankle Instability With and Without Subfibular Ossicle. Am J Sports Med 2016; 44:3158-3164. [PMID: 27528610 DOI: 10.1177/0363546516660069] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Subfibular ossicles are frequently found in patients with chronic lateral ankle instability (CLAI). However, there is a lack of consensus about the optimal surgical treatment for CLAI with subfibular ossicle. PURPOSE To evaluate the clinical and radiographic outcomes of the modified Broström procedure with subfibular ossicle excision compared with the same procedure for CLAI without subfibular ossicle. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Ninety-six patients (96 ankles) treated with the modified Broström procedure using bone tunnel and suture anchor techniques for CLAI constituted the study cohort. The 96 ankles were divided into 2 groups with and without subfibular ossicles. The ossicle group (42 ankles) and nonossicle group (54 ankles) consisted of patients with a mean age of 26.6 and 30.3 years, respectively, at the time of surgery with a mean follow-up duration of 63.7 and 62.1 months, respectively. Subfibular ossicles were excised in the ossicle group. RESULTS Mean Karlsson scores improved from 55.2 to 95.3 in the ossicle group and from 56.4 to 94.8 in the nonossicle group at final follow-up. Mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores also improved from 63.3 to 95.9 in the ossicle group and from 62.8 to 95.1 in the nonossicle group at final follow-up. Mean talar tilt angles were 14.0° in the ossicle group and 12.2° in the nonossicle group preoperatively and 7.6° and 6.8° at the final follow-up, respectively. Mean anterior talar translations in the ossicle group and nonossicle groups improved from 9.3 and 9.4 mm preoperatively to 5.8 and 5.7 mm at final follow-up, respectively. No significant differences were found between the 2 groups in terms of Karlsson score, AOFAS score, talar tilt angle, and anterior talar translation at final follow-up (P > .05). CONCLUSION The modified Broström procedure with subfibular ossicle excision provided similarly good clinical and radiographic outcomes compared with the same procedure without subfibular ossicle excision. Accordingly, the study results suggest that these procedures appear to be effective and reliable method for the treatment of CLAI with subfibular ossicle.
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Affiliation(s)
- Hyeon-Wook Ahn
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Keun-Bae Lee
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
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Richter M, Zech S, Hahn S, Naef I, Merschin D. Combination of pedCAT® for 3D Imaging in Standing Position With Pedography Shows No Statistical Correlation of Bone Position With Force/Pressure Distribution. J Foot Ankle Surg 2016; 55:240-6. [PMID: 26915685 DOI: 10.1053/j.jfas.2015.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Indexed: 02/03/2023]
Abstract
pedCAT(®) (CurveBeam, Warrington, PA) is a technology for 3-dimensional (3D) imaging with full weightbearing that has been proved to exactly visualize the 3D bone position. For the present study, a customized pedography sensor (Pliance; Novel, Munich, Germany) was inserted into the pedCAT(®). The aim of our study was to analyze the correlation of the bone position and force/pressure distribution. A prospective consecutive study of 50 patients was performed, starting July 28, 2014. All patients underwent a pedCAT(®) scan and simultaneous pedography with full weightbearing in the standing position. The following parameters were measured on the pedCAT(®) image for the right foot by 3 different investigators 3 times: lateral talo-first metatarsal angle, calcaneal pitch angle, and minimum height of the fifth metatarsal base, second to fifth metatarsal heads, and medial sesamoid. From the pedography data, the following parameters were defined using the standardized software algorithm: midfoot contact area, maximum force of midfoot, maximum force of midfoot lateral, maximum force of entire foot, and maximum pressure of first to fifth metatarsal. The values of the corresponding pedCAT(®) and pedographic parameters were correlated (Pearson). The intra- and interobserver reliability of the pedCAT(®) measurements were sufficient (analysis of variance, p > .8 for each, power >0.8). No sufficient correlation was found between the pedCAT(®) and pedographic parameters (r < 0.05 or r > -0.38).3D bone position did not correlate with the force and pressure distribution under the foot sole during simultaneous pedCAT(®) scanning and pedography. Thus, the bone positions measured with pedCAT(®) do not allow conclusions about the force and pressure distribution. However, the static pedographic parameters also do not allow conclusions about the 3D bone position.one position and force/pressure distribution are important parameters for diagnostics, planning, and follow-up examinations in foot and ankle surgery.
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Affiliation(s)
- Martinus Richter
- Professor and Surgeon, Department for Foot and Ankle Surgery, Rummelsberg and Nuremberg, Germany.
| | - Stefan Zech
- Head Attending Surgeon, Department for Foot and Ankle Surgery, Rummelsberg and Nuremberg, Germany
| | - Sarah Hahn
- Surgeon, Department for Foot and Ankle Surgery, Rummelsberg and Nuremberg, Germany
| | - Issam Naef
- Surgeon, Department for Foot and Ankle Surgery, Rummelsberg and Nuremberg, Germany
| | - David Merschin
- Surgeon, Department for Foot and Ankle Surgery, Rummelsberg and Nuremberg, Germany
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Abstract
Chronic ankle joint instability often necessitates operative treatment. Operative treatment methods are classified into non-anatomical tenodesis, anatomical reconstruction and direct repair. In addition to open approaches, arthroscopic techniques are increasingly becoming established. This article describes the various operative treatment procedures, their advantages and disadvantages and in particular the arthroscopic feasibility.
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Walker R, Kunkle WA, Carreira DS. Arthroscopic Approach to Osteochondral Defects, Impingement, and Instability. Clin Sports Med 2015; 34:689-703. [PMID: 26409590 DOI: 10.1016/j.csm.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Osteochondral defects, impingement, and instability of the ankle are common injuries in athletes. In this article, we review these diagnoses and their treatment options, with a focus on arthroscopic approaches. The treatment options continue to evolve, supported by innovation and outcome studies. In this article, we describe the advantages and disadvantages of both open and arthroscopic treatments using published evidence.
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Affiliation(s)
- Roger Walker
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA
| | - William Aaron Kunkle
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA
| | - Dominic S Carreira
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA.
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12
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Molloy AP, Ajis A, Kazi H. The modified Broström-Gould procedure--early results using a newly described surgical technique. Foot Ankle Surg 2014; 20:224-8. [PMID: 25103713 DOI: 10.1016/j.fas.2014.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 01/07/2014] [Accepted: 01/11/2014] [Indexed: 02/04/2023]
Abstract
Ankle lateral ligament injuries are one of the most common sporting injuries, with the majority being successfully treated conservatively. However, reconstruction is required if this fails. We present the clinical results of a newly described surgical technique of triple-breasting the lateral ligament complex using suture anchors. Sixteen patients (18 ankles) were treated with this new technique. The mean duration of symptoms was 77 months. The mean follow-up was 25 months. All patients underwent an arthroscopy followed by lateral ligament reconstruction by this new technique. Additional pathology included osteoarthritis (2), ankle impingement due to anterior cheilus (2), osteochondral defects (3) and non-union of fracture of anterior process of calcaneus. Additional procedures above diagnostic arthroscopy, soft tissue debridement and modified Broström-Gould repair included debridement and microfracture (3), open excision of anterior calcaneal process (1) and arthroscopic anterior ankle cheilectomy (2). At final follow-up, all ankles were subjectively and objectively stable. Mean AOFAS score improved from 53 to 88. This was statistically significant (p<0.05). Eight patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity. The early results of our modification show it to be safe, successful and comparable with previously published series with all patients having objectively and subjectively stable ankles at final follow-up.
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Affiliation(s)
- Andy P Molloy
- University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
| | - Adam Ajis
- University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
| | - Hussain Kazi
- University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
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Abstract
Chronic lateral ankle instability is a condition frequently encountered by orthopedic surgeons treating highly active patient populations, particularly military service members. Providers treating military service members must have a high index of suspicion for this condition when signs and symptoms of functional or mechanical instability exist. Stress testing and ankle MRI, although not definitive in sensitivity for detecting instability or other concomitant injuries, should be considered during the treatment decision-making process. Appropriate nonoperative treatment should be attempted initially; however, when nonoperative treatment fails, surgical management is warranted to prevent untoward long-term sequelae. Proper surgical treatment and subsequent postoperative management are at the discretion of the individual surgeon but must account for the concomitant diseases frequently associated with chronic lateral ankle instability. Low recurrence of lateral instability can be achieved even in high-demand military patient populations with a focused treatment plan.
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Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA, LaPrade RF. Qualitative and Quantitative Anatomic Investigation of the Lateral Ankle Ligaments for Surgical Reconstruction Procedures. J Bone Joint Surg Am 2014; 96:e98. [PMID: 24951749 DOI: 10.2106/jbjs.m.00798] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral ankle sprains are common sports injuries that may require surgery for chronic lateral ankle instability. Anatomic repair or reconstruction is desired, yet there is a scarcity of quantitative information regarding the origins and insertions of the lateral ligaments related to surgically pertinent osseous landmarks. METHODS Fourteen ankle specimens were dissected to isolate the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament. A three-dimensional coordinate measurement device was used to determine the origins, insertions, footprint areas, orientations, and distances from osseous landmarks. RESULTS A single-banded anterior talofibular ligament was identified in seven of the fourteen specimens, and a double-banded anterior talofibular ligament was identified in the remaining seven. The single-banded anterior talofibular ligament originated an average of 13.8 mm (95% confidence interval [CI], 12.3 to 15.3) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 17.8 mm (95% CI, 16.3 to 19.3) superior to the apex of the lateral talar process along the anterior border of the talar lateral articular facet. The calcaneofibular ligament originated an average of 5.3 mm (95% CI, 4.2 to 6.5) from the inferior tip of the lateral malleolus at the anterior fibular border and inserted an average of 16.3 mm (95% CI, 14.5 to 18.1) from the posterior point of the peroneal tubercle. The posterior talofibular ligament was the largest ligament and originated an average of 4.8 mm (95% CI, 3.7 to 5.9) superior to the inferior tip of the lateral malleolus in the digital fossa to insert an average of 13.2 mm (95% CI, 11.5 to 14.9) from the talar posterolateral tubercle. The cervical ligament originated on the superior part of the calcaneus and inserted at a point that was approximately 50% of the talar neck anteroposterior distance. CONCLUSIONS Consistent distances from the anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and cervical ligament footprint centers to osseous landmarks were identified. CLINICAL RELEVANCE Footprint center distances from surgically relevant osseous landmarks identified in this study can be used during reconstructive surgery of the lateral ankle ligaments and may result in more anatomically accurate placement of the reconstructed ligaments.
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Affiliation(s)
- Thomas O Clanton
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Kevin J Campbell
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Katharine J Wilson
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Max P Michalski
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Mary T Goldsmith
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Coen A Wijdicks
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
| | - Robert F LaPrade
- Steadman Philippon Research Institute (T.O.C., K.J.C., K.J.W., M.P.M., M.T.G., C.A.W., and R.F.L.), Suite 1000, and The Steadman Clinic (T.O.C. and R.F.L.), Suite 400, 181 West Meadow Drive, Vail, CO 81657. E-mail address for Thomas O. Clanton:
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Wang B, Xu XY. Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int 2013; 34:711-5. [PMID: 23447511 DOI: 10.1177/1071100713478916] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Multiple techniques have been described for reconstruction of the lateral ligaments of the ankle. Most require extensive exposure and dissection, which may lead to potential problems with wound healing, higher risk of nerve injury, fibrosis, and stiffness. This study reports on the results of a minimally invasive method to reconstruct the ligaments using a semitendinosus tendon autograft and achieve a stable ankle while avoiding these problems. MATERIALS AND METHODS From September 2006 to May 2010, 25 patients (14 males, 11 females) with chronic ankle instability underwent lateral ligament reconstruction. The average age was 32.4 (range, 17 to 62) years old. A semitendinosus autograft was harvested through 2 small knee incisions. For the ankle reconstruction, 4 small incisions of 5 mm each were made at the medial and lateral side of the fibular tip, the talar neck, and the middle of the calcaneus. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) was then performed through these small incisions. The mean final follow-up was 32.3 (range, 12 to 56) months. AOFAS questionnaires were used to measure clinical outcomes and donor site morbidity and patient satisfaction are also reported. Preoperative and postoperative stress tests were performed and radiographic parameters were measured. RESULTS The mean AOFAS score increased on average from 71.1 to 95.1 (P < .001). Two patients reported residual instability on uneven ground. No patient reported weakness or disability from the donor site. The satisfaction level was excellent in 20 patients and good in 5 patients. Significant improvement in stress radiographic parameters was noted for the talar tilt angle, with reduction from a mean of 14.0 to 3.8 degrees (P < .001); anterior talar displacement reduced from a mean of 12.3 to 4.6 mm (P < .001). CONCLUSION Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach can achieve a stable ankle while avoiding extensive exposure and risk of nerve injury. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Bibo Wang
- Shanghai Institute of Traumatology and Orthopaedics, China
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Maffulli N, Del Buono A, Maffulli GD, Oliva F, Testa V, Capasso G, Denaro V. Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up. Am J Sports Med 2013; 41:858-64. [PMID: 23388673 DOI: 10.1177/0363546512474967] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term. HYPOTHESIS This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity. STUDY DESIGN Case series; Level of evidence, 4. METHODS We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared. RESULTS Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72). CONCLUSION Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.
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Affiliation(s)
- Nicola Maffulli
- The Royal London Hospital (Mile End), 275 Bancroft Road, London, UK.
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Morelli F, Perugia D, Vadalà A, Serlorenzi P, Ferretti A. Modified Watson-Jones technique for chronic lateral ankle instability in athletes: clinical and radiological mid- to long-term follow-up. Foot Ankle Surg 2011; 17:247-51. [PMID: 22017895 DOI: 10.1016/j.fas.2010.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 08/17/2010] [Accepted: 08/21/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND We clinically and radiologically assessed mid- to long-term follow-up of a group of patients treated with a modified Watson-Jones technique for chronic ankle instability. METHODS Fourteen athletes were retrospectively evaluated with physical examination, and Tegner, Good and AOFAS scales; moreover, a 2-view stress, side-to-side X-ray, was performed. RESULTS All patients were followed-up at a mean of 10.8 years. No one reported further ankle sprains. Mean Good scale value decreased from 3.7 to 1.6, while the Tegner scale decreased from 6.8 to 5.1; the mean AOFAS score was 92.2. Mean sagittal-plane ROM was 62.3° (4.9° S/S difference), while mean coronal-plane ROM was 25.5° (3.8° S/S difference). Mean X-ray talar tilt angle was 4.5° (0.1° S/S difference), while mean anterior drawer test angle was 5.4 mm (0.5 mm S/S difference). CONCLUSIONS The modified Watson-Jones procedure seems to be a reliable technique in providing satisfactory mid- to long-term clinical and radiological results.
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Affiliation(s)
- Federico Morelli
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome Sapienza, Via Grottarossa, 1035 Rome, Italy
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Ibrahim SA, Hamido F, Al Misfer AK, Ghafar SA, Awad A, Salem HK, Alhran H, Khirait S. Anatomical reconstruction of the lateral ligaments using Gracillis tendon in chronic ankle instability; a new technique. Foot Ankle Surg 2011; 17:239-46. [PMID: 22017894 DOI: 10.1016/j.fas.2010.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 06/25/2010] [Accepted: 07/25/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many surgical technique have been described to assess the outcome of anatomical reconstruction of the lateral ligaments using Gracillis tendon. This technique aims to restore the stability of the ankle by reconstruction of the talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using the Gracillis tendon. METHODS From January 2004 to February 2008; inclusive, 16 patients; 11 male and 5 female, underwent an anatomic reconstruction of the lateral ankle ligament for chronic ankle instability. Their ages ranged from 18 to 29 giving a mean age of 25 years. Patients were then subjected to radiologic and clinical assessments for a period of at least 33.5 months. For pain scoring the Americans Orthopaedic Foot and Ankle Society (AOFAS) scores were used; whilst subjective symptom was evaluated using the Olerud and Molander ankle scoring system. RESULTS All patients returned for the final evaluation and subjective excellent or good results were recorded on self-assessment, pain scores, AOFAS and Karissons scores. Additionally Olerud and Molander ankle scoring was also done. During the final follow-up, the mean post-operative AOFAS score was 96 (range 80-100), the Visual analog score was 6 (range 0-4), Karissons score was 94.7 (range 80-100) and last but not least Olerud and Molander score was 87.5 (range 70-100). It was noted that the ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was reduced from a mean of 12-4° (p<0.0001) and the anterior drawer was reduced from a mean of 11-4mm (p<0.001) by the ankle ligament reconstruction. CONCLUSION Anatomical reconstruction of the lateral ligaments of chronic ankle instability using Gracillis tendon graft resulted in successful results, excellent ankle stability, significant reduction in pain and negligible loss of ankle and hind foot motion.
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Affiliation(s)
- S A Ibrahim
- Al Razi Orthopaedic Hospital, Sports Medical Centre, Clinical Tutor Medical School, Kuwait University, Kuwait.
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Arthroskopische laterale OSG-Stabilisierung in modifizierter Broström-Gould-Technik. ARTHROSKOPIE 2011. [DOI: 10.1007/s00142-010-0612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev 2011:CD004124. [PMID: 21833947 DOI: 10.1002/14651858.cd004124.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered. OBJECTIVES To compare different treatments, conservative or surgical, for chronic lateral ankle instability. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010. SELECTION CRITERIA All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled. MAIN RESULTS Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial). AUTHORS' CONCLUSIONS Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.
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Affiliation(s)
- Jasper S de Vries
- Department of Orthopaedic Surgery, Tergooiziekenhuizen, Van Riebeeckweg 212, Hilversum, Noord-Holland, Netherlands, 1213 XZ
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Kramer D, Solomon R, Curtis C, Zurakowski D, Micheli LJ. Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes. Foot Ankle Spec 2011; 4:18-28. [PMID: 20826848 DOI: 10.1177/1938640010379912] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There is no consensus regarding optimum surgical treatment for chronic ankle instability. The purpose of this study is to describe a variation of the Chrisman-Snook lateral ligament reconstruction that the senior author uses in patients with chronic ankle instability recalcitrant to conservative management. All patients who underwent reconstruction from 1997 to 2006 were identified, and those with a minimum 2-year follow-up were included, representing a total of 44 ankles in 43 patients. All underwent clinical evaluation and completion of the Foot and Ankle Outcome Survey and the Kaikkonen Scale. At mean follow-up of 4.4 years, mean dorsiflexion loss was 2° compared with the nonoperative side. The postoperative mean Foot and Ankle Outcome Survey score was 74 ± 16 (range, 36-98), while the mean Kaikkonen total score was 77 ± 14 (range, 40-95). Thirty-eight patients (84.6%) were satisfied with their result. Six patients (13.6%) underwent reoperation, including 4 with peroneal tendon scarring requiring tenolysis. Return to sport was achieved in 28 of 35 patients (80%) at a median of 6 months postoperatively. It is concluded that dorsiflexion loss can be minimized and return to sport expected in most patients following this variation of the Chrisman-Snook reconstruction.
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Affiliation(s)
- Dennis Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Childrens Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
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Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK. Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Foot Ankle Int 2011; 32:153-7. [PMID: 21288414 DOI: 10.3113/fai.2011.0153] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The short-term results of modified Brostrom procedures (MBP) have been satisfactory. However, the long-term results of anatomical reconstruction have been less frequently reported. We report on our long-term results in our patient group. MATERIALS AND METHODS Thirty patients with chronic ankle instability who were treated using the MBP without CFL reconstruction from March 1997 to June 1999 were evaluated retrospectively. This consecutive series of patients was comprised of 26 males and four females. The mean age of the patients at the time of operation was 23 years. The mean followup period was 10.6 years. Twenty-four of the 30 were high-level amateur or professional athletes. The operation procedure involved only ATFL imbrication with inferior extensor retinaculum (IER) reinforcement. Clinical outcomes were evaluated by reviewing clinical charts, retrospectively. Functional outcome scores were obtained using the Hamilton scale, a VAS, and AOFAS score at final followup visit, when each patient underwent a physical examination and stress radiography. RESULTS Mean AOFAS score was 91 and the mean VAS at final followup was 87. According to the Hamilton classification, 12 achieved an excellent result, 16 a good result, and two a fair result. Mean anterior translation values at final followup were 6.9 and 6.1 mm on ipsilateral and contralateral sides. Furthermore, mean talar tilt angles were 3.0 and 2.5 degrees for ipsilateral and contralateral sides. Twenty-eight of the 30 patients were restored to pre-injury activity levels. CONCLUSION The long-term surgical results of the MBP without CFL reconstruction for chronic lateral ankle instability were good to excellent in terms of functional, clinical, and radiographic assessments.
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Affiliation(s)
- Kyung Tai Lee
- Foot and Ankle Clinic, Department of Orthopaedic Surgery, Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
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Prisk VR, Imhauser CW, O'Loughlin PF, Kennedy JG. Lateral ligament repair and reconstruction restore neither contact mechanics of the ankle joint nor motion patterns of the hindfoot. J Bone Joint Surg Am 2010; 92:2375-86. [PMID: 20962188 PMCID: PMC2947355 DOI: 10.2106/jbjs.i.00869] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle sprains may damage both the lateral ligaments of the hindfoot and the osteochondral tissue of the ankle joint. When nonoperative treatment fails, operative approaches are indicated to restore both native motion patterns at the hindfoot and ankle joint contact mechanics. The goal of the present study was to determine the effect of lateral ligament injury, repair, and reconstruction on ankle joint contact mechanics and hindfoot motion patterns. METHODS Eight cadaveric specimens were tested with use of robotic technology to apply combined compressive (200-N) and inversion (4.5-Nm) loads to the hindfoot at 0° and 20° of plantar flexion. Contact mechanics at the ankle joint were simultaneously measured. A repeated-measures experiment was designed with use of the intact condition as control, with the other conditions including sectioned anterior talofibular and calcaneofibular ligaments, the Broström and Broström-Gould repairs, and graft reconstruction. RESULTS Ligament sectioning decreased contact area and caused a medial and anterior shift in the center of pressure with inversion loads relative to those with the intact condition. There were no significant differences in inversion or coupled axial rotation with inversion between the Broström repair and the intact condition; however, medial translation of the center of pressure remained elevated after the Broström repair relative to the intact condition. The Gould modification of the Broström procedure provided additional support to the hindfoot relative to the Broström repair, reducing inversion and axial rotation with inversion beyond that of intact ligaments. There were no significant differences in center-of-pressure excursion patterns between the Broström-Gould repair and the intact ligament condition, but this repair increased contact area beyond that with the ligaments intact. Graft reconstruction more closely restored inversion motion than did the Broström-Gould repair at 20° of plantar flexion but limited coupled axial rotation. Graft reconstruction also increased contact areas beyond the lateral ligament-deficient conditions but altered center-of-pressure excursion patterns relative to the intact condition. CONCLUSIONS No lateral ankle ligament reconstruction completely restored native contact mechanics of the ankle joint and hindfoot motion patterns.
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Affiliation(s)
- Victor R. Prisk
- Department of Orthopaedic Surgery (V.R.P., P.F.O'L., and J.G.K.) and Department of Biomechanics (C.W.I.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.F. O'Loughlin:
| | - Carl W. Imhauser
- Department of Orthopaedic Surgery (V.R.P., P.F.O'L., and J.G.K.) and Department of Biomechanics (C.W.I.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.F. O'Loughlin:
| | - Padhraig F. O'Loughlin
- Department of Orthopaedic Surgery (V.R.P., P.F.O'L., and J.G.K.) and Department of Biomechanics (C.W.I.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.F. O'Loughlin:
| | - John G. Kennedy
- Department of Orthopaedic Surgery (V.R.P., P.F.O'L., and J.G.K.) and Department of Biomechanics (C.W.I.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.F. O'Loughlin:
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Richter M, Zech S. [Intraoperative pedography]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2010; 22:44-51. [PMID: 20349169 DOI: 10.1007/s00064-010-3009-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
THE PROBLEM Intraoperative assessment of the restored or maintained physiological plantar force distribution during foot and ankle corrections is very difficult. THE SOLUTION Intraoperative assessment of the restored or maintained physiological plantar force distribution during foot and ankle corrections with intraoperative pedography (IP). SURGICAL TECHNIQUE Bilateral pedography with the "Kraftsimulator Intraoperative Pedographie" (KIOP, R-Innovation, Coburg, Germany) and a mat sensor (Pliance, custom-made, Novel, Munich, Germany) in the preparation room under anesthesia. Three measurements each side with a total force corresponding to half of the body weight are performed. Transfer of the patient to the operating room and correction including definitive internal fixation following the planning and findings. Sterile draping of the sensor mat and usage of a sterile KIOP for IP of the operated foot with three measurements, and assessment and comparison with preoperative, contralateral and physiological pedographic findings. When a correction of the force distribution is indicated, modification of the correction and internal fixation and renewed IP. POSTOPERATIVE MANAGEMENT IP has no influence on the postoperative management. RESULTS IP was validated in an earlier study. In a prospective, randomized, controlled clinical study, the potential clinical benefit of IP in a sufficient number of cases in comparison to cases treated without IP was analyzed. 100 cases were included until April 11, 2008. 52 patients were randomized for the use of IP. Mean interruption of the operative procedure for the IP was 321 +/- 39 s. In 24 of the 52 patients (46%), the correction was modified after IP during the same operation. The changes were done most commonly in midfoot correction arthrodeses (64%), and least commonly in subtalar joint arthrodeses (25%).
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Affiliation(s)
- Martinus Richter
- II. Chirurgische Klinik, Unfallchirurgie, Orthopädie und Fusschirurgie, Klinikum Coburg, Coburg, Germany.
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Richter M, Zech S. Is intraoperative pedography helpful in clinical use--preliminary results of 100 cases from a consecutive, prospective, randomized, controlled clinical study. Foot Ankle Surg 2010; 15:198-204. [PMID: 19840752 DOI: 10.1016/j.fas.2009.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 01/24/2009] [Accepted: 03/31/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to assess the clinical use, and to analyze the potential clinical benefit of intraoperative pedography (IP) in a sufficient number of cases in comparison with cases treated without IP. METHODS Patients (age 18 years and older) which sustained an arthrodesis and/or correction of the foot and ankle were included. RESULTS One hundred cases were included (ankle correction arthrodesis, n=12; subtalar joint correction arthrodesis, n=14; arthrodesis without correction midfoot, n=15; correction arthrodesis midfoot, n=26; correction forefoot, n=33). Fifty-two patients were randomized for the use of IP. In 24 of the 52 patients (46%), the correction was modified after IP during the same operation. CONCLUSIONS In 46% of the cases a modification of the surgical correction was made after IP in the same surgical procedure. Whether IP improve the plantar force distribution of the foot and the mid- or long-term clinical outcome has to be critically analyzed when longer follow-up is completed.
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Affiliation(s)
- Martinus Richter
- Department for Trauma, Orthopaedic and Foot Surgery, Coburg Clinical Center, Coburg, Germany.
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Schuberth JM, Smith PR, Jennings MM. An anatomic and autologous lateral ankle stabilization. J Foot Ankle Surg 2009; 48:700-5. [PMID: 19857833 DOI: 10.1053/j.jfas.2009.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Indexed: 02/03/2023]
Abstract
A new technique for stabilization of the lateral ankle ligaments is presented. The procedure uses a split peroneus longus tendon to recreate the calcaneofibular and anterior talofibular ligaments. The new ligaments follow a precise anatomic course that replicates the pathway of the original ligaments. The procedure also capitalizes on interference screw technology so that accurate ligament tension can be obtained. This technique is most useful for severe ligamentous insufficiency involving both the calcaneofibular and anterior talofibular ligaments. Biomechanical rationale for the use of peroneus longus is also discussed.
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Affiliation(s)
- John M Schuberth
- Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, 450 6th Avenue, San Francisco, CA 94118, USA.
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Mahajan RH, Dalal RB. Modified incision for Brostrom lateral ligament reconstruction of the ankle. J Orthop Surg (Hong Kong) 2009; 17:199-201. [PMID: 19721152 DOI: 10.1177/230949900901700216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To describe a modified incision for the Brostrom procedure to correct lateral ankle instability. METHODS 14 men and 12 women aged 23 to 38 (mean, 27) years with lateral ankle instability underwent the Brostrom procedure with a modified incision to repair both the anterior talofibular and calcaneofibular ligaments, without endangering the sural or superficial peroneal nerves. The incision ran longitudinally over the distal fibula extending 2.5 cm distal to the tip of the lateral malleolus. RESULTS There were no instances of wound healing problems, neurological damage, and repair failure. Surgical exposure of all patients was graded as excellent. CONCLUSION The modified incision enables easy repair without endangering the sural and superficial peroneal nerves. Access to the peroneal tendons is allowed if necessary.
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Affiliation(s)
- Ravindra H Mahajan
- Department of Orthopaedics, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, United Kingdom.
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Abstract
Ankle instability in the athlete is a common problem that is routinely treated non-operatively, with a 90% success rate. With proprioceptive training, preventive equipment (bracing/taping), and closed kinetic chain strengthening, surgery for ankle instability is uncommon. Nonetheless, some athletes present with recurrent ankle instability that, despite work-up and conservative treatment, requires surgical correction. The use of a primary ligament repair (Brostrom procedure) versus augmented (anatomic) reconstructions is discussed in detail in this article.
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Affiliation(s)
- Robert C Schenck
- Department of Orthopaedic Surgery, UNM Lobos, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131-5296, USA.
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De Vries JS, Krips R, Blankevoort L, Fievez AW, Van Dijk CN. Arthroscopic Capsular Shrinkage for Chronic Ankle Instability with Thermal Radiofrequency: Prospective Multicenter Trial. Orthopedics 2008. [DOI: 10.3928/01477447-20080701-05] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Muijs SPJ, Dijkstra PDS, Bos CFA. Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle. ACTA ACUST UNITED AC 2008; 90:50-6. [DOI: 10.1302/0301-620x.90b1.19210] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We performed a retrospective study to assess the long-term outcome of non-augmented anatomical direct repair of the lateral ankle ligaments, as originally described by Duquennoy et al, for the treatment of chronic lateral instability of the ankle. This procedure aims to restore stability by the re-insertion and tightening of the original talofibular and calcaneofibular ligaments without division of the ligament. We examined the outcome in terms of the post-operative quality of life, the function of the joint and the development of osteoarthritis. Between 1985 and 2002, 23 patients (11 males, 12 females) with a mean age of 32 years (15 to 58) who had undergone this procedure completed the Short-Form 36 assessment of quality of life and the Olerud and Molander Ankle score for the subjective evaluation of symptoms. Clinical re-evaluation, including examination of the ankle and the completion of the American Orthopaedic Foot and Ankle Society questionnaire was performed on 21 patients after a mean follow-up of 13 years (3 to 22.2). At the final follow-up radiographs of both ankles were taken to assess the development of osteoarthritis. The mean total Short-Form 36 and Olerud and Molander Ankle scores in 23 patients at final follow-up were 79.6 points (37 to 100) and 81.6 points (40 to 100), respectively. The mean total post-operative American Orthopaedic Foot and Ankle Society score in 21 patients was 89.7 points (72 to 100). We found a significant post-operative reduction in talar tilt and anterior drawer sign (chi-squared test, p < 0.001). The functional outcome of the procedure was excellent in ten patients (48%), good in seven (33%) and fair in four (19%). The results in terms of ankle function and stability did not deteriorate with time and there was little restriction in movement. This procedure is simple and effective with a very low rate of complications.
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Affiliation(s)
- S. P. J. Muijs
- Department of Orthopaedic Surgery, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC Leiden, The Netherlands
| | - P. D. S. Dijkstra
- Department of Orthopaedic Surgery, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC Leiden, The Netherlands
| | - C. F. A. Bos
- Department of Orthopaedic Surgery, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC Leiden, The Netherlands
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Frigg A, Frigg R, Hintermann B, Barg A, Valderrabano V. The biomechanical influence of tibio-talar containment on stability of the ankle joint. Knee Surg Sports Traumatol Arthrosc 2007; 15:1355-62. [PMID: 17628787 DOI: 10.1007/s00167-007-0372-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 05/30/2007] [Indexed: 12/26/2022]
Abstract
Chronic ankle instability (CAI) is a frequent sport orthopaedic entity. Although many risk factors have been studied extensively, little is known how it is influenced by the osseous joint configuration. Based on lateral X-rays, the radius of the talar surface and the tibial coverage of the talus (sector alpha) were measured on a DICOM/PACS system in 52 patients with CAI and an age- and sex-matched control group. The talar radius was found to be larger in patients with CAI (21.2 +/- 2.4 mm) than in the control group (17.7 +/- 1.9 mm; P < 0.0001). The tibio-talar sector was smaller in patients with CAI (80 degrees +/- 5.1 degrees ) than in the control group (88.4 degrees +/- 7.2 degrees ; P < 0.0001). The aim of this study is to analyse the biomechanical influence of the clinical data on stability of the ankle joint. A two-dimensional model of the tibio-talar joint in the sagittal plane was developed. The joint configuration was described by the tibio-talar sector (alpha) and the radius (r) of the talus. The force (F = F (BW) tan alpha/2) and energy (E = F (BW) r [1 - cos alpha/2]) to dislocate the talus out of the tibial plafond were deduced. Ankle stability is a function of the tibio-talar sector: the force necessary to dislocate the joint is decreasing with a smaller sector. The clinical data show that the force needed to dislocate the ankle of CAI patients was 14% weaker than the one needed in the case of healthy subjects (P < 0.0001). The energy to dislocate the ankle depends both on the sector and the radius. The clinical data do not show a significant difference between the energy needed to dislocate the joint of CAI patients and the one of healthy subjects. This is because there is a correlation of a small sector and a large radius for CAI ankles. CAI is associated with an unstable osseous joint configuration, which is characterized by a larger radius of the talus and a smaller tibio-talar sector. The findings of the biomechanical model explain the clinical observations and demonstrate how stability of the ankle joint is influenced by the osseous configuration. Surgical ankle ligament stabilization might be more recommended in patients with an unstable osseous configuration as such patients have a disposition for recurrent sprains. Removing anterior osteophytes for anterior impingement should be done carefully in CAI patients because this would decrease the tibial coverage of the talus and thus dispose the talus to dislocate anteriorly. People who have an unstable ankle configuration and who nevertheless engage in activities with high risk of ankle sprains could be asked to wear ankle protecting sports equipment.
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Affiliation(s)
- Arno Frigg
- Department of Orthopaedic Surgery, University of Basel, Basel, Switzerland.
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Frigg A, Magerkurth O, Valderrabano V, Ledermann HP, Hintermann B. The effect of osseous ankle configuration on chronic ankle instability. Br J Sports Med 2007; 41:420-4. [PMID: 17261556 PMCID: PMC2465368 DOI: 10.1136/bjsm.2006.032672] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic ankle instability (CAI) is a common orthopaedic entity in sport. Although other risk factors have been studied extensively, little is known about how it is influenced by the osseous joint configuration. AIM To study the effect of osseous ankle configuration on CAI. DESIGN Case-control study, level III. SETTING Radiological examination with measurement of lateral x rays by an independent radiologist using a digital DICOM/PACS system. PATIENTS A group of 52 patients who had had at least three recurrent sprains was compared with an age-matched and sex-matched control group of 52 healthy subjects. MAIN OUTCOME MEASURES The radius of the talar surface, the tibial coverage of the talus (tibiotalar sector) and the height of the talar body were measured. RESULTS The talar radius was found to be larger in patients with CAI (21.2 (2.4) mm) than in controls (17.7 (1.9) mm; p<0.001, power >95%). The tibiotalar sector, representing the tibial coverage of the talus, was smaller in patients with CAI (80 degrees (5.1 degrees )) than in controls (88.4 degrees (7.2 degrees ); p<0.001, power >95%). No significant difference was observed in the height of the talar body between patients with CAI (28.8 (2.6) mm) and controls (27.5 (4.0) mm; p = 0.055). CONCLUSION CAI is associated with an unstable osseous joint configuration characterised by a larger radius of the talus and a smaller tibiotalar sector. There is evidence that a higher talus might also play some part, particularly in women.
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Affiliation(s)
- Arno Frigg
- Orthopaedic Department, Musculoskeletal Care Centre, University Hospital of Basel, Basel, Switzerland.
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Abstract
BACKGROUND A wide variety of procedures have been described to treat chronic lateral ankle instability. Nonanatomic procedures sacrifice normal tissue and can restrict motion. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments, supplemented by reefing of the exstensor retinaculum (modified Broström procedure) provides good long-term stability with minimal drawbacks. METHODS Twenty-one patients had arthroscopic evaluation followed by the Gould modification of the Broström procedure. All patients filled out a detailed questionnaire, including the American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Score, Modified Weber Score, and Hamilton Score at an average of 60 months after surgery. All patients were re-examined, and 14 had stress radiographs for comparison with the preoperative films. RESULTS Ninety-five percent of the patients (20 of 21) had associated intra-articular problems. The mean score for the Modified Weber Score was 96; for the Ankle/Hindfoot Score, 97; and for the Hamilton score, 100% good and excellent results. All 14 patients recorded a side-to-side difference of less than 3 degrees on their postoperative stress radiographs. CONCLUSIONS A high percentage of patients with lateral ankle instability have intra-articular pathology. Excellent results can be expected in patients with ankle instability who undergo arthroscopic treatment of associated intra-articular pathology and the modified Broström procedure.
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Affiliation(s)
- Richard D Ferkel
- Southern California Orthopaedic Institute, 6815 Noble Avenue, Van Nuys, CA 91405, USA.
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Abstract
BACKGROUND Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered. OBJECTIVES To compare different treatments, both conservative and surgical, for chronic lateral ankle instability. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles. SELECTION CRITERIA All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. MAIN RESULTS Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer. AUTHORS' CONCLUSIONS In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.
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Affiliation(s)
- J S de Vries
- Orthotrauma Research Center Amsterdam (ORCA) Academic Medical Center, Orthopaedic Surgery, Meibergdreef 9, PO Box 22660, Amsterdam, Noord-Holland, Netherlands.
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Richter M, Frink M, Zech S, Vanin N, Geerling J, Droste P, Krettek C. Intraoperative pedography: a validated method for static intraoperative biomechanical assessment. Foot Ankle Int 2006; 27:833-42. [PMID: 17054887 DOI: 10.1177/107110070602701014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A new device was developed to perform intraoperative static pedography. The purpose of this study was to validate the introduced method by a comparison with the standard method for dynamic and static pedography. METHODS A device known as Kraftsimulator Intraoperative Pedographie (KIOP) was developed for intraoperative placement of standardized forces to the sole of the foot. Pedographic measurements were done with a custom-made mat that was inserted into the KIOP (Pliance, Novel Inc., St. Paul, MN, USA). Validation was done in two steps: (1) comparison of standard dynamic pedography walking on a platform, standard static pedography in standing on a platform, and pedography with KIOP in supine position in 30 healthy volunteers, and (2) comparison of static pedography in standing position, pedography with KIOP supine awake, and pedography with KIOP supine with 30 patients under anesthesia. Individuals who had operative procedures at the knee or distal to the knee were excluded. The different measurements were compared (one-way ANOVA, t-test; significance level 0.05). RESULTS No significant differences were found among all measurements for the hindfoot compared to midfoot-forefoot force distribution. For the medial compared to lateral force distribution and the 10-region-mapping, significant differences were found when comparing all measurements (steps 1 and 2) and when comparing the measurements of step 1 only. No differences were found for these distributions when comparing the measurements of step 2 alone or when comparing the measurements of step 1 and 2 without the platform measurements of step 1 (dynamic walking pedography and static standing pedography). No significant differences in the force distributions were found in step 2 when comparing subjects without anesthesia, with general anesthesia, and with spinal anesthesia. CONCLUSIONS The KIOP device allows a valid static intraoperative pedography measurement. No statistically significant force distribution differences were found between standing subjects and anesthetized subjects in the supine position.
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Affiliation(s)
- Martinus Richter
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neurberg-Str. 1, 30625 Hannover, Germany.
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36
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Boyer DS, Younger ASE. Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft. Foot Ankle Clin 2006; 11:585-95. [PMID: 16971250 DOI: 10.1016/j.fcl.2006.06.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many techniques have been described for surgical management of lateral ankle instability. Anatomic repair and nonanatomic reconstruction have higher recurrence rates, and may be complicated by ankle stiffness. Anatomic reconstruction should be considered in stabilization for deficiencies of the lateral ankle ligament complex, as the initial construct is stronger while maintaining normal ankle mechanics.
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Affiliation(s)
- Dory S Boyer
- British Columbia's Foot and Ankle Clinic, Suite 560 1144 Burrard Street, Vancouver, British Columbia, Canada V6Z 3E8
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Abstract
Ankle sprains are common in both sport and leisure activities. Despite the high success rates of conservative management, approximately 10% to 30% patients develop chronic instability. Surgery yields high success rates, but clinical problems such as functional and mechanical instability, persistent talar tilt, range of motions limitations, and pain may persist despite surgery.
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Affiliation(s)
- Murat Bozkurt
- Orthopedics and Traumatology Clinic, Diskapi Yildirim Beyazid Research and Education Hospital, Tirebolu sokak, Omrumce Apt., 27/18, Yukariayanci, Ankara 06550, Turkey.
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Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med 2006; 34:975-8. [PMID: 16399935 DOI: 10.1177/0363546505282616] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The procedure described by Broström has been used to address chronic lateral ankle instability; the long-term results of this procedure have not been reported. HYPOTHESIS The Broström procedure provides good results over the long term for active patients with chronic lateral ankle instability. STUDY DESIGN Case series; Level of evidence, 4. METHODS Thirty-one male patients (32 ankles) who underwent the Broström procedure for chronic lateral ankle instability while enrolled as students at the United States Naval Academy were identified. Each patient was mailed a questionnaire that included a functional outcome measure as described by Roos et al, a score described by Good et al, and a single-number ankle functional assessment. The mean age was 20.7 years (range, 18-23 years) at the time of operation. A functional outcome score was completed on each patient, with a mean follow-up of 26.3 years (range, 24.6-27.9 years). RESULTS The follow-up included 22 of the 31 original patients. The mean numeric score for overall ankle function was 91.2 of 100 (standard deviation, 10.2). The foot and ankle outcome score (described by Roos et al) was 92.0 (92%; standard deviation, 12.8) averaged over 5 functional areas. Ninety-one percent of the patients described their ankle function as good or excellent using the scale devised by Good et al. CONCLUSION The long-term results of the Broström procedure for chronic lateral ankle instability are excellent with 26-year follow-up.
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Affiliation(s)
- S Josh Bell
- Clinical Investigation Department, Suite 5, 34800 Bob Wilson Drive, San Diego, CA 92134-1005, USA.
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Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of Modified Broström and Evans Procedures in Simulated Lateral Ankle Injury. Med Sci Sports Exerc 2006; 38:1025-31. [PMID: 16775540 DOI: 10.1249/01.mss.0000222827.56982.40] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities. METHODS Six normal cadaveric ankles were loaded with inversion and internal rotation stress through the range of ankle flexion, and three-dimensional motion of the calcaneus and talus relative to the tibia were measured. An ankle stability testing device and a magnetic tracking system were used. Testing was performed in the intact condition, unstable condition after sectioning both the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), after the Gould modification of the Broström procedure, and after the Evans procedure. RESULTS With inversion loading, both operations resulted in a significantly more stable ankle-hindfoot complex (calcaneal-tibial) than the unstable condition, but there was restricted motion after the Evans operation from neutral to plantarflexion. Tibiotalar inversion motion approximated normal after both operations, but subtalar motion was markedly restricted in the Evans procedure throughout the range of ankle flexion. With internal rotation loading, the Broström operation stabilized the ankle-hindfoot joint complex in plantarflexion. The Evans operation improved internal rotation stability, but restricted motion in all positions. Both operations improved tibiotalar internal rotation stability, but not to normal. The subtalar internal rotation was the same as the intact condition after the Broström operation, but markedly restricted after the Evans operation through the range of ankle flexion. CONCLUSIONS Both operations improved ankle-hindfoot stability, but neither was successful in restoring it to normal as determined with the ankle stability testing device. The Evans procedure improved stability at the expense of creating abnormal subtalar function. The Broström operation improved stability without excessively restricting subtalar movement, but was not effective in addressing the internal rotation laxity.
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Affiliation(s)
- Tadashi Fujii
- Department of Orthopaedic Surgery, Takai Hospital, Tenri, JAPAN
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Abstract
The ankle joint is the most congruent joint of the human body. Stability is provided by the bony configuration of the ankle mortise and the talar dome and by the ankle ligaments. During ankle motions, rotation and translation around and along the movement axes occur. Soft tissue stability is provided mainly by the ligaments. This article discusses ankle instability, injuries, and reconstruction.
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Affiliation(s)
- Rover Krips
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DD Amsterdam, The Netherlands.
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Computer based systems in foot and ankle surgery at the beginning of the 21st century. ACTA ACUST UNITED AC 2006. [DOI: 10.1007/s10302-006-0154-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Clinical gait analysis comprises a well defined repertoire of various methods for valid and reliable assessment. The rapid development of corresponding hardware and software has substantially decreased the efforts necessary for data processing and has promoted the clinical applicability of the procedures. The clinical question defines the amount of methodological input. Clinical gait analysis may provide diagnostic insight into the pathobiomechanics and the pathophysiology of complex gait disorders for which a profound understanding of the underlying causes is a prerequisite for adequate treatment. The methods may help in the screening of gait function following reconstructive surgery as a measure of quality control, the assessment of the severity of a gait disturbance, the evaluation of a rehabilitation process, or the quantification of the effect of orthoses, insoles or specific shoe ware. Simple procedures of gait analysis may suffice to obtain information on gait function which can not be derived by mere clinical observation and which can be incorporated into a clinical concept.
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Affiliation(s)
- T Mittlmeier
- Abt. für Unfall- und Wiederherstellungschirurgie, Chirurgische Klinik und Poliklinik der Universität Rostock.
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Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H. Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med 2005; 33:814-23. [PMID: 15933205 DOI: 10.1177/0363546504272688] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Few anatomical and minor invasive procedures have been reported for surgical reconstruction of the lateral ligaments to treat lateral instability of the ankle. Furthermore, there are no standards according to which ligaments should be reconstructed. HYPOTHESIS A new technique for anatomically reconstructing the lateral ligaments of the ankle using an interference fit anchoring system and determining which ligaments need to be reconstructed according to the results of standard stress radiography of the talocrural and subtalar joints will be effective for treating lateral instability of the ankle. STUDY DESIGN Case series; level of evidence, 4. METHODS Twenty-one patients with lateral instability of the ankle underwent surgery using the proposed interference fit anchoring system. Standard stress radiographs of the subtalar joint were performed, and if the talocalcaneal angle was less than 10 degrees , only the anterior talofibular ligament was reconstructed; if there was a 10 degrees or greater opening of the talocalcaneal angle, both the anterior talofibular ligament and the calcaneofibular ligament were reconstructed. RESULTS In the 17 patients who received only the anterior talofibular ligament reconstruction, the mean talar tilt angle on standard stress radiography of the talocrural joint was 14.5 degrees +/- 1.7 degrees before surgery and 2.6 degrees +/- 0.8 degrees 2 years after surgery (P < .0001). For the 4 patients who had both the anterior talofibular ligament and calcaneofibular ligament reconstructed, the mean talar tilt angle was 16.5 degrees +/- 1.5 degrees before surgery and 3.0 degrees +/- 0.5 degrees 2 years after surgery (P = .0015). The overall mean talocalcaneal angle on standard stress radiography of the subtalar joint was 11.3 degrees +/- 1.4 degrees before surgery and 3.5 degrees +/- 0.8 degrees 2 years after surgery (P = .0060). CONCLUSION The proposed system has several advantages, including anatomical reconstruction with normal stability and range of motion restored, the need for only a small incision during the reconstruction, and sufficient strength at the tendon graft-bone tunnel junction, in comparison with the tension strength of the lateral ligaments of the ankle.
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Affiliation(s)
- Masato Takao
- Department of Orthopaedic Surgery, Shimane University School of Medicine, 89-1, Enya, Izumo, Shimane 693-8501, Japan.
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Schmidt R, Benesch S, Friemert B, Herbst A, Claes L, Gerngross H. Anatomical repair of lateral ligaments in patients with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc 2005; 13:231-7. [PMID: 15824935 DOI: 10.1007/s00167-004-0562-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 07/09/2004] [Indexed: 01/30/2023]
Abstract
In a prospective study, 19 patients with chronic ankle instability underwent clinical and radiographic reexaminations 36 months after anatomical reconstruction. In addition, dynamic pedography was conducted and peroneal reaction time measured on a tilting platform for an evaluation of functional aspects. Prior to this examination, 32 patients had been asked to fill in a questionnaire and make a detailed subjective evaluation of current discomfort, stability, flexibility and sporting abilities. Eighty-eight percent of the patients reported satisfactory results; only 3% complained of persistent instability. In 71% the ability to take part in sports had improved after surgery, and 85% of the patients reported unrestricted walking abilities. Supination ability was impaired in 5% of the patients at the follow-up. The radiographic examination showed restored ankle stability with a significant reduction of talar tilt and talar translation; a postoperative increase in signs and symptoms of arthrosis was not observed. Dynamic pedography showed a large degree of symmetry of plantar pressure distribution after surgery. There were no significant differences in peroneal reaction time in the repaired and intact ankles. The results of the study show that it is possible to restore ankle stability with anatomical reconstruction without impairing the range of movement in the ankle joint complex. Progressive osteoarthrosis can be prevented.
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Affiliation(s)
- R Schmidt
- Department of Surgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany.
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Baltopoulos P, Tzagarakis GP, Kaseta MA. Midterm results of a modified evans repair for chronic lateral ankle instability. Clin Orthop Relat Res 2004:180-5. [PMID: 15187854 DOI: 10.1097/01.blo.0000128645.84131.af] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Twenty-eight ankles in 27 patients with chronic instability were treated with a modification of the Evans procedure during a 10-year period. The diagnosis was assessed by clinical evaluation and radiographic stress tests. The reconstruction procedure consists of using the peroneal brevis tendon to repair ankle instability and restore the loss of anatomic integrity of the injured structures. Twenty-five patients (26 ankles) were available at a mean followup of 99.6 months or 8.3 years (range, 28-117 months). Midterm results were evaluated using the ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society, and postoperative radiographic stress tests. According to this scoring system, the current reconstruction procedure resulted in 92.64 points (range, 63-100 points). However, moderate restriction in hindfoot inversion was seen in nine patients (34.61%). Three ankles (11.5%) had a positive anterior drawer sign (> 8 mm). In five ankles (19.2%), there were mild degenerative joint changes. Therefore, the current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale.
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Affiliation(s)
- Panayiotis Baltopoulos
- Department of Functional Anatomy of Athens University, KAT Hospital, Kifissia, Athens, Greece
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Coughlin MJ, Schenck RC, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int 2004; 25:231-41. [PMID: 15132931 DOI: 10.1177/107110070402500407] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this retrospective study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability using both a direct repair of the anterior talofibular ligament and a free gracilis tendon transfer to reconstruct anatomically the anterior talofibular and calcaneofibular ligaments. METHODS Between December 1998 and February 2002, 28 patients (29 ankles) underwent an anatomic reconstruction of the lateral ankle ligaments for chronic ankle instability. Patients returned for a clinical and radiologic follow-up evaluation at an average of 23 months following surgery (range, 12-52 months). Outcomes were assessed by comparison of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analog pain scores as well as a postoperative Karlsson score. A subjective self-assessment rating was also obtained. All patients underwent preoperative and postoperative radiographic assessment including talar tilt and anterior drawer stress radiographs. RESULTS Twenty-eight patients (29 ankles) (100%) returned for final evaluation. Good or excellent outcome was noted on patient subjective self-assessment, pain scores, AOFAS, and Karlsson scores at final follow-up in all patients. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was reduced from a mean of 13 degrees to 3 degrees (p <.0001) and the anterior drawer was reduced from a mean of 10 mm to 5 mm (p <.0001) by the lateral ankle ligamentous reconstruction. CONCLUSION In the present study, lateral ankle reconstruction with a direct anterior talofibular ligament repair and free gracilis tendon graft augmentation resulted in a high percentage of successful results, excellent ankle stability with a minimal loss of ankle or hindfoot motion, and marked reduction of pain at an average follow-up of almost 2 years.
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Affiliation(s)
- Michael J Coughlin
- Idaho Foot and Ankle Fellowship Program, 901 N. Curtis Road, Ste. #503, Boise, ID 83706, USA.
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Schmidt R, Cordier E, Bertsch C, Eils E, Neller S, Benesch S, Herbst A, Rosenbaum D, Claes L. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int 2004; 25:31-6. [PMID: 14768962 DOI: 10.1177/107110070402500107] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND If conservative therapy fails, the standard treatment for chronic ankle instability is surgical reconstruction of the lateral ligaments. For the last seventy years, the tenodesis principles have been used for reconstruction. Recently however, surgical reconstructions--respecting the intact joint anatomy--have been developed, thus called "anatomical reconstruction principles". METHODS This study focused on the investigation of the range of motion of the ankle and the subtalar joint following anatomical reconstruction surgery. Three different types of anatomical reconstruction procedures were compared: Direct ligament repair, tendon graft and carbon-fiber implant. RESULTS All procedures restored the original range of motion of the subtalar joint, except for the plantarflexed/dorsiflexed positions. As for the talocrural joint, the tendon graft and the carbon fiber implant left a small laxity for movements of inversion/eversion and internal/external rotation. The direct repair procedure achieved a more accurate result and restored the physiologic kinematics almost completely. During each procedure the insertion points and the direction of the original ligaments were maintained. However, the different results for the procedure of direct ligament repair compared to the other two anatomical reconstruction procedures showed that this condition alone is not sufficient to perfectly restore the kinematics of the talocrural and subtalar joints. It is important to note that none of the procedures caused a restriction of the range of motion. CONCLUSIONS The maintenance of the range of hindfoot motion decreases the risk of osteoarthritis as well as chronic pain or problems for the patient to walk on uneven surface. Therefore, we believe that standard therapy for chronic instability of the ankle should include direct surgical reconstruction of the ligaments. If this direct procedure cannot be performed because of poor quality of the ligaments an alternative anatomical reconstruction procedure should be considered.
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Affiliation(s)
- R Schmidt
- Military Hospital, Surgical Department, Ulm, Germany.
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Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W. Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med 2004; 32:183-90. [PMID: 14754742 DOI: 10.1177/0095399703258789] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Very little objective data are available regarding medial ankle instability. HYPOTHESIS Several structures contribute to the stabilization of the medial ankle, and, in the case of injury, they are not involved in a uniform way. STUDY DESIGN Explorative, prospective case series. METHODS Fifty-one patients (52 ankles; males 27, females 25; age 36.4 [16 to 60] years) were surgically treated because of medial ankle instability. All clinical findings and structural changes, as found by arthroscopy and surgical exploration, were compared with the clinical diagnosis and then addressed for surgical reconstruction. RESULTS Pain in the medial gutter was noted in all ankles (100%). Arthroscopy verified a clinically expected additional lateral instability in 40 ankles (77%). At 4.43 years (2 to 6.5 years) after surgical reconstruction, the clinical result was considered to be good/excellent in 46 cases (90%), fair in 4 cases (8%), and poor in 1 case (2%). CONCLUSION The clinical characteristics of medial ankle instability are a feeling of giving way, pain on the medial gutter of the ankle, and a valgus and pronation deformity of the foot that can typically be actively corrected by the posterior tibial muscle. Arthroscopy was shown to be a very helpful diagnostic tool in verifying medial instability.
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Affiliation(s)
- Beat Hintermann
- Clinic of Orthopaedic Surgery, University of Basel, Basel, Switzerland
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