Reconstruction of the lateral ligaments of the ankle using solvent-dried and gamma-irradiated allogeneic fascia lata

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Lateral Ligament Reconstruction for Ball-and-Socket Ankle Accompanying Lateral Ankle Instability: A Case Report and Literature Review

The ball-and-socket ankle joint is a rare deformity characterized by the loss of concavity in the trochlear surface of the talus with rounding of the articular surfaces of the distal fibula and tibia. Frequently, tarsal coalitions, fibular hypoplasia, and shortening of the limb accompany this deformity. To date, no data have been reported on surgical treatment of lateral ankle joint instability and peroneal tendon dislocation concomitant with a ball-and-socket ankle joint. In the present study, we report the case of a 43-year-old male patient with right lateral ankle joint instability and peroneal tendon dislocation in a ball-and-socket ankle joint, with accompanying tarsal coalition. This was surgically treated by lateral ankle joint ligament reconstruction and tenodesis.

Comparative Evaluation Between Anatomic and Nonanatomic Lateral Ligament Reconstruction Techniques in the Ankle Joint: A Computational Study

Biomechanical studies have indicated that the conventional nonanatomic reconstruction techniques for lateral ankle sprain (LAS) tend to restrict subtalar joint motion compared to intact ankle joints. Excessive restriction in subtalar motion may lead to chronic pain, functional difficulties, and development of osteoarthritis (OA). Therefore, various anatomic surgical techniques to reconstruct both the anterior talofibular and calcaneofibular ligaments (CaFL) have been introduced. In this study, ankle joint stability was evaluated using multibody computational ankle joint model to assess two new anatomic reconstruction and three popular nonanatomic reconstruction techniques. An LAS injury, three popular nonanatomic reconstruction models (Watson-Jones, Evans, and Chrisman–Snook) and two common types of anatomic reconstruction models were developed based on the intact ankle model. The stability of ankle in both talocrural and subtalar joint were evaluated under anterior drawer test (150 N anterior force), inversion test (3 N·m inversion moment), internal rotational test (3 N·m internal rotation moment), and the combined loading test (9 N·m inversion and internal moment as well as 1800 N compressive force). Our overall results show that the two anatomic reconstruction techniques were superior to the nonanatomic reconstruction techniques in stabilizing both talocrural and subtalar joints. Restricted subtalar joint motion, which is mainly observed in Watson-Jones and Chrisman–Snook techniques, was not shown in the anatomical reconstructions. Evans technique was beneficial for subtalar joint as it does not restrict subtalar motion, though Evans technique was insufficient for restoring talocrural joint inversion. The anatomical reconstruction techniques best recovered ankle stability.

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

The use of MRI in pre-operative evaluation of anterior talofibular ligament in chronic ankle instability

OBJECTIVES

To evaluate the applicability of MRI for the quantitative assessment of anterior talofibular ligaments (ATFLs) in symptomatic chronic ankle instability (CAI).

METHODS

Between 1997 and 2010, 39 patients with symptomatic CAI underwent surgical treatment (22 male, 17 female, mean age 25.4 years (15 to 40)). In all patients, the maximum diameters of the ATFLs were measured on pre-operative T2-weighted MR images in planes parallel to the path of the ATFL. They were classified into three groups based on a previously published method with modifications: 'normal', diameter = 1.0 - 3.2 mm; 'thickened', diameter > 3.2 mm; 'thin or absent', diameter < 1.0 mm. Stress radiography was performed with the maximum manual force in inversion under general anaesthesia immediately prior to surgery. In surgery, ATFLs were macroscopically divided into two categories: 'thickened', an obvious thickened ligament and 'thin or absent'. The imaging results were compared with the macroscopic results that are considered to be of a gold standard.

RESULTS

Agreement was reached when comparison was made between groups, based on MRI and macroscopic findings. ATFLs were abnormal in all 39 cases and classified as ten 'thickened' and 29 'thin or absent'. As to talar tilt stress radiography, a clear cut-off angle, which would allow discrimination between 'thickened' and 'thin or absent' patients, was not identified.

CONCLUSION

MRI is valuable as a pre-operative assessment tool that can provide the quantitative information of ATFLs in patients with CAI. Cite this article Bone Joint Res 2014;3:241-5.

Near-anatomic allograft tenodesis of chronic lateral ankle instability

BACKGROUND

Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.

METHODS

Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.

RESULTS

Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.

CONCLUSION

Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft

PURPOSE

The purpose of our study is to evaluate the clinical results of anatomical reconstruction of the lateral ligaments with semitendinosus allograft.

METHODS

Thirty-six patients with chronic lateral instability underwent anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and the Karlsson score were used to evaluate the clinical results before and after surgery.

RESULTS

A total of 35 patients (97.2 %) (36 ankles) were followed up for a mean of 37.9 months. The mean AOFAS score improved from 42.3 ± 4.9 points preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively.

CONCLUSIONS

Anatomical reconstruction of the lateral ligaments with semitendinosus allograft achieves a satisfactory surgical outcome for chronic ankle instability.

Results of anatomic lateral ankle ligament reconstruction with tendon allograft

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

Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability

The management of chronic lateral instability of the ankle remains controversial. In general, the anterior talofibular ligament (ATFL) must be reconstructed in all patients. Some will also need reconstruction of the calcaneofibular ligament (CFL) (or its function) to regain stability of both the ankle and the subtalar joints, and to avoid recurrence of instability. After reconstruction, most authors report good to excellent results in 80% to 85% of patients. We describe the augmented reconstruction technique of ATFL and CFL with a semitendinosus tendon allograft through a peroneal bone tunnel fixed with biodegradable anchors, and advocate this procedure as a safe, effective method to manage lateral ankle instability.

Treatment of lateral ankle instability with transfer of the extensor digitorum brevis muscle

Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, some injuries may be followed by chronic lateral pain and instability, and surgical stabilization is sometimes necessary. In select cases, there is little or no residual ligament or scar tissue remaining for late reconstruction. Proximal transfer of the origin of the extensor digitorum brevis muscle as a substitute for deficient ligament tissue can be used in these difficult cases. During the years 1971 to 1992, 13 ankles in 10 patients underwent surgery using the proximal extensor digitorum brevis muscle transfer method. At follow-up, all the ankles manifested functional stability and were stable with no clinical drawer sign. All had a normal range of motion in the ankle joint but showed a desired decreased supination range of motion throughout the hindfoot and ankle. The functional Karlsson scores were 84.5 +/- 18.8 before injury, 26.4 +/- 18.7 before surgery, and 83.6 +/- 18.7 at follow-up. Thus, the extensor digitorum brevis muscle transfer seems to be a useful alternative method of long-term ankle stabilization in these difficult chronic case; the results correlate well with a few other studies using this method.

Histologic analysis of the tibial bone tunnel after anterior cruciate ligament reconstruction using solvent-dried and gamma-irradiated fascia lata allograft

Anterior cruciate ligament (ACL) reconstruction using free tendon graft requires biologic fixation in the bone tunnel. This report describes the intratunnel histology retrieved from a 47-year-old woman who underwent high tibial osteotomy 17 months after ACL reconstruction using a hybrid graft (a solvent-dried and gamma-irradiated fascia lata allograft as a core wrapped with iliotibial autograft). The patient underwent revision because of pain resulting from osteoarthrotic change, and the graft appeared to be taut and healthy on second-look arthroscopy. The sample was taken from the site of the metaphyseal osteotomy site. Histologic examination of the samples was performed with a light microscope (H&E and Masson trichrome stain). Biologic fixation of the graft to the bone was evident from observation of collagen fiber continuities, resembling Sharpey fibers. Integration of the autograft and allograft seemed to have occurred; the junction between the allograft and the autograft could not be determined. However, there was a difference in ligamentization depending on location. In the peripheral region of the graft (the autograft region), the collagen fibers showed a distinct crimped pattern; the fibroblasts were arranged regularly along the major axis of the collagen fiber bundle. In the central part of the graft (the allograft region), remodeling seemed to be delayed. There were acellular, bubbly or myxoid degeneration areas in which the fiber bundles were less oriented and there was increased vascularity.