Lateral ligament repair and reconstruction restore neither contact mechanics of the ankle joint nor motion patterns of the hindfoot

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

Return to Sport After Anatomic Lateral Ankle Stabilization Surgery for Chronic Ankle Instability: A Systematic Review and Meta-analysis

BACKGROUND

Chronic lateral ankle instability that develops after ankle sprains has a severe, negative influence on the patient's lower extremity function. Anatomic repair or reconstruction of the lateral ankle ligament is an effective treatment for people with chronic lateral ankle instability who want to regain their preinjury levels of work and sport.

PURPOSE

To determine the rate of return to sport (RTS) and related factors after anatomic lateral ankle stabilization (ALAS) surgery.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Electronic databases including Medline, Embase, the Cochrane Library, and EBSCO Rehabilitation & Sports Medicine Source were searched from the earliest feasible entrance until August 2021. Articles reporting the number of patients who returned to sport after ALAS surgery and analyzing the relevant factors were included. The results were combined using proportion meta-analyses.

RESULTS

A total of 25 publications were reviewed, with a total of 1384 participants. Results showed that 95% of patients (95% CI, 91%-99%) returned to any sport, 83% (95% CI, 73%-91%) returned to their preinjury level of sport, and 87% (95% CI, 71%-98%) returned to competitive sport after surgery. The mean time to RTS was 12.45 weeks (95% CI, 10.8-14.1 weeks). Each decade of age increased the likelihood of RTS failure by 6%, and increases in body mass index (BMI) of 5 kg/m2 raised the risk of RTS failure by 4%. The rate of RTS was higher in professional and competitive athletes (93%; 95% CI, 73%-100%) than in recreational athletes (83%; 95% CI, 76%-89%). Analysis showed no differences for arthroscopy versus open surgery, repair versus reconstruction, and early versus late weightbearing.

CONCLUSION

In most cases, patients may return to some kind of sport after ALAS surgery, and some patients RTS at their preinjury level. The relative risk of RTS failure increases according to the magnitude of the increase in age and BMI. Elite athletes are more likely to return compared with nonelite athletes.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

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

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

Functional effects of arthroscopic modified Broström procedure on lateral ankle instability: A pilot study

BACKGROUND

This study aims to assess the mechanical and functional effects of the arthroscopic modified Broström procedure (AMBP) on patients with lateral ankle instability.

METHODS

Eight patients with unilateral ankle instability treated with AMBP and eight healthy subjects were recruited. Healthy subjects, preoperative and one-year postoperative patients were assessed using outcome scales and the Star Excursion Balance Test (SEBT) for dynamic postural control. One-dimensional statistical parametric mapping was performed to compare ankle angle and muscle activation curve during stair descent.

RESULTS

The patients with lateral ankle instability showed good clinical outcomes and increased posterior lateral reach during the SEBT after the AMBP (p = 0.046). The medial gastrocnemius activation after initial contact was reduced (p = 0.049), and the peroneal longus activation after initial contact was promoted (p = 0.014).

CONCLUSION

The AMBP has functional effects of promoting dynamic postural control and peroneal longus activation within one year of follow-up, which can benefit patients with functional ankle instability. However, the medial gastrocnemius activation was unexpectedly reduced post operation.

Anatomic reconstruction using the autologous gracilis tendon achieved less sprain recurrence than the Broström-Gould procedure but delayed recovery in chronic lateral ankle instability

PURPOSE

To compare the return-to-activity and long-term clinical outcomes between anatomic lateral ligament reconstruction using the autologous gracilis tendon and modified Broström-Gould (MBG) procedure in chronic lateral ankle instability (CLAI). It was hypothesised that there was no difference between the two techniques.

METHODS

From 2013 to 2018, 30 CLAI patients with grade III joint instability confirmed by anterior drawer test underwent anatomic reconstruction of lateral ankle ligament with the autologous gracilis tendon (reconstruction group) in our institute. Another 30 patients undergoing MBG procedure (MBG group) were matched in a 1:1 ratio based on demographic parameters. The post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner activity score, Karlsson-Peterson score, surgical complications, return-to-activities and work were retrospectively evaluated and compared between the two groups.

RESULTS

All subjective scores significantly improved after the operation (all with p < 0.001) without difference between the two groups (all n.s.). The MBG group showed a significantly higher proportion of postoperative sprain recurrence than the reconstruction group (26.7% vs. 0, p = 0.002). The reconstruction group showed a significantly longer period to start walking with full weight-bearing (10.5 ± 6.9 vs. 7.0 ± 3.1 weeks, p = 0.015), jogging (17.1 ± 8.9 vs. 12.7 ± 6.9 weeks, p = 0.043) and return-to-work (13.5 ± 12.6 vs. 8.0 ± 4.7 weeks, p = 0.039) than the MBG group.

CONCLUSIONS

Both anatomic reconstruction using the autologous gracilis tendon and MBG procedure could equally achieved reliable long-term clinical outcomes and the tendon reconstruction showed a relatively lower incidence of postoperative sprain recurrence but delayed recovery to walking, jogging and return-to-work. The MBG procedure was still the first choice with rapid recovery but the tendon reconstruction was recommended for patients with higher strength demand.

LEVEL OF EVIDENCE

III.

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

Background

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

Methods

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

Results

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

Conclusions

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

Ultrasound-Guided Anterior Talofibular Ligament Repair With Augmentation Can Restore Ankle Kinematics: A Cadaveric Biomechanical Study

Background:

Anterior talofibular ligament (ATFL) repair of the ankle is a common surgical procedure. Ultrasound (US)-guided anchor placement for ATFL repair can be performed anatomically and accurately. However, to our knowledge, no study has investigated ankle kinematics after US-guided ATFL repair.

Hypothesis:

US-guided ATFL repair with and without inferior extensor retinaculum (IER) augmentation will restore ankle kinematics.

Study Design:

Controlled laboratory study; Level of evidence, 4.

Methods:

A 6 degrees of freedom robotic testing system was used to apply multidirectional loads to fresh-frozen cadaveric ankles (N = 9). The following ankle states were evaluated: ATFL intact, ATFL deficient, combined ATFL repair and IER augmentation, and isolated US-guided ATFL repair. Three loading conditions (internal-external rotation torque, anterior-posterior load, and inversion-eversion torque) were applied at 4 ankle positions: 30° of plantarflexion, 15° of plantarflexion, 0° of plantarflexion, and 15° of dorsiflexion. The resulting kinematics were recorded and compared using a 1-way repeated-measures analysis of variance with the Benjamini-Hochberg test.

Results:

Anterior translation in response to an internal rotation torque significantly increased in the ATFL-deficient state compared with the ATFL-intact state at 30° and 15° of plantarflexion (P = .022 and .03, respectively). After the combined US-guided ATFL repair and augmentation, anterior translation was reduced significantly compared with the ATFL-deficient state at 30° and 15° of plantarflexion (P = .0012 and .005, respectively). Anterior translation was not significantly different for the isolated ATFL-repair state compared with the ATFL-deficient or ATFL-intact states at 30° and 15° of plantarflexion.

Conclusion:

Combined US-guided ATFL repair with augmentation of the IER reduced lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair did not reduce laxity due to ATFL deficiency, nor did it increase instability compared with the intact ankle.

Clinical Relevance:

US-guided ATFL repair with IER augmentation is a minimally-invasive technique to reduce lateral ankle laxity due to ATFL deficiency. Isolated US-guided ATFL repair may be a viable option if accompanied by a period of immobilization.

Concomitant osteochondral lesions of the talus affect the stair descent biomechanics of patients with chronic ankle instability: A pilot study

BACKGROUND

Previous studies on the kinematics of patients with chronic ankle instability (CAI) that did not incorporate MRI and arthroscopic assessment could not differentiate between patients with CAI without osteochondral lesion of the talus (OLT) and patients with CAI and OLT and have thus presented contradictory results.

RESEARCH QUESTION

This study aimed to investigate the kinematic and electromyographic differences between patients with and without OLT.

METHODS

Sixteen subjects with CAI (eight without OLT and eight with OLT confirmed through MRI and arthroscopic assessment) and eight healthy subjects underwent gait analysis in a stair descent setting. The three groups' patient-reported outcomes; ankle joint range of motion in flexion, inversion and rotation; and muscle activation of the peroneus, tibialis anterior, and gastrocnemius during a gait cycle were analyzed and compared. A curve analysis, namely, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalized time series.

RESULTS

The patients with and without OLT had no difference in patient-reported outcomes. The maximal ankle plantarflexion of the patients without OLT and the healthy subjects was significantly larger than that of patients with OLT (p = 0.005). The maximal ankle internal rotation of patients without OLT was significantly larger than that of patients with OLT (p = 0.048). The peroneal activation during 0-6% of the gait cycle of patients with OLT was reduced compared with the healthy subjects.

SIGNIFICANCE

Patients with CAI and OLT and patients with CAI without OLT have no difference in patient-reported outcomes, but patients with OLT can be differentiated using the post-initial-contact peroneal activation deficit and the restriction of ankle plantarflexion and internal rotation during stair descent. These variables can be utilized to monitor the function of patients with CAI and their possibility of developing OLT.

Ligament Augmentation Reconstruction System (LARS) for Ankle Lateral Ligament Reconstruction in Higher-Risk Patients: A 5-Year Prospective Cohort Study

Background:

The modified Broström-Gould (MBG) procedure is the gold standard for patients with chronic ankle instability (CAI), but it is relatively contraindicated for patients with higher body weight or generalized ligamentous laxity (GLL). The use of the ligament augmentation reconstruction system (LARS) is an alternative.

Hypothesis:

It was hypothesized that clinical outcomes would be similar in patients with increased body weight (>90 kg) or GLL, relative to controls.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 66 patients satisfying the inclusion criteria were invited to participate and were divided into 3 groups: controls (no risk factors for inferior clinical outcome), patients with body weight >90 kg, and patients with GLL (Beighton score, ≥5 of 9). All patients underwent imbrication of the lateral collateral ligament complex augmented with the LARS. Primary outcomes of interest were Tegner activity scale (TAS) and Foot and Ankle Outcome Score (FAOS) subscale scores. Secondary outcomes were recurrence of ankle instability, the need for further surgery, and/or complications. Patients were reviewed at 2 and 5 years postoperatively, and outcomes between groups were compared using repeated-measures analysis of variance.

Results:

Complete data were available for 63 patients (21 patients in each group). TAS improved in all groups from preoperatively to 2 years and 5 years postoperatively (P < .001 for all). Relative to the controls, the TAS scores were lower in the >90-kg group at 2 years and 5 years (P < .001 for both periods), while the GLL group had similar scores to controls at both postoperative periods. Both the >90-kg and the GLL groups showed no significant difference in improvement on any FAOS subscale scores relative to the controls, at both 2 and 5 years postoperatively. There were no recurrences, repeat surgeries, or major complications.

Conclusion:

Relative to controls, patients with body weight >90 kg or GLL had similar FAOSs, and TAS scores were lower in the >90-kg group, at 2 and 5 years, after the use of the LARS to augment lateral collateral ligament imbrication for CAI. Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated.

Effects of the Ankle Flexion Angle During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

This study aimed to evaluate the effects of the ankle flexion angle during anterior talofibular ligament (ATFL) reconstruction on ankle kinematics, laxity, and in situ force of a graft.

METHODS

Twelve cadaveric ankles were evaluated using a 6-degrees of freedom robotic system to apply passive plantar flexion and dorsiflexion motions and multidirectional loads. A repeated measures experiment was designed using the intact ATFL, transected ATFL, and reconstructed ATFL. During ATFL reconstruction (ATFLR), the graft was fixed at a neutral position (ATFLR 0 degrees), 15 degrees of plantar flexion (ATFLR PF15 degrees), and 30 degrees of plantar flexion (ATFLR PF30 degrees) with a constant initial tension of 10 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ force of the ATFL and reconstructed grafts were calculated using the principle of superposition.

RESULTS

The in situ forces of the reconstructed grafts in ATFLR 0 degrees and ATFLR PF 15 degrees were significantly higher than those of intact ankles. The ankle kinematics and laxity produced by ATFLR PF 30 degrees were not significantly different from those of intact ankles. The in situ force on the ATFL was 19.0 N at 30 degrees of plantar flexion. In situ forces of 41.0, 33.7, and 21.9 N were observed at 30 degrees of plantar flexion in ATFLR 0, 15, and 30 degrees, respectively.

CONCLUSION

ATFL reconstruction with the peroneus longus (PL) tendon was performed with the graft at 30 degrees of plantar flexion resulted in ankle kinematics, laxity, and in situ forces similar to those of intact ankles. ATFL reconstructions performed with the graft fixed at 0 and 15 degrees of the plantar flexion resulted in higher in situ forces on the reconstructed graft.

CLINICAL RELEVANCE

Fixing the ATFL tendon graft at 30 degrees of plantar flexion results in an in situ force closest to that of an intact ankle and avoids the excessive tension on the reconstructed graft.

Decreasing the Abnormal Internally Rotated Talus After Lateral Ankle Stabilization Surgery

Background

Increased internal rotation of the talus has been found in patients with mechanical ankle instability (MAI).

Purpose/Hypothesis

To evaluate and compare the talar rotation position before and after lateral ankle lateral stabilization surgery in patients with MAI. We hypothesized that the abnormal internal talus rotation in patients with MAI will decrease after surgery for ankle lateral instability and that there will be no significant difference in internal talus rotation between the ligament repair and reconstruction groups.

Study Design

Case-control study; Level of evidence, 3.

Methods

We retrospectively studied 56 patients with MAI who underwent ankle lateral stabilization surgery after arthroscopic evaluation (repair, 36 cases; reconstruction, 20 cases). Before and after the operation, magnetic resonance images of all the participants were reviewed. The rotated position of the talus was measured and calculated by the Malleolar Talus Index at the magnetic resonance axial plane.

Results

The internal rotation of the talus decreased significantly after ankle lateral stabilization surgery in patients with MAI as compared with before surgery (mean ± SD, 83.3° ± 3.3° vs 86.7° ± 3.9°; P < .01). However, there was no statistically significant difference between the ligament repair and reconstruction groups before or after the operation.

Conclusion

Abnormal internal rotation of the talus in patients with MAI was decreased after ankle lateral stabilization surgery.

Current Concepts on Subtalar Instability

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review

One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for "kinetic outcomes," "kinematic outcomes," "Broström procedure," and "lateral ligament repair." Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.

Revision Lateral Ankle Reconstruction 40 Years After Chrisman-Snook Procedure: A Case Report

CASE

A 70-year-old active woman presented with lateral ankle instability 40 years after a lateral ankle reconstruction procedure. Examination demonstrated gross instability, and advanced imaging revealed attenuation of her previous graft. She underwent anatomic reconstruction through a modified Brostrom-Gould technique and was able to return to hiking without pain.

CONCLUSION

Recurrent lateral ankle instability after reconstruction represents a unique challenge for orthopaedic surgeons. Utilization of a modified Brostrom-Gould procedure with suture tape augmentation is a promising alternative to allograft or autograft reconstruction for patients with active lifestyle goals in the context of recurrent instability.

Cartilage Matrix Changes in Hindfoot Joints in Chronic Ankle Instability Patients After Anatomic Repair Using T2-Mapping: Initial Experience With 3-Year Follow-Up

BACKGROUND

Anatomic repair is widely accepted as the primary surgical treatment for chronic lateral ankle instability (CLAI). T2-mapping is a powerful tool for quantitative assessment of biochemical changes in cartilage matrix.

PURPOSE

To longitudinally evaluate cartilage matrix changes in the hindfoot joints of CLAI patients before and after anatomic repair by using T2-mapping with magnetic resonance imaging (MRI).

STUDY TYPE

Prospective.

SUBJECTS

Thirty-two CLAI patients (males/females = 20/12) and 21 healthy controls (males/females = 13/7).

FIELD STRENGTH/SEQUENCE

3 T; sagittal multi-echo spin-echo technique (T2-mapping), coronal, sagittal, and axial spin-echo PD-FS, and sagittal T1WI sequences.

ASSESSMENT

MRI examinations were performed in CLAI patients at baseline (prior to surgery) and 3 years after anatomic repair and in healthy controls. On T2-maps, the hindfoot joints were segmented into 16 cartilage subregions. The T2 value of each subregion was measured. All patients were evaluated with the American Orthopedic Foot and Ankle Society (AOFAS) scale at baseline and after surgery.

STATISTICAL TESTS

Analysis of variance (ANOVA) and Student's t-test were used. The differences corresponding to P < 0.05 were considered statistically significant.

RESULTS

At baseline, the T2 values in most cartilage subregions of talar dome and medial posterior subtalar joint (pSTJ) were higher in CLAI patients than in healthy controls. After surgery, only the T2 value of anteriomedial talar dome decreased from that at baseline (31.11 ± 3.88 msec vs. 34.27 ± 5.30 msec). The T2 values of other subregions with elevated T2 values remained higher than healthy controls. There were no significant differences in T2 values in the midtarsal joints between CLAI patients and healthy controls (P = 0.262, 0.104, 0.169, 0.103). Postoperatively, the patients' AOFAS scores improved significantly from 67.81 to 89.13.

DATA CONCLUSION

CLAI patients exhibited elevated T2 values in most subregions of talar dome and medial pSTJ. After anatomic repair, although the patients exhibited good clinical outcomes, the elevated T2 values could not be fully recovered.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 4.

Strain patterns in normal anterior talofibular and calcaneofibular ligaments and after anatomical reconstruction using gracilis tendon grafts: A cadaver study

Background

Inversion ankle sprains, or lateral ankle sprains, often result in symptomatic lateral ankle instability, and some patients need lateral ankle ligament reconstruction to reduce pain, improve function, and prevent subsequent injuries. Although anatomically reconstructed ligaments should behave in a biomechanically normal manner, previous studies have not measured the strain patterns of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) after anatomical reconstruction. This study aimed to measure the strain patterns of normal and reconstructed ATFL and CFLs using the miniaturization ligament performance probe (MLPP) system.

Methods

The MLPP was sutured into the ligamentous bands of the ATFLs and CTLs of three freshly frozen cadaveric lower-extremity specimens. Each ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N m force was applied to the ankle and subtalar joint complex.

Results

The normal and reconstructed ATFLs exhibited maximal strain (100) during supination in three-dimensional motion. Although the normal ATFLs were not strained during pronation, the reconstructed ATFLs demonstrated relative strain values of 16–36. During the axial motion, the normal ATFLs started to gradually tense at 0° plantar flexion, with the strain increasing as the plantar flexion angle increased, to a maximal value (100) at 30° plantar flexion; the reconstructed ATFLs showed similar strain patterns. Further, the normal CFLs exhibited maximal strain (100) during plantar flexion-abduction and relative strain values of 30–52 during dorsiflexion in three-dimensional motion. The reconstructed CFLs exhibited the most strain during dorsiflexion-adduction and demonstrated relative strain values of 29–62 during plantar flexion-abduction. During the axial motion, the normal CFLs started to gradually tense at 20° plantar flexion and 5° dorsiflexion.

Conclusion

Our results showed that the strain patterns of reconstructed ATFLs and CFLs are not similar to those of normal ATFLs and CFLs.

Arthroscopic Surgical Technique for Lateral Ankle Ligament Instability

In the past several years, arthroscopic repair of the lateral ankle ligaments has grown because it has shown comparable results with the traditional open Brostrom-Gould procedure. In addition, arthroscopic repair allows reduced swelling and cosmesis. This article discusses the authors' technique for lateral ankle instability, with published data supporting biomechanical equivalency to the standard open Brostrom-Gould procedure. An optional internal brace can provide further strength to the repair and lead to a quicker recovery. Arthroscopic repair both with and without the internal brace have shown positive clinical outcomes for patients as well as high satisfaction rates.

Magnetic Resonance Imaging T2* Mapping of the Talar Dome and Subtalar Joint Cartilage 3 Years After Anterior Talofibular Ligament Repair or Reconstruction in Chronic Lateral Ankle Instability

BACKGROUND

Cartilage degeneration is a common issue in patients with chronic lateral ankle instability. However, there are limited studies regarding the effectiveness of lateral ligament surgery on preventing talar and subtalar joint cartilage from further degenerative changes.

PURPOSE

To longitudinally evaluate talar and subtalar cartilage compositional changes using magnetic resonance imaging T2* mapping in anatomic anterior talofibular ligament (ATFL)-repaired and ATFL-reconstructed ankles and to compare them with measures in asymptomatic controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2015 and December 2016, patients with chronic lateral ankle instability who underwent anatomic ATFL repair (n = 19) and reconstruction (n = 20) were prospectively recruited. Patients underwent 3.0-T magnetic resonance imaging at baseline and 3-year follow-up. As asymptomatic controls, 21 healthy volunteers were recruited and underwent imaging at baseline. Talar dome cartilage was divided into (1) medial anterior, central, and posterior and (2) lateral anterior, central, and posterior. Posterior subtalar cartilage was divided into (1) central talus and calcaneus and (2) lateral talus and calcaneus. Ankle function was assessed using the American Orthopaedic Foot & Ankle Society scores.

RESULTS

There were significant increases in T2* values in medial and lateral posterior and central talus cartilage from baseline to 3-year follow-up in patients who underwent repair. T2* values were significantly higher in ATFL-repaired ankles at follow-up for all cartilage regions of interest, except medial and lateral anterior and lateral central, compared with those in healthy controls. From baseline to 3-year follow-up, ATFL-reconstructed ankles had a significant increase in T2* values in lateral central and posterior cartilage. T2* values in ATFL-reconstructed ankles at follow-up were elevated in all cartilage regions of interest, except medial and lateral anterior, compared with those in healthy controls. ATFL-repaired ankles showed a greater decrease of T2* values from baseline to follow-up in lateral calcaneus cartilage than did ATFL-reconstructed ankles (P = .031). No significant differences in American Orthopaedic Foot & Ankle Society score were found between repair and reconstruction procedures (mean ± SD, 19.11 ± 7.45 vs 16.85 ± 6.24; P = .311).

CONCLUSION

Neither anatomic ATFL repair nor reconstruction could prevent the progression of talar dome and posterior subtalar cartilage degeneration; however, ankle function and activity levels were not affected over a short period. Patients who underwent ATFL repair exhibited lower T2* values in the lateral calcaneus cartilage than did those who underwent reconstruction.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.

All-Inside Arthroscopic Modified Broström Technique to Repair Anterior Talofibular Ligament Provides a Similar Outcome Compared With Open Broström-Gould Procedure

PURPOSE

To introduce an all-inside modified Broström technique to suture the anterior talofibular ligament (ATFL) and inferior extensor retinaculum (IER) under arthroscopy and to compare its outcomes with those of the conventional open procedure.

METHODS

All patients who underwent arthroscopic or open repair of the ATFL between June 2014 and December 2017 were included in this study. Visual analog scale (VAS), Karlsson and Peterson (K-P), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot, and Tegner activity scores, as well as manual anterior drawer test (ADT), were used to evaluate the patients preoperatively and ≥2 years after surgery. The Sefton grading system was used to assess the level of satisfaction after surgery. Detailed surgical data and intraoperative findings were documented at the time of surgery.

RESULTS

A total of 67 patients, 31 in the arthroscopic group and 36 in the open group, were included in this study (43 men and 24 women, mean body mass index 24.00, range 19.53 to 30.03). The surgical duration in the arthroscopic group (median, 34 minutes; range, 25 to 74) was significantly shorter than that in the open group (mean, 43.08 ± 8.11 minutes; 95% confidence interval [CI] 40.34 to 45.83) (P = .007). At the last follow-up, the subjective functional scores and ADT results improved significantly in both cohorts (P < .001). However, no significant difference was found in the VAS score (1.74 ± 1.24, 95% CI 1.29 to 2.2, in the open group versus 1.58 ± 1.2, 95% CI 1.18 to 1.99, in the arthroscopic group; P = .581), AOFAS score (91.71 ± 5.46, 95% CI 89.71 to 93.71, versus 90.67 ± 5.59, 95% CI 88.78 to 92.56; P = .444), K-P score (87.52 ± 7.59, 95% CI 84.73 to 90.3, versus 88.75 ± 5.56, 95% CI 86.87 to 90.63; P = .446), and ADT evaluation (normal: 96.77% versus 94.44%, P = .557) between the arthroscopic and open groups, respectively. In addition, 28 cases (90.32%) in the arthroscopic group and 32 (88.89%) in the open group achieved satisfactory results based on the Sefton grading system (P = .736). Seventeen patients (47.2%) in the open group and 18 patients (58.1%) in the arthroscopic group underwent Tegner evaluation after surgery, which showed no significant difference (5, interquartile range [IQR] 1 in the open group versus 5, IQR 3 in the arthroscopic group; P = .883). Complications were reported in 4 (11.1%) and 2 (6.5%) patients who underwent open and arthroscopic surgeries, respectively (P = .813).

CONCLUSIONS

Both open and arthroscopic modified Broström surgeries generated favorable outcomes, with a significant improvement compared with the preoperative condition. Compared with the open Broström-Gould procedure, the all-inside arthroscopic modified Broström technique produced equivalent functional and clinical results at a minimum of 2 years after the operation, with a shorter surgical duration. Arthroscopic repair might be a safe and viable alternative to open surgery for lateral ankle stabilization.

LEVEL OF EVIDENCE

III.

Functional Results of All-Inside Arthroscopic Broström-Gould Surgery With 2 Anchors Versus Single Anchor

BACKGROUND

The all-inside arthroscopic Broström-Gould technique gained particular attention among clinicians and researchers due to its high rate of satisfactory results. Thus far, there is a lack of evidence regarding the differences in clinical outcomes between the use of 1 anchor and 2 anchors. The purpose of this study was to compare the differences in clinical function and activity levels in patients treated with 1 or 2 anchors in all-inside arthroscopic Broström-Gould surgery for chronic lateral ankle instability (CLAI).

METHODS

The data of 75 patients with CLAI (unilateral) admitted from May 2013 to July 2016 were retrospectively analyzed. All patients were treated with all-inside arthroscopic Broström-Gould surgery. The patients were divided into a single-anchor group (n = 36) and double-anchor group (n = 39) according to the number of anchors used. There was no statistical difference in general characteristics between the 2 groups before surgery. After 36 to 72 months of follow-up, the pain visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Foot and Ankle Outcome Score (FAOS) were used to evaluate and compare the clinical function results between the 2 groups.

RESULTS

The incidence of wound complications; reaction to the suture; injury to the nerve, blood vessel, or tendon; and length of postoperative hospitalization were similar between the 2 groups. At the last follow-up, there was no significant difference in the VAS and AOFAS scores between single- and double-anchor groups, but the KAFS and FAOS in the double-anchor group were significantly higher than in the single-anchor group. Additionally, more patients in the double-anchor group returned to preinjury sports activities.

CONCLUSION

All-inside arthroscopic Broström-Gould surgery for the treatment of CLAI yielded a better functional effect and better recovery to preinjury mobility when 2 anchors were used instead of a single anchor.

LEVEL OF EVIDENCE

Level III, comparative study.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.

PURPOSE/HYPOTHESIS

This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.

RESULTS

Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.

CONCLUSION

Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.

CLINICAL RELEVANCE

This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Engagement of the Secondary Ligamentous and Meniscal Restraints Relative to the Anterior Cruciate Ligament Predicts Anterior Knee Laxity

BACKGROUND

Patients with high-grade preoperative side-to-side differences in anterior laxity as assessed via the Lachman test after unilateral anterior cruciate ligament (ACL) rupture are at heightened risk of early ACL graft failure. Biomechanical factors that predict preoperative side-to-side differences in anterior laxity are poorly understood.

PURPOSE

To assess, in a cadaveric model, whether the increase in anterior laxity caused by sectioning the ACL (a surrogate for preoperative side-to-side differences in anterior laxity) during a simulated Lachman test is associated with two biomechanical factors: (1) the tibial translation at which the secondary anterior stabilizers, including the remaining ligaments and the menisci, begin to carry force, or engage, relative to that of the ACL or (2) the forces carried by the ACL and secondary stabilizers at the peak applied anterior load.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seventeen fresh-frozen human cadaveric knees underwent Lachman tests simulated through a robotic manipulator with the ACL intact and sectioned. The net forces carried by the ACL and secondary soft tissue stabilizers (the medial meniscus and all remaining ligaments, measured as a whole) were characterized as a function of anterior tibial translation. The engagement points of the ACL (with the ACL intact) and each secondary stabilizer (with the ACL sectioned) were defined as the anterior translation at which they began to carry force, or engaged, during a simulated Lachman test. Then, the relative engagement point of each secondary stabilizer was defined as the difference between the engagement point of each secondary stabilizer and that of the ACL. Linear regressions were performed to test each association (P < .05).

RESULTS

The increase in anterior laxity caused by ACL sectioning was associated with increased relative engagement points of both the secondary ligaments (β = 0.87; P < .001; R² = 0.75) and the medial meniscus (β = 0.66; P < .001; R² = 0.58). Smaller changes in anterior laxity were also associated with increased in situ medial meniscal force at the peak applied load when the ACL was intact (β = -0.06; P < .001; R² = 0.53).

CONCLUSION

The secondary ligaments and the medial meniscus require greater anterior tibial translation to engage (ie, begin to carry force) relative to the ACL in knees with greater changes in anterior laxity after ACL sectioning. Moreover, with the ACL intact, the medial meniscus carries more force in knees with smaller changes in anterior laxity after ACL sectioning.

CLINICAL RELEVANCE

Relative tissue engagement is a new biomechanical measure to characterize in situ function of the ligaments and menisci. This measure may aid in developing more personalized surgical approaches to reduce high rates of ACL graft revision in patients with high-grade laxity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Early stage and small medial osteochondral lesions of the talus in the presence of chronic lateral ankle instability: A retrospective study

BACKGROUND

In chronic lateral ankle instability (CLAI), the instability of the ankle joint results in repeated microtrauma to the articular cartilage. How the lesion condition or stage is affected by the presence of lateral instability in medial osteochondral lesions of the talus (OLT) is unclear. We aimed to examine whether CLAI is associated with the size and staging of medial OLT on radiographs, magnetic resonance (MR) images, and arthroscopy.

METHODS

Forty-five patients with medial OLTs in 45 ankles were reviewed. Radiographs were assessed for damage and lesion classification. The tibio-talar tilting angle (TTA) was measured. The patients were divided into two groups: the CLAI group and the stable group. The lesion classification on radiographs, MR images, and arthroscopy, and size on MR images were statistically compared.

RESULTS

The CLAI group had a mean TTA of 8.15 ± 3.41°, whereas the stable group had a mean TTA of 2.24 ± 1.64°. The CLAI group had a lower clinical score than the stable group at the initial visit to our clinic. The CLAI group presented with lesions of significantly shorter longitudinal and transverse diameters. Stages of medial OLT on radiographs, MR images, and arthroscopic evaluation were earlier in the CLAI group than those in the stable group.

CONCLUSIONS

Patients with CLAI presented in the early stages of OLT and had significantly smaller lesions than those without CLAI. The patients without CLAI may be selected for surgery at an early phase.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery

CONTEXT

Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA.

OBJECTIVE

To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players.

DESIGN

Case-control study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

Data from the Retired NFL Players General Health Survey.

MAIN OUTCOME MEASURE(S)

We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities.

RESULTS

Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries.

CONCLUSIONS

Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery

CONTEXT

Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA.

OBJECTIVE

To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players.

DESIGN

Case-control study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

Data from the Retired NFL Players General Health Survey.

MAIN OUTCOME MEASURE(S)

We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities.

RESULTS

Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries.

CONCLUSIONS

Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

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

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

The Role of Calcaneofibular Ligament Injury in Ankle Instability: Implications for Surgical Management

BACKGROUND

Acute inversion ankle sprains are among the most common musculoskeletal injuries. Higher grade sprains, including anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, can be particularly challenging. The precise effect of CFL injury on ankle instability is unclear.

HYPOTHESIS

CFL injury will result in decreased stiffness, decreased peak torque, and increased talar and calcaneal motion and will alter ankle contact mechanics when compared with the uninjured ankle and the ATFL-only injured ankle in a cadaveric model.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Ten matched pairs of cadaver specimens with a pressure sensor in the ankle joint and motion trackers on the fibula, talus, and calcaneus were mounted on a material testing system with 20° of ankle plantarflexion and 15° of internal rotation. Intact specimens were axially loaded to body weight and then underwent inversion along the anatomic axis of the ankle from 0° to 20°. The ATFL and CFL were sequentially sectioned and underwent inversion testing for each condition. Linear mixed models were used to determine significance for stiffness, peak torque, peak pressure, contact area, and inversion angles of the talus and calcaneus relative to the fibula across the 3 conditions.

RESULTS

Stiffness and peak torque did not significantly decrease after sectioning of the ATFL but decreased significantly after sectioning of the CFL. Peak pressures in the tibiotalar joint decreased and mean contact area increased significantly after CFL release. Significantly more inversion of the talus and calcaneus as well as calcaneal medial displacement was seen with weightbearing inversion after sectioning of the CFL.

CONCLUSION

The CFL contributes considerably to lateral ankle instability. Higher grade sprains that include CFL injury result in significant decreases in rotation stiffness and peak torque, substantial alteration of contact mechanics at the ankle joint, increased inversion of the talus and calcaneus, and increased medial displacement of the calcaneus.

CLINICAL RELEVANCE

Repair of an injured CFL should be considered during lateral ligament reconstruction, and there may be a role for early repair in high-grade injuries to avoid intermediate and long-term consequences of a loose or incompetent CFL.

Arthroscopic Treatment of Ankle Instability: Brostrom

Over the last 10 years, significant advances have been made and successful techniques have now been developed that effectively treat ankle instability via the arthroscope.Currently arthroscopic lateral ligament repair techniques can be grouped into "arthroscopic-assisted techniques," "all-arthroscopic techniques," and "all-inside techniques." Recent studies have proven these arthroscopic techniques to be a simple, safe, and biomechanically equivalent, stable alternative to open Brostrom Gould lateral ligament reconstruction.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Effect of Initial Graft Tension During Calcaneofibular Ligament Reconstruction on Ankle Kinematics and Laxity

BACKGROUND

Although a variety of surgical procedures for lateral ankle ligament reconstruction have frequently been reported, little is known about the effects of initial graft tension. Purpose/Hypothesis: The purpose was to investigate the effects of initial graft tension in calcaneofibular ligament (CFL) reconstruction. It was hypothesized that a high degree of initial graft tension would cause abnormal kinematics, laxity, and excessive graft tension.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a 6 degrees of freedom robotic system to apply passive plantarflexion-dorsiflexion motion and multidirectional loads. A repeated-measures experiment was designed with the CFL intact, CFL transected, and CFL reconstructed with 4 initial tension conditions (10, 30, 50, and 70 N). The 3-dimensional path and reconstructed graft tension were simultaneously recorded.

RESULTS

The calcaneus in CFL reconstruction with an initial tension of 70 N had the most eversion relative to the intact condition (mean eversion translations of 1.2, 3.0, 5.0, and 6.2 mm were observed at initial tensions of 10, 30, 50, and 70 N, respectively). The calcaneus also moved more posteriorly with external rotation as the initial tension increased. The reconstructed graft tension tended to increase as the initial tension increased.

CONCLUSION

Ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. Moreover, excessive initial graft tension caused excessive tension on the reconstructed graft.

CLINICAL RELEVANCE

This study indicated the importance of initial graft tension during CFL reconstruction. Overtensioning during CFL reconstruction should be avoided to imitate a normal ankle.

Treatment of talus osteochondral defects in chronic lateral unstable ankles: small-sized lateral chondral lesions had good clinical outcomes

PURPOSE

To assess and compare the clinical and MRI outcomes of patients with talus osteochondral defect (OCD) and patients without OCD in a cohort with chronic lateral ankle instability.

METHODS

All patients who underwent open or arthroscopic anterior talofibular ligament repair of the lateral ligament complex by a single surgeon were included in this study. Ankle arthroscopic surgery was initially performed to manage any intra-articular OCD, including debridement and microfracture. Functional scores (AOFAS, Karlsson score) and Tegner activity level scores were determined. An MRI scan was performed at follow-up to assess talus OCD after treatment. Spearman's correlation coefficients were calculated between functional scores and various factors.

RESULTS

A total of 104 patients with chronic ankle instability were included in this study. Among them, 33 patients had cartilage injury on the talus (OCD group), and the other 71 patients had no cartilage injury (control group). After surgery, there was a significant increase in the AOFAS scores (p < 0.001), the Karlsson scores (p < 0.001), and the Tegner activity scores (p < 0.001) in both the OCD group and the control group. However, there was no significant difference in the AOFAS scores (90.7 ± 6.6 vs. 92.5 ± 8.5; n.s.), the Karlsson scores (89.7 ± 9.3 vs. 91.2 ± 9.1; n.s.), or the Tegner activity scores (5 vs. 6; n.s.) between the OCD group and the control group postoperatively. In the OCD group, there was a significant negative association between the functional scores (AOFAS, Karlsson score, or Tegner score) and the number of intra-articular lesions. For the lateral OCD, the mean lesion area significantly decreased from 49.0 ± 10.7 mm² preoperatively to 18.3 ± 13.1 mm² at the final follow-up (p < 0.001).

CONCLUSION

No significant difference in functional outcomes was found between the OCD group and the control group postoperatively. Arthroscopic microfracture is a good option for the long-term treatment of lateral talus OCD.

LEVEL OF EVIDENCE

III.

Anterior laxity, lateral tibial slope, and in situ ACL force differentiate knees exhibiting distinct patterns of motion during a pivoting event: A human cadaveric study

Knee instability following anterior cruciate ligament (ACL) rupture compromises function and increases risk of injury to the cartilage and menisci. To understand the biomechanical function of the ACL, previous studies have primarily reported the net change in tibial position in response to multiplanar torques, which generate knee instability. In contrast, we retrospectively analyzed a cohort of 13 consecutively tested cadaveric knees and found distinct motion patterns, defined as the motion of the tibia as it translates and rotates from its unloaded, initial position to its loaded, final position. Specifically, ACL-sectioned knees either subluxated anteriorly under valgus torque (VL-subluxating) (5 knees) or under a combination of valgus and internal rotational torques (VL/IR-subluxating) (8 knees), which were applied at 15 and 30° flexion using a robotic manipulator. The purpose of this study was to identify differences between these knees that could be driving the two distinct motion patterns. Therefore, we asked whether parameters of bony geometry and tibiofemoral laxity (known risk factors of non-contact ACL injury) as well as in situ ACL force, when it was intact, differentiate knees in these two groups. VL-subluxating knees exhibited greater sagittal slope of the lateral tibia by 3.6 ± 2.4° (p = 0.003); less change in anterior laxity after ACL-sectioning during a simulated Lachman test by 3.2 ± 3.2 mm (p = 0.006); and, at the peak applied valgus torque (no internal rotation torque), higher posteriorly directed, in situ ACL force by 13.4 ± 11.3 N and 12.0 ± 11.6 N at 15° and 30° of flexion, respectively (both p ≤ 0.03). These results may suggest that subgroups of knees depend more on their ACL to control lateral tibial subluxation in response to uniplanar valgus and multiplanar valgus and internal rotation torques as mediated by anterior laxity and bony morphology.

Surgical Procedures for Chronic Lateral Ankle Instability

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

Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures

PURPOSE

Over 50 % of the patients with chronic lateral ankle instability present with some degree of intra-articular pathology. To date, no consensus regarding the concomitant ankle arthroscopy procedures along with ankle ligament procedures has been reached. The purpose of current study was to investigate reoperation rates and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures.

METHODS

Reoperations and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures were investigated using the PearlDiver Patient Record Database (PearlDiver Technologies, Inc.; Fort Wayne, IN, USA) between 2007 and 2011. Ankle ligament procedures, including ligament repair and reconstruction, and ankle arthroscopic procedures were investigated as primary surgery. Subsequently, the reoperation procedures, including ankle ligament procedures, arthroscopic procedures, autologous osteochondral transplantation, and ankle arthrodesis, as well as wound complications and nerve injury following primary ankle ligament procedures were identified.

RESULTS

In 8014 patients receiving ligament repair, the arthroscopic group had a significantly higher reoperation rate in comparison with the non-arthroscopic group (8.8 vs. 6.5 %, odds ratio: 1.1, [p < 0.01], 95 % confidence interval (CI) 1.2-1.7). However, the non-arthroscopic group included 29 open arthrodesis procedures following the primary surgery, whereas arthroscopic group had none. Of the 8055 patients who received a ligament reconstruction, there was no significant difference in reoperation rate between the groups (5.9 vs. 5.9 %, odds ratio: 1.0, [n.s], 95 % CI 0.8-1.2). As seen in the ligament repair group, the non-arthroscopic group had a 4.9 % rate of ankle arthrodesis as a secondary procedure. Arthroscopic group had a significantly lower rate of wound dehiscence following ankle ligament procedures than non-arthroscopic group.

CONCLUSION

Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation. However, there was a lower incidence of ankle arthrodesis and a lower rate of wound complications in the arthroscopic group when compared to those in non-arthroscopic group. Based on the results of the study, which analysed 16.069 patients, concomitant ankle arthroscopy is recommended.

LEVEL OF EVIDENCE

IV.

Operative treatment of lateral ligament instability

PURPOSE OF REVIEW

Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.

RECENT FINDINGS

Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

Load Sharing Among Collateral Ligaments, Articular Surfaces, and the Tibial Post in Constrained Condylar Knee Arthroplasty

The normal knee joint maintains stable motion during activities of daily living. After total knee arthroplasty (TKA), stability is achieved by the conformity of the bearing surfaces of the implant components, ligaments, and constraint structures incorporated in the implant design. The large, rectangular tibial post in constrained condylar knee (CCK) arthroplasty, often used in revision surgery, provides added stability, but increases susceptibility to polyethylene wear as it contacts the intercondylar box on the femoral component. We examined coronal plane stability to understand the relative contributions of the mechanisms that act to stabilize the CCK knee under varus-valgus loading, namely, load distribution between the medial and lateral condyles, contact of the tibial post with the femoral intercondylar box, and elongation of the collateral ligaments. A robot testing system was used to determine the joint stability in human cadaveric knees as described by the moment versus angular rotation behavior under varus-valgus moments at 0 deg, 30 deg, and 90 deg of flexion. The angular rotation of the CCK knee in response to the physiological moments was limited to ≤1.5 deg. The primary stabilizing mechanism was the redistribution of the contact force on the bearing surfaces. Contact between the tibial post and the femoral box provided a secondary stabilizing mechanism after lift-off of a condyle had occurred. Collateral ligaments provide limited stability because little ligament elongation occurred under such small angular rotations. Compressive loads applied across the knee joint, such as would occur with the application of muscle forces, enhanced the ability of the bearing surfaces to provide resisting internal varus-valgus moment and, thus, reduced the exposure of the tibial post to the external varus-valgus loads. Our results suggest that the CCK stability can be refined by considering both the geometry of the bearing surfaces and the contacting geometry between the tibial post and femoral box.

Biomechanical Assessment of the Anterolateral Ligament of the Knee: A Secondary Restraint in Simulated Tests of the Pivot Shift and of Anterior Stability

BACKGROUND

Injury to the lateral capsular tissues of the knee may accompany rupture of the anterior cruciate ligament (ACL). A distinct lateral structure, the anterolateral ligament, has been identified, and reconstruction strategies for this tissue in combination with ACL reconstruction have been proposed. However, the biomechanical function of the anterolateral ligament is not well understood. Thus, this study had two research questions: (1) What is the contribution of the anterolateral ligament to knee stability in the ACL-sectioned knee? (2) Does the anterolateral ligament bear increased load in the absence of the ACL?

METHODS

Twelve cadaveric knees from donors who were a mean (and standard deviation) of 43 ± 15 years old at the time of death were loaded using a robotic manipulator to simulate clinical tests of the pivot shift and anterior stability. Motions were recorded with the ACL intact, with the ACL sectioned, and with both the ACL and anterolateral ligament sectioned. In situ loads borne by the ACL and anterolateral ligament in the ACL-intact knee and borne by the anterolateral ligament in the ACL-sectioned knee were determined.

RESULTS

Sectioning the anterolateral ligament in the ACL-sectioned knee led to mean increases of 2 to 3 mm in anterior tibial translation in both anterior stability and simulated pivot-shift tests. In the ACL-intact knee, the load borne by the anterolateral ligament was a mean of ≤10.2 N in response to anterior loads and <17 N in response to the simulated pivot shift. In the ACL-sectioned knee, the load borne by the anterolateral ligament increased on average to <55% of the load normally borne by the ACL in the intact knee. However, in the ACL-sectioned knee, the anterolateral ligament engaged only after the tibia translated beyond the physiologic limits of motion of the ACL-intact knee.

CONCLUSIONS

The anterolateral ligament is a secondary stabilizer compared with the ACL for the simulated Lachman, anterior drawer, and pivot shift examinations.

CLINICAL RELEVANCE

Since the anterolateral ligament engages only during pathologic ranges of tibial translation, there is a limited need for anatomical reconstruction of the anterolateral ligament in a well-functioning ACL-reconstructed knee.

Foot-ankle simulators: A tool to advance biomechanical understanding of a complex anatomical structure

In vitro gait simulations have been available to researchers for more than two decades and have become an invaluable tool for understanding fundamental foot-ankle biomechanics. This has been realised through several incremental technological and methodological developments, such as the actuation of muscle tendons, the increase in controlled degrees of freedom and the use of advanced control schemes. Furthermore, in vitro experimentation enabled performing highly repeatable and controllable simulations of gait during simultaneous measurement of several biomechanical signals (e.g. bone kinematics, intra-articular pressure distribution, bone strain). Such signals cannot always be captured in detail using in vivo techniques, and the importance of in vitro experimentation is therefore highlighted. The information provided by in vitro gait simulations enabled researchers to answer numerous clinical questions related to pathology, injury and surgery. In this article, first an overview of the developments in design and methodology of the various foot-ankle simulators is presented. Furthermore, an overview of the conducted studies is outlined and an example of a study aiming at understanding the differences in kinematics of the hindfoot, ankle and subtalar joints after total ankle arthroplasty is presented. Finally, the limitations and future perspectives of in vitro experimentation and in particular of foot-ankle gait simulators are discussed. It is expected that the biofidelic nature of the controllers will be improved in order to make them more subject-specific and to link foot motion to the simulated behaviour of the entire missing body, providing additional information for understanding the complex anatomical structure of the foot.

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

In Vivo Talocrural Joint Contact Mechanics With Functional Ankle Instability

BACKGROUND

Functional ankle instability (FAI) may involve abnormal kinematics and contact mechanics during ankle internal rotation. Understanding of these abnormalities is important to prevent secondary problems in patients with FAI. However, there are no in vivo studies that have investigated talocrural joint contact mechanics during weightbearing ankle internal rotation. The objective of this study to determine talocrural contact mechanics during weightbearing ankle internal rotation in patients with FAI.

METHODS

Twelve male subjects with unilateral FAI (age range, 18-26 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities were obtained during weightbearing passive ankle joint complex rotation. Three-dimensional bone models created from the computed tomographic images were matched to the fluoroscopic images to compute 6 degrees of freedom for talocrural joint kinematics. The closest contact area in the talocrural joint in ankle neutral rotation and maximum internal rotation during either dorsiflexion or plantar flexion was determined using geometric bone models and talocrural joint kinematics data.

RESULTS

The closest contact area in the talus shifted anteromedially during ankle dorsiflexion-internal rotation, whereas it shifted posteromedially during ankle plantar flexion-internal rotation. The closest contact area in FAI joints was significantly more medial than that in healthy joints during maximum ankle internal rotation and was associated with excessive talocrural internal rotation or inversion.

DISCUSSION

This study demonstrated abnormal talocrural kinematics and contact mechanics in FAI subjects. Such abnormal kinematics may contribute to abnormal contact mechanics and may increase cartilage stress in FAI joints.

LEVEL OF EVIDENCE

Therapeutic, Level IV: cross-sectional case-control study.

Extrinsic Muscle Forces Affect Ankle Loading Before and After Total Ankle Arthroplasty

BACKGROUND

Joint loading conditions have an effect on the development and management of ankle osteoarthritis and on aseptic loosening after total ankle arthroplasty (TAA). Apart from body weight, compressive forces induced by muscle action may affect joint loading. However, few studies have evaluated the influence of individual muscles on the intraarticular pressure distribution in the ankle.

QUESTION/PURPOSES

The purpose of this study was to measure intraarticular pressure distribution and, in particular, (1) to quantify the effect of individual muscle action on peak-pressure magnitude; and (2) to identify the location of the center of pressure in the weightbearing native ankles and ankles that had TAA.

METHODS

Peak pressure and intraarticular center of pressure were quantified during force alterations of four muscle groups (peronei, tibialis anterior, tibialis posterior, and triceps surae) in 10 cadaveric feet. The pressure was measured with a pressure sensitive array before and after implantation of a three-component mobile-bearing TAA prosthesis. Linear mixed-effects models were calculated and the y-intercept (b0) and the slope (b1) of the regression were used to quantify the size of the effect.

RESULTS

Mean maximum peak pressures of 2 MPa (± 2.6 MPa) and 6.2 MPa (± 3.6 MPa) were measured for the native and TAA joint respectively. The triceps surae greatly affect the magnitude of peak pressure in the native ankle (slope b1 = 0.174; p = 0.001) and TAA joint (slope b1 = 0.416; p = 0.001). Furthermore, the force of most muscles caused a posterior and lateral shift of the center of pressure in both conditions.

CONCLUSIONS

Our results suggest that muscle force production has the potential to alter the pressure distribution in the native ankles and those with and TAA.

CLINICAL RELEVANCE

Our study results help us to understand the effect of muscle forces on joint loading conditions which could be used in muscle training strategies and the design of better prosthetic components. Physical therapy or guided exercises may provide the potential to relieve areas in the joint that show signs of early osteoarthritis or reduce the contact stress on prosthetic components, potentially reducing the risk of TAA failure attributable to wear.