Persistent Pain After Operative Treatment for Chronic Lateral Ankle Instability

Advanced Imaging in the Chronic Lateral Ankle Instability: An Algorithmic Approach

Imaging examinations are a fundamental part of assessing chronic lateral ankle instability (CLAI). Plain radiographs are used in the initial examination, whereas stress radiographs can be requested to actively search for instability. Ultrasonography (US) and Magnetic Resonance Imaging (MRI) allow direct visualization of ligamentous structures, with the advantage of dynamic evaluation for US, and assessment of associated lesions and intra-articular abnormalities for MRI, which plays an essential role in surgical planning. This article reviews imaging methods to diagnose and follow up on CLAI, along with illustrative cases and an algorithmic approach.

Neurofascial Dextrose Prolotherapy for Managing Chronic Ankle Ligament Injury

Objectives

Due to the anti-inflammatory effects of dextrose prolotherapy, we evaluated the effectiveness of extra-articular, neurofascial dextrose prolotherapy in chronic ankle ligament injury.

Methods

Patients with chronic ankle ligament injury entered this uncontrolled before-after study based on eligibility criteria. Patients who consented to participate in the study filled out the prepared questionnaire containing demographic data, the Cumberland ankle instability tool (CAIT), and the Visual Analogue Scale (VAS). The initial CAIT score of less than 25 indicated functional instability following an ankle sprain. Patients underwent neurofascial prolotherapy with dextrose 12.5%. Two injections within one month were done. The CAIT was completed one, three, and six months after the intervention.

Results

Twenty-five patients with chronic ankle ligament injury were investigated. The mean CAIT score was 1.88 (± 2.35) before the intervention, which increased significantly over the study (P < 0.001). The CAIT score reached 21.84 (± 6.04) in the sixth month after the intervention. Moreover, the VAS score decreased significantly over the study from 6.12 (± 2.35) before the intervention to 1.24 (± 0.43) in the sixth month after the intervention (P < 0.001).

Conclusions

Our findings revealed the therapeutic effectiveness of dextrose neurofascial prolotherapy in decreasing pain and functional instability in patients suffering chronic ankle pain due to ligamentous injury accompanied by chronic ankle instability.

A high rate of talocalcaneal interosseous ligament tears was found in chronic lateral ankle instability with sinus tarsi pain

PURPOSE

To evaluate the arthroscopic findings of subtalar joints, including interosseous talocalcaneal ligament (ITCL) tear, in patients with chronic lateral ankle instability (CLAI) and sinus tarsi pain.

METHODS

A total of 118 ankles (109 patients) having CLAI with sinus tarsi pain who had undergone subtalar arthroscopy and lateral ankle ligament surgery were evaluated. The medical records, radiologic images, and the arthroscopic images and videos were reviewed. ITCL tears were classified into 4 grades: grade 0 (no tear), grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The efficacy of magnetic resonance imaging (MRI) in diagnosing ITCL tears was also evaluated by comparing preoperative official readings of MRI to arthroscopic findings. The pre- and postoperative functional scores were also assessed.

RESULTS

The overall tear rate of ITCL was 107/118 (90.7%). There were 29 ankles (23.6%) with grade 1, 42 ankles (35.6%) with grade 2, and 36 ankles (30.5%) with grade 3 tears. Isolated lateral ankle instability (LAI) was diagnosed in 43 ankles (36.4%), subtalar instability (STI) in 30 ankles (25.4%), and LAI with STI in 45 ankles (38.1%). There was a statistically significant relationship between the ITCL tear grade and the final diagnosis. ITCL tear was confirmed or suspected in 81 ankles (68.6%) on preoperative MRI. Pain Visual Analog Score and functional outcome scores including the American Orthopaedic Foot & Ankle Society and Karlsson-Peterson scores showed significant improvement after the surgery.

CONCLUSION

A high rate (90.7%) of ITCL tears was noted in CLAI patients with sinus tarsi pain. ITCL damage may play an important role in subtalar instability in patients with CLAI and sinus tarsi pain. Subtalar arthroscopic evaluation for ITCL tear is important for correct diagnosis for CLAI with sinus tarsi pain.

LEVEL OF EVIDENCE

IV.

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

PURPOSE

Despite being a significant public health problem, ankle sprains' prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

METHODS

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

RESULTS

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

CONCLUSION

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

LEVEL OF EVIDENCE

Level III.