Arthroscopic four-step treatment for chronic ankle instability

Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review

BACKGROUND

"Failure" is a term that is frequently used to describe an unfavorable outcome for patients who undergo surgical treatment for lateral ankle instability (LAI). A standard definition of failure for the surgical treatment of ankle instability has not been established by clinicians and researchers.

PURPOSE

To identify the definitions of ankle instability treatment failure that are currently in the literature and to work toward the standardization of the definition.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of MEDLINE, SPORTDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for LAI and included information about surgical failure. Studies with level of evidence 1 to 4 were included in this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinions were excluded. The included studies were then reviewed for definitions of failure of any surgical procedure that was performed to correct LAI.

RESULTS

Of the 1200 studies found, 3.5% (42/1200) published between 1984 and 2021 met the inclusion criteria and were analyzed. After reviewing the data, we found numerous definitions were reported in the literature for LAI surgical failure. The most common was recurrent instability (40% [17/42]), followed by rerupture (19% [8/42]). For the original surgical procedure, the anatomic Broström-Gould technique was used most frequently (57% [24/42]). The failure rate of the Broström-Gould technique ranged from 1.1% to 45.2% depending on the definition of failure.

CONCLUSION

There were multiple definitions of failure for the surgical treatment of LAI, which is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. This definition should include specific, objective physical examination findings that eliminate the ambiguity surrounding failure.

A four-step approach improves long-term functional outcomes in patients suffering from chronic ankle instability: a retrospective study with a follow-up of 7-16 years

PURPOSE

The aim of the present study was to assess the long-term outcomes of the treatment of chronic ankle instability (CAI) with a four-step protocol.

METHODS

Fifty-four patients with isolated anterior talo-fibular ligament (ATFL) lesion suffering from CAI who underwent surgical treatment between 2000 and 2009 were assessed. All the patients underwent a four-step protocol including synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Median age at surgery was 31.6 years (18-48). Patients were examined preoperatively and at follow-up. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion (ROM) and manual laxity tests.

RESULTS

AOFAS (preoperative, 64.8; postoperative, 92.4; p < 0.001) and Karlsson-Peterson score (preoperative, 62.5; postoperative, 88.8; p < 0.001) significantly improved after a median 11 years follow-up (7-16 years). Similarly median Tegner activity level significantly increased at follow-up compared to pre-operatory status (6.0 and 4.0 respectively, p < 0.001). Objective examination documented a statistically significant improvement in terms of ankle stability compared to pre-operative manual laxity tests, with negative anterior drawer test observed in 48 (88.9%) patients (p < 0.001). Sagittal ROM was full in 50 patients (92%). Nine patients had subsequent ankle sprains (15.6%), two patients required further surgery, while seven were treated conservatively. No major complications were reported.

CONCLUSION

Satisfying subjective and objective clinical outcomes in selected patients with isolated ATFL lesion suffering from CAI were reported with a treatment protocol including arthroscopic synovectomy, debridement of ATFL remnants, capsular shrinkage, and immobilization. These findings are of clinical relevance because they provide a suitable minimally invasive method for the treatment of mild to moderate ankle instability.

LEVEL OF EVIDENCE

Level IV.

Does the Association of Microfractures for the Treatment of Osteochondral Lesions of the Talus Affect the Outcome Following Arthroscopic Treatment for Chronic Ankle Instability?

BACKGROUND

The purpose of the present study was to retrospectively compare the outcomes of patients who underwent arthroscopic thermal capsular shrinkage with those who underwent both arthroscopic thermal capsular shrinkage and arthroscopic osteochondral lesion (OCL) treatment with microfractures. Our hypothesis was that the simultaneous treatment does not negatively affect the outcome of the combined surgical procedure by influencing the postoperative rehabilitation protocol and does not significantly differ from capsular shrinkage alone in terms of subjective and objective outcomes.

METHODS

Seventy-six patients with chronic ankle instability were treated at our department from 2004 to 2012 and reviewed retrospectively. Forty-two patients underwent arthroscopic thermal-assisted capsular shrinkage (group A), and 34 patients underwent combined arthroscopic capsular shrinkage and microfractures for OCL lesions of the talus (group B). All patients underwent a four-step surgical procedure including synovectomy, debridement, capsular shrinkage, and bracing and nonweightbearing for 21 days. In patients with OCL lesions, microfractures of the OCL were associated. Clinical assessment included objective examination, the American Orthopaedic Foot and Ankle Society ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale.

RESULTS

The median follow-up was 6 years (range, 2-9 years). The median postoperative visual analogue scale score, American Orthopaedic Foot and Ankle Society score, and Tegner score were improved from the preoperative level for both groups (P < .001). No significant difference was found between the two groups for the subjective scores and satisfaction rate (P = not significant). Similarly, no significant difference regarding the incidence of range-of-motion restriction was reported between the two groups (P = not significant).

CONCLUSIONS

The association of microfractures for the treatment of osteochondral lesions does not affect the outcome following arthroscopic treatment for chronic ankle instability up to 6 years from surgery.

Autograft versus allograft tenodesis for chronic ankle instability: a single-center retrospective comparative study

Aim: To compare the outcomes of patients who underwent autograft tenodesis with those who underwent allograft tenodesis for the treatment of chronic mechanical ankle instability. Patients & methods: Ten patients who underwent allograft lateral tenodesis were compared with 15 patients who underwent lateral tenodesis using a split peroneus brevis tendon. Patients were followed up after an average time of 10.5 years. Results: No statistically significant differences concerning American Orthopaedic Foot and Ankle Society and Karlsson-Peterson scores were reported (p = n.s.). A reduced average radiographic anterior talar translation was observed in the autograft group compared with the allograft group (1.4 and 4.0 mm respectively, p < 0.001). Conclusion: Both surgical techniques significantly improved subjective and objective outcomes in patients suffering from chronic ankle instability compared with pre-operatory status. Autograft stabilization provided reduced post-operative anterior talar translation compared with allograft tenodesis.

All-Inside Arthroscopic Anterior Talofibular Ligament Anatomic Reconstruction With a Gracilis Tendon Autograft for Chronic Ankle Instability in High-Demand Patients

The goal of this study was to evaluate the surgical technique and clinical outcome of all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon autograft for chronic ankle instability in high-demand patients. Fifteen consecutive patients (14 [93.3%] males and 1 [6.7%] female, mean age 31.9 ± 7.8 [range 21 to 48] years) with chronic ankle instability were enrolled in this study. Under direct arthroscopic visualization, bone tunnels were created in the fibula and talus by a 4.5-mm cannulated drill system. The gracilis tendon autograft was passed through the tunnels and secured by 5.0-mm interference screws. At the final follow-up, functional evaluation was carried out according to the Ankle-Hindfoot Score by the American Orthopaedic Foot and Ankle Society, Sefton grading system, and visual analog scale score. Complications were also recorded. Mean follow-up was 19.5 ± 1.8 (range 18 to 24) months. No complications of wound infection and nerve injury were noted. No patients experienced recurrent ankle instability. Radiologically, the mean varus tilting angle was 15.2° ± 1.5° before surgery and 4.3° ± 1.2° at the last follow-up (p ≤ .001). The anterior drawer distance was 13.2 ± 1.5 mm before surgery and 4.8 ± 1.1 mm at last follow-up (p ≤ .001). The mean American Orthopaedic Foot and Ankle Society and visual analog scale scores were 56.8 ± 10.5 and 5.7 ± 1.3 before surgery, which became 90.2 ± 6.2 and 0.5 ± 0.8 after surgery. Fourteen (93.3%) patients reported excellent/good functional results according to the Sefton grading system (6 [40.0%] excellent, 8 [53.3%] good, and 1 [6.7%] fair). From our clinical experience, all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon is an effective treatment for chronic ankle instability in high-demand patients.

Lateral ligament reconstruction and augmented direct anatomical repair restore ligament laxity in patients suffering from chronic ankle instability up to 15 years from surgery

PURPOSE

The purpose of the present study was to compare the outcomes of patients who underwent augmented direct anatomical repair using a Broström-Gould procedure with those who underwent lateral ligament reconstruction using a split peroneus brevis tendon for the treatment of chronic ankle instability.

METHODS

Forty patients aged 18-40 years underwent surgical treatment for chronic lateral ankle instability between 1997 and 1998: 20 patients underwent direct anatomical repair using Broström-Gould procedure (Group A); 20 patients underwent lateral tenodesis using a split peroneus brevis tendon (Group B). Median age at surgery was 22.6 years (range 18-40). Patients were assessed pre-operatively and 15 years after surgery with functional assessment including AOFAS scale, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending ROM, anterior drawer sign and talar tilt test. Telos Stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

No major complications were reported. Mean overall AOFAS, Karlsson-Peterson and Tegner scores significantly increased at follow-up compared to pre-operatory status, although no statistically significant differences concerning these variables were reported between the two groups. Sagittal ROM was full in 36 patients: 4 subjects in the Group B experienced 5 degrees dorsiflexion limitation compared to the contralateral side. Patients treated with lateral tenodesis reported a statistically significant reduction in the values of radiographic anterior talar translation (1.4 mm, SD: 0.9) compared to patients in Group A (5.7 mm, SD: 1.1, p < 0.001).

CONCLUSION

Augmented direct anatomical repair and lateral tenodesis provide satisfying long-term outcomes in terms of subjective and objective parameters up to 15 years from surgery in patients with chronic ankle instability without leading to significant artrhitic changes. Objectively, lateral tenodesis appears to improve more effectively restoration of laxity; the reduced ROM reported in 20% of patients did not considerably affect the overall functional outcome.

LEVEL OF EVIDENCE

Comparative case series, Level III.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

[Lateral instability of the upper ankle joint]

Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.

Minimally invasive surgical treatment for chronic ankle instability: a systematic review

PURPOSE

The purpose of this study was to determine the evidence-based support for the treatment for chronic ankle instability (CAI) using minimally invasive surgery (MIS) techniques.

METHODS

A systematic comprehensive review of the literature was performed on 4 September 2015 using PubMed, EMBASE, Cochrane databases and Web of Science along with the two search concepts: lateral ligament of the ankle (patients) and minimally invasive surgical procedure (intervention). Articles of clinical study on MIS for CAI were included in this review and classified into four MIS categories (arthroscopic repair, non-arthroscopic minimally invasive repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction) based on the adopted surgical procedure. Included articles were reviewed and assigned a classification according to the research method quality of evidence (Level I-V evidence). Analysis of these studies was then conducted to provide a grade of recommendation for each MIS category.

RESULTS

The systematic literature review generated 430 articles, and 33 articles met our inclusion criteria. The highest recommendation was Grade C (poor-quality evidence) to support the use of the arthroscopic repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction. Insufficient evidence was currently available to make any recommendation (Grade I) for non-arthroscopic minimally invasive repair category.

CONCLUSIONS

Despite recent increases in publications on MIS for the treatment for CAI, there was currently poor quality of evidence that was insufficient to allow a high grade of recommendation to support the use of the MIS. This paper should stimulate those surgeons performing higher quality studies in the form of prospective and preferably randomized comparative studies that will be necessary to allow better recommendations for the treatment for CAI with MIS. The present study showed thorough evidence-based recommendation for the clinical use of the MIS based on the comprehensive review of the literature.

LEVEL OF EVIDENCE

Systematic review, Level IV.

The anterior talofibular ligament: A detailed morphological study

The anterior talofibular ligament (ATFL) is commonly injured and may result in ankle instability. Good results from ATFL reconstruction have been reported; however complications and movement restrictions have also been observed. ATFL differences have been reported; however details of its precise bony attachment are lacking. This study provides a detailed morphology of the ATFL with respect to surgical and clinical applications. ATFL morphology, number of bands and the exact insertion points were studied in 50 formaldehyde embalmed feet. ATFL length was measured in different joint positions to assess its functional role: ATFL length varied from 18.81 mm in dorsiflexion to 21.06 mm in plantarflexion: mid-length width and thickness were 4.97 mm and 1.01 mm respectively. The bony attachment lengths were also measured: mean proximal and distal bony attachment lengths were 4.68 mm and 3.1mm respectively, while 13.04 mm had no bony attachment. One (22.9%), two (56.3%) and three (20.8%) band morphologies were observed originating 10.37 mm anterosuperior to the lateral malleolar tip and inserting 3.92 mm anterior to the anterior lateral malleolar line (ALML). Detailed morphology of the ATFL may help in restoring injured ATFL function by appropriate ligament reconstruction, as well as aid the understanding of the mechanism of ligament injury.

Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique

Arthroscopy is becoming an essential tool for the treatment of chronic lateral ankle instability. It allows the surgeon to determine which ligaments are injured and choose the most appropriate surgical repair technique, and also to assess and treat any associated injuries. Several arthroscopic techniques for lateral ankle ligament repair have recently been developed. As a consequence, it may be possible to carry out complete lateral ligament reconstruction with an all-arthroscopic procedure. Such an arthroscopic lateral ankle ligament reconstruction technique is described in this article.

Arthroscopic synovectomy in the treatment of functional ankle instability: outcomes and gait analysis

BACKGROUND

Natural consequence of repetitive ankle sprains is the chronic ankle instability. Objective of this study was to clarify the gait patterns of functional ankle instability (FAI) patients after arthroscopic synovectomy, but also assessment of postoperative recovery.

PATIENTS AND METHODS

Arthroscopic synovectomy was performed to 14 FAI patients with history of unilateral repetitive ankle sprains, pain, and subjective sensation of instability. At a mean 54 months of follow-up (27-84), clinical assessment was conducted with respect to pain, number of ankle sprains, and American Orthopaedics Foot and Ankle Society (AOFAS) scores. Gait analysis was conducted to determine the temporospatial, kinetic and kinematic parameters at the last follow-up.

RESULTS

Mean AOFAS scores increased from 68 (range 55-75) to 89 (range 77-100) points (P < 0.01). Mean ankle sprains was 13 in a period of 23 (range 14-48) months (0.58 per month) and decreased to three sprains in a mean time period of 54 months (0.053 per month) (P < 0.01). Mean preoperative and postoperative VAS scores were 8.0 and 2.9, respectively (P < 0.01). During gait analysis, no significant differences were found in ankle joint, including foot progression angles, ankle dorsi-plantar flexion degrees and ground reaction forces (P > 0.01). Among temporospatial parameters, only double support time showed a significant difference (P < 0.01). All patients were satisfied from the procedure and returned to their previous activity level.

CONCLUSION

Improved long-term clinical results and scores were obtained in our patient group when compared with the preoperative scores. Also, three-dimensional gait analysis showed that the involved ankles demonstrate similar gait patterns to the uninvolved ankles in patients with FAI.

Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability

INTRODUCTION

Chronic ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. In case of severe joint laxity, surgical treatment with reconstruction of the lateral ligamental complex is recommended. The aim of this study was to evaluate the functional outcome of patients treated with lateral ligament reconstruction with allograft for severe chronic lateral ankle instability.

MATERIALS AND METHODS

We performed a retrospective cohort study of ten patients who underwent allograft external non-anatomic ligamentoplasty for severe chronic lateral ankle instability between 2009 and 2011, with an average follow-up of 16.3 months (SD 8.2). Median age at surgery was 29 years (range 25-35). All patients presented both ATFL and CFL lesion. Patients were evaluated using American Orthopaedic Foot and Ankle Society score, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending range of motion, anterior drawer sign and talar tilt test. Telos stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

Follow-up examination at an average of 16.3 months (SD 8.2) after surgery showed significant improvement of all variables compared to pre-operative values (p < 0.001). Most patients rated their outcome as good/excellent. Telos stress radiographs documented improvement in joint stability.

CONCLUSIONS

Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability.

Muscle stretching after immobilization applied at alternate days preserves components of articular cartilage

We compared the response of articular cartilage subjected to muscle stretching at different frequencies after joint immobilization. Wistar rats with immobilized left hind limbs were classified into the following groups: immobilization, immobilization followed by muscle stretching applied daily (group IS7) or three times a week (IS3), muscle stretching applied daily (S7) or three times a week (S3), and a control group (C) that underwent no intervention. We then evaluated the cartilage for cellularity, loss of proteoglycans, collagen density, and immunostaining of fibronectin and chondroitin 4-sulfate. Group IS7 showed a significant increase in cellularity and significant loss of proteoglycan compared with the control. In addition, IS7 group had less proteoglycan than IS3. Thin collagen fibrils were significantly reduced in IS7 rats, compared with IS3 and C. There was a significant decrease in the amount of thick fibrils in all groups compared with the control. Groups IS7 and IS3 showed significantly more intense fibronectin immunostaining than the other groups. Our results show that if applied daily after immobilization, muscle stretching is harmful to articular cartilage. However, when applied on alternate days, muscle stretching preserves the components of articular cartilage. We suggest that the latter frequency is more suitable for treatment.

Treatment of post-traumatic osteochondral lesions of the talus: a four-step approach

PURPOSE

The purpose of this retrospective study was to assess the treatment of post-traumatic osteochondral lesions (OCLs) of the ankle with a four-step protocol.

METHODS

Thirty-eight patients with at least one MRI-documented OCL of the ankle were treated from 2004 to 2010. Median age at surgery was 39 years (range: 18-52). Mean lesion size was 1.0 cm(2) (SD: 0.2). All patients underwent a four-step surgical procedure including synovectomy, debridement and microfractures of the OCL, capsular shrinkage, and bracing and non-weightbearing for 21 days. Clinical assessment included objective examination, the AOFAS ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale. MRI scans were taken 18 months after surgery in all patients.

RESULTS

Follow-up examination at an average of 4 years (SD: 1.1) after surgery showed significant improvement of all variables compared to pre-operative values (P < 0.05). Most patients rated their outcome as good/excellent. MRI scans taken 18 months after surgery documented completely repaired lesion in 27 ankles, slight bone marrow oedema with partially repaired defect in 9 patients, and visible defect in 2 ankles.

CONCLUSION

Based on the present results, we propose a comprehensive four-step protocol as a safe and clinically effective treatment option in patients with post-traumatic OCLs of the ankle.