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Goru P, Talha S, Majeed H. Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature. Indian J Orthop 2021; 56:208-215. [PMID: 35140851 PMCID: PMC8789970 DOI: 10.1007/s43465-021-00532-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/19/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported. AIMS AND OBJECTIVES The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery. MATERIALS AND METHODS We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included. MAIN RESULTS After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play. CONCLUSION Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00532-0.
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Affiliation(s)
- Poornanand Goru
- Trauma and Orthopaedics, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK ,Warrington, UK
| | - Samir Talha
- Trauma and Orthopaedics, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Haroon Majeed
- Trauma and Orthopaedics, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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Trichine F, Friha T, Boukabou A, Belaid L, Bouzidi T, Bouzitouna M. Surgical Treatment of Chronic Lateral Ankle Instability Using an Inferior Extensor Retinaculum Flap: A Retrospective Study. J Foot Ankle Surg 2018; 57:226-231. [PMID: 28826786 DOI: 10.1053/j.jfas.2017.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Indexed: 02/03/2023]
Abstract
Chronic lateral ankle instability causes significant problems with physical activity. The purpose of the present study was to evaluate the results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap. A consecutive series of 38 patients were included with a minimum follow-up duration of 2 years. The functional results were assessed using the Karlsson and American Orthopaedic Foot and Ankle Society scale scores. The pre- and postoperative radiologic assessment was performed using stress radiographs to measure varus tilt and anterior drawer tests. All 38 patients were followed up for 2.5 to 7.2 years, and 35 patients were satisfied. The American Orthopaedic Foot and Ankle Society scale score had improved significantly from 57 (range 20 to 70) points preoperatively to 95 (range 80 to 100) points postoperatively (p < .0001), and 35 patients believed their ankle was more stable after surgery. The patients had returned to their previous sports activities an average of 4.7 (range 2 to 12) months after surgery. On the stress radiographs, the mean talar tilt angle had improved significantly from 15.2° (range 6° to 26°) preoperatively to 3.8° (range 1° to 8°) at the final follow-up visit (p < .001), and the mean anterior talar had improved significantly from 13.2 (range 8 to 18) mm preoperatively to 4 (range 4 to 7) mm at the final follow-up visit (p < .002). Regarding the prognostic factors, a link was found between the functional result and residual radiologic laxity measured on the stress radiographs. Reconstruction of the lateral ligaments for chronic ankle instability combining capsuloligamentous retensioning and reinforcement with an extensor retinaculum flap resulted in successful outcomes, excellent ankle stability, and preservation of ankle joint mobility. This technique addressed both lateral ankle and subtalar instability by developing an extraarticular interosseous ligament.
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Affiliation(s)
- Faycal Trichine
- Surgeon, Department of Orthopaedic Surgery and Traumatology, University Military Hospital of Constantine, Constantine, Algeria.
| | - Toufik Friha
- Surgeon, Department of Orthopaedic Surgery and Traumatology, University Military Hospital of Constantine, Constantine, Algeria
| | - Azzedine Boukabou
- Surgeon, Department of Orthopaedic Surgery and Traumatology, University Military Hospital of Constantine, Constantine, Algeria
| | - Lamine Belaid
- Surgeon, Department of Orthopaedic Surgery and Traumatology, University Military Hospital of Constantine, Constantine, Algeria
| | - Terek Bouzidi
- Surgeon, Department of Orthopaedic Surgery and Traumatology, University Military Hospital of Constantine, Constantine, Algeria
| | - Mahdjoub Bouzitouna
- Professor, Department of Orthopaedic Surgery and Traumatology, Academic Medical Center of Constantine, Constantine, Algeria
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Walker R, Kunkle WA, Carreira DS. Arthroscopic Approach to Osteochondral Defects, Impingement, and Instability. Clin Sports Med 2015; 34:689-703. [PMID: 26409590 DOI: 10.1016/j.csm.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Osteochondral defects, impingement, and instability of the ankle are common injuries in athletes. In this article, we review these diagnoses and their treatment options, with a focus on arthroscopic approaches. The treatment options continue to evolve, supported by innovation and outcome studies. In this article, we describe the advantages and disadvantages of both open and arthroscopic treatments using published evidence.
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Affiliation(s)
- Roger Walker
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA
| | - William Aaron Kunkle
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA
| | - Dominic S Carreira
- Sports Medicine and Orthopedics, Broward Health Medical Center, 1601 South Andrews Avenue, 2nd Floor, Fort Lauderdale, FL 33316, USA.
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Morelli F, Perugia D, Vadalà A, Serlorenzi P, Ferretti A. Modified Watson-Jones technique for chronic lateral ankle instability in athletes: clinical and radiological mid- to long-term follow-up. Foot Ankle Surg 2011; 17:247-51. [PMID: 22017895 DOI: 10.1016/j.fas.2010.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 08/17/2010] [Accepted: 08/21/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND We clinically and radiologically assessed mid- to long-term follow-up of a group of patients treated with a modified Watson-Jones technique for chronic ankle instability. METHODS Fourteen athletes were retrospectively evaluated with physical examination, and Tegner, Good and AOFAS scales; moreover, a 2-view stress, side-to-side X-ray, was performed. RESULTS All patients were followed-up at a mean of 10.8 years. No one reported further ankle sprains. Mean Good scale value decreased from 3.7 to 1.6, while the Tegner scale decreased from 6.8 to 5.1; the mean AOFAS score was 92.2. Mean sagittal-plane ROM was 62.3° (4.9° S/S difference), while mean coronal-plane ROM was 25.5° (3.8° S/S difference). Mean X-ray talar tilt angle was 4.5° (0.1° S/S difference), while mean anterior drawer test angle was 5.4 mm (0.5 mm S/S difference). CONCLUSIONS The modified Watson-Jones procedure seems to be a reliable technique in providing satisfactory mid- to long-term clinical and radiological results.
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Affiliation(s)
- Federico Morelli
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome Sapienza, Via Grottarossa, 1035 Rome, Italy
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Kramer D, Solomon R, Curtis C, Zurakowski D, Micheli LJ. Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes. Foot Ankle Spec 2011; 4:18-28. [PMID: 20826848 DOI: 10.1177/1938640010379912] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There is no consensus regarding optimum surgical treatment for chronic ankle instability. The purpose of this study is to describe a variation of the Chrisman-Snook lateral ligament reconstruction that the senior author uses in patients with chronic ankle instability recalcitrant to conservative management. All patients who underwent reconstruction from 1997 to 2006 were identified, and those with a minimum 2-year follow-up were included, representing a total of 44 ankles in 43 patients. All underwent clinical evaluation and completion of the Foot and Ankle Outcome Survey and the Kaikkonen Scale. At mean follow-up of 4.4 years, mean dorsiflexion loss was 2° compared with the nonoperative side. The postoperative mean Foot and Ankle Outcome Survey score was 74 ± 16 (range, 36-98), while the mean Kaikkonen total score was 77 ± 14 (range, 40-95). Thirty-eight patients (84.6%) were satisfied with their result. Six patients (13.6%) underwent reoperation, including 4 with peroneal tendon scarring requiring tenolysis. Return to sport was achieved in 28 of 35 patients (80%) at a median of 6 months postoperatively. It is concluded that dorsiflexion loss can be minimized and return to sport expected in most patients following this variation of the Chrisman-Snook reconstruction.
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Affiliation(s)
- Dennis Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Childrens Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
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Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of Modified Broström and Evans Procedures in Simulated Lateral Ankle Injury. Med Sci Sports Exerc 2006; 38:1025-31. [PMID: 16775540 DOI: 10.1249/01.mss.0000222827.56982.40] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities. METHODS Six normal cadaveric ankles were loaded with inversion and internal rotation stress through the range of ankle flexion, and three-dimensional motion of the calcaneus and talus relative to the tibia were measured. An ankle stability testing device and a magnetic tracking system were used. Testing was performed in the intact condition, unstable condition after sectioning both the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), after the Gould modification of the Broström procedure, and after the Evans procedure. RESULTS With inversion loading, both operations resulted in a significantly more stable ankle-hindfoot complex (calcaneal-tibial) than the unstable condition, but there was restricted motion after the Evans operation from neutral to plantarflexion. Tibiotalar inversion motion approximated normal after both operations, but subtalar motion was markedly restricted in the Evans procedure throughout the range of ankle flexion. With internal rotation loading, the Broström operation stabilized the ankle-hindfoot joint complex in plantarflexion. The Evans operation improved internal rotation stability, but restricted motion in all positions. Both operations improved tibiotalar internal rotation stability, but not to normal. The subtalar internal rotation was the same as the intact condition after the Broström operation, but markedly restricted after the Evans operation through the range of ankle flexion. CONCLUSIONS Both operations improved ankle-hindfoot stability, but neither was successful in restoring it to normal as determined with the ankle stability testing device. The Evans procedure improved stability at the expense of creating abnormal subtalar function. The Broström operation improved stability without excessively restricting subtalar movement, but was not effective in addressing the internal rotation laxity.
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Affiliation(s)
- Tadashi Fujii
- Department of Orthopaedic Surgery, Takai Hospital, Tenri, JAPAN
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Abstract
The ankle joint is the most congruent joint of the human body. Stability is provided by the bony configuration of the ankle mortise and the talar dome and by the ankle ligaments. During ankle motions, rotation and translation around and along the movement axes occur. Soft tissue stability is provided mainly by the ligaments. This article discusses ankle instability, injuries, and reconstruction.
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Affiliation(s)
- Rover Krips
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DD Amsterdam, The Netherlands.
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Schmidt R, Benesch S, Friemert B, Herbst A, Claes L, Gerngross H. Anatomical repair of lateral ligaments in patients with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc 2005; 13:231-7. [PMID: 15824935 DOI: 10.1007/s00167-004-0562-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 07/09/2004] [Indexed: 01/30/2023]
Abstract
In a prospective study, 19 patients with chronic ankle instability underwent clinical and radiographic reexaminations 36 months after anatomical reconstruction. In addition, dynamic pedography was conducted and peroneal reaction time measured on a tilting platform for an evaluation of functional aspects. Prior to this examination, 32 patients had been asked to fill in a questionnaire and make a detailed subjective evaluation of current discomfort, stability, flexibility and sporting abilities. Eighty-eight percent of the patients reported satisfactory results; only 3% complained of persistent instability. In 71% the ability to take part in sports had improved after surgery, and 85% of the patients reported unrestricted walking abilities. Supination ability was impaired in 5% of the patients at the follow-up. The radiographic examination showed restored ankle stability with a significant reduction of talar tilt and talar translation; a postoperative increase in signs and symptoms of arthrosis was not observed. Dynamic pedography showed a large degree of symmetry of plantar pressure distribution after surgery. There were no significant differences in peroneal reaction time in the repaired and intact ankles. The results of the study show that it is possible to restore ankle stability with anatomical reconstruction without impairing the range of movement in the ankle joint complex. Progressive osteoarthrosis can be prevented.
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Affiliation(s)
- R Schmidt
- Department of Surgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany.
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Baltopoulos P, Tzagarakis GP, Kaseta MA. Midterm results of a modified evans repair for chronic lateral ankle instability. Clin Orthop Relat Res 2004:180-5. [PMID: 15187854 DOI: 10.1097/01.blo.0000128645.84131.af] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Twenty-eight ankles in 27 patients with chronic instability were treated with a modification of the Evans procedure during a 10-year period. The diagnosis was assessed by clinical evaluation and radiographic stress tests. The reconstruction procedure consists of using the peroneal brevis tendon to repair ankle instability and restore the loss of anatomic integrity of the injured structures. Twenty-five patients (26 ankles) were available at a mean followup of 99.6 months or 8.3 years (range, 28-117 months). Midterm results were evaluated using the ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society, and postoperative radiographic stress tests. According to this scoring system, the current reconstruction procedure resulted in 92.64 points (range, 63-100 points). However, moderate restriction in hindfoot inversion was seen in nine patients (34.61%). Three ankles (11.5%) had a positive anterior drawer sign (> 8 mm). In five ankles (19.2%), there were mild degenerative joint changes. Therefore, the current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale.
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Affiliation(s)
- Panayiotis Baltopoulos
- Department of Functional Anatomy of Athens University, KAT Hospital, Kifissia, Athens, Greece
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Abstract
Complications after ankle ligament reconstruction are infrequent, but present significant challenges to the treating orthopaedist. Local wound problems and nerve injuries may cause difficulty in the early postoperative period. Recurrent instability may be attributable to failure of the operation, poor rehabilitation, reinjury, or unrecognized predisposing factors. Postoperative stiffness of the subtalar and ankle joints frequently is reported after anatomic and nonanatomic tenodesis procedures and may cause significant morbidity. The current author reviews reported complications and treatment options in failed lateral ankle ligament surgery.
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Affiliation(s)
- V J Sammarco
- Center for Orthopaedic Care, Cincinnati, OH 45219, USA
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Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, Karlsson J. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int 2001; 22:415-21. [PMID: 11428761 DOI: 10.1177/107110070102200510] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The long-term clinical outcome after anatomical reconstruction and tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicentre study. The first group (AR) consisted of 25 patients (mean age at operation 22 yrs +/- 5.7) who underwent anatomical reconstruction and the second group (TE) of 29 patients (mean age 23 yrs +/- 6.6) who underwent tenodesis. For both groups, the mean follow-up period was 12.3 yrs (AR +/- 2.5 yrs, TE +/- 2.7 yrs). At physical examination, there were significantly more patients in the TE group (n=18) with a positive anterior drawer sign as compared with the AR group (n=7) (p=0.02). Medially located degenerative changes in the ankle joint as seen on standard radiographs were seen more often in the TE group (n=7) than in the AR group (n=1) (p=0.03). The mean talar tilt, 4.7 degrees in the AR group vs 6.9 degrees in the TE group, (p=0.02) and anterior talar translation, 2.9 mm in the AR group vs 4.3 mm in the TE group, (p=0.04) were significantly higher in the TE group at radiographic stress examination. According to the rating system developed by Good et al. (1975), significantly fewer patients in the TE group (n=8) had an excellent result as compared with the AR group (n=15) (p=0.03) and more patients in the TE group (n=9) had a fair or poor result (p=0.04) as compared with the AR group (n=2). We conclude that a tenodesis procedure does not restore the normal anatomy of the lateral ankle ligaments. When compared with anatomical reconstruction, a tenodesis leads to inferior results in terms of functional and mechanical stability, as well as overall satisfaction at long-term follow-up.
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Affiliation(s)
- R Krips
- Academic Medical Center, Amsterdam, The Netherlands
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Rosenbaum D, Becker HP, Sterk J, Gerngross H, Claes L. Functional evaluation of the 10-year outcome after modified Evans repair for chronic ankle instability. Foot Ankle Int 1997; 18:765-71. [PMID: 9429877 DOI: 10.1177/107110079701801202] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The Evans tenodesis is an operative treatment for chronic ankle instability with good short-term results. The disadvantage of impaired hind foot kinematics and restricted motion has been described, and only few reports of long-term results can be found. No techniques have been used to assess the outcome objectively. We wanted to determine whether a modified Evans procedure led to a satisfactory clinical and functional outcome. Nineteen patients were available at a 10-year follow-up. The clinical examination included a detailed questionnaire and stress radiographs. Foot function was evaluated with plantar pressure distribution measurements during walking and peroneal reaction time measurements elicited on a rapidly tilting platform (recorded with surface electromyography). High subjective patient satisfaction was contrasted with a high rate of residual instability, pain, and swelling. The radiographs showed an increased number of exostoses. The gait analysis revealed reduced peak pressures under the lateral heel and increased values under the longitudinal arch. The reaction times of the peroneal muscles were shorter on the operated side (significant: peroneus longus). The persistent clinical problems as well as the functional changes indicate that the disturbed ankle joint kinematics permanently alter foot function and may subsequently support the development of arthrosis. Therefore, the Evans procedure should only be applied if anatomical reconstruction of the lateral ankle ligaments is not feasible.
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Affiliation(s)
- D Rosenbaum
- Dept. Unfallchirurgische Forschung und Biomechanik, University of Ulm, Germany
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Rosenbaum D, Bertsch C, Claes LE. NOVEL Award 1996: 2nd prize Tenodeses do not fully restore ankle joint loading characteristics: a biomechanical in vitro investigation in the hind foot. Clin Biomech (Bristol, Avon) 1997; 12:202-209. [PMID: 11415696 DOI: 10.1016/s0268-0033(97)00017-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE: In order to understand the biomechanical consequences of ligament injuries and surgical reconstruction procedures, their effects on intra-articular loading in the ankle joint complex and Chopart joint line and on the plantar pressure patterns were investigated in vitro. METHODS: Twelve fresh-frozen lower leg specimens were freed of soft tissue down to the malleoli and prepared for accessing the talocrural, subtalar, talonavicular and calcaneocuboid joints. The specimens were fixed in a loading simulator and axially loaded with 600 N in six experimental conditions: intact; after cutting the anterior talofibular ligament; after additionally cutting the calcaneofibular ligament; after performing three common types of tenodeses, the Evans, Watson-Jones and Chrisman-Snook procedures. The intra-articular loading characteristics were determined with pressure sensitive film. Plantar loading patterns were measured with a capacitive EMED pressure distribution platform. RESULTS: Average intra-articular pressures were increased and were related either to decreased contact areas or to increased contact forces found in all joints after ligament resections and tenodeses. Plantar loading was increased under the medial aspect of the foot and decreased under the midfoot region. CONCLUSIONS: The results indicate that ankle ligament injuries, as well as surgical reconstructions by tenodeses, affect joint loading characteristics and may exacerbate joint degeneration. RELEVANCE: Excessive laxity of the ankle joint is considered a pre-arthrotic condition and is treated with various surgical procedures. Some of these procedures that utilize the tendon of the peroneus brevis have been shown to change joint kinematics. The aim was to evaluate joint loading characteristics and the potential danger of developing arthritis as a consequence of various tenodeses techniques. For this purpose, in vitro investigations are needed to directly determine intra-articular pressure measurements.
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Affiliation(s)
- D Rosenbaum
- Abteilung Unfallchirurgische Forschung und Biomechanik Universität Ulm-Klinikum, Ulm, Germany
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