Chronic ankle instability: Current perspectives

Bröstrom Repair Review

Since its introduction in 1966, the Bröstrom repair has been the workhorse for the treatment of chronic ankle instability. The procedure has expanded with the advent of arthroscopy, ultrasound, and other techniques. Because chronic ankle sprains/instability pose a barrier to athletes who perform high-level activities for a living, discussions concerning postoperative recovery and return to play criteria are important. Here we present an update on the Bröstrom-Gould procedure from preoperative management to return to play.Level of Evidence: Level V.

Treatment of Chronic Ankle Instability in the Military Population: A Systematic Review

BACKGROUND

The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare and evaluate chronic ankle instability treatment strategies in the military population.

METHODS

Electronic databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews guidelines for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports.

RESULTS

Eight studies met the inclusion criteria, representing 695 military service members-625 males (89.9%) and 70 females (10.1%)-and 4 treatment strategies: Broström-related procedures, modified Watson-Jones procedure, Colville's technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of satisfactory outcomes was 100% for Colville's technique, and ranged from 73.2% to 94.7% for Broström-related procedures and 72% to 80% for the modified Watson-Jones procedure. Mean American Orthopaedic Foot and Ankle Society scores, anterior drawer displacement, talar tilt, and visual analogue scale scores were also reported.

CONCLUSION

This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville's technique is another promising option for this patient population but would require additional studies to support this claim.

LEVELS OF EVIDENCE

Level IV.

Predictive Modeling for Functional Outcomes After All-Inside Arthroscopic Anterior Talofibular Ligament Repair of Chronic Ankle Instability

BACKGROUND

Arthroscopic anterior talofibular ligament repair (AATFLR) is a surgical strategy to treat chronic ankle instability (CAI) patients. This study identified risk factors that influenced the functional outcomes of AATFLR for CAI and developed prognostic nomogram for predicting functional outcomes in future AATFLR cases.

METHODS

Patients undergoing AATFLR from January 2016 to June 2022 with at least 10 months of follow-up were included in the study. The Karlsson Ankle Functional Score (KAFS) was evaluated preoperatively and at last follow-up visit. A total of 15 potential predictors including age, sex, body mass index, side affected, time from injury to surgery, sports-related injury, osteophyte, loose bodies, distal tibiofibular syndesmosis, ATFL avulsion fracture, Outerbridge classification of osteochondral lesions, postoperative immobilization method, ambulation time, walking time, and follow-up time, were recorded. We first used univariate binary logistic regression analysis to select the potential significant prognostic features, which were then subjected to the least absolute shrinkage and selection operator (LASSO) regression algorithm for final feature selection. A nomogram based on the regression model was developed to estimate the functional outcomes of patients. Models were validated internally using bootstrapping and externally by calculating their performance on a validation cohort.

RESULTS

Overall, 200 ankles fit inclusion criteria. Of these 200, a total of 185 (92.5%) ankles were eligible and divided into development (n = 121) and validation (n = 64) cohorts. Four predictors were ultimately included in the prognostic nomogram model: age, sex, sports-related injury, and postoperative immobilization method.

CONCLUSION

We found in our cohort that the significant predictors of poorer functional outcomes of AATFLR were postoperative immobilization with lower-leg cast, female sex, non-sports-related ankle sprain, and increasing age. Prognostic nomograms were created.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery

BACKGROUND

Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments.

METHODS

A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention.

RESULTS

Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months.

CONCLUSION

The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

High Prevalence of Musculoskeletal Disorders Among Dental Professionals: A Study on Ergonomics and Workload in Yemen

BACKGROUND Dentists frequently have work-related musculoskeletal disorder (MSD) diseases, which are the profession's second most common cause of disability. Awareness of dental ergonomics is necessary for controlling MSDs associated with dental workload. Dental professionals need additional training in dental ergonomics to reduce serious complications associated with dental workload. This questionnaire-based study aimed to evaluate the understanding of physical ergonomics and musculoskeletal disorders in 310 dental health professionals and students in Yemen. MATERIAL AND METHODS This was a cross-sectional study was conducted among 400 dental professionals working in various clinics and universities in Sana'a City, Yemen. They received a self-administered questionnaire that was developed from earlier studies. Five sections made up the questionnaire. The first section of the survey included questions about sex, age, and clinical professions; the second section focused on ergonomic awareness; the third section asked about work conditions; the fourth section asked about the prevalence of musculoskeletal disorders; and the fifth section asked about interventions used. Data were analyzed using SPSS version 25.0, and a P value of ≤0.05 was considered significant. RESULTS Only 310 questionnaires were completed. The participants'; level of understanding of ergonomics was low. One-way ANOVA showed a significant portion of respondents reported having MSDs, and they frequently reported pain related to workload. The neck, lower back, upper back, and shoulders experienced the highest levels of pain. CONCLUSIONS The prevalence of MSDs was high among dental professionals, especially in the lower back, upper back, and shoulder. This necessitates preventive measures like ergonomic positions, ergonomic equipment, regular exercise, and work breaks.

Imaging of osteoarthritis from the ankle through the midfoot

Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.

Brace for Impact: A Retrospective Analysis of the Modified Broström-Gould Procedure With and Without Internal Brace Augmentation

Background Chronic lateral ankle instability (CLAI) is caused by lateral ankle ligament weakness or rupture secondary to recurrent sprains. The surgical management has traditionally involved a modified Broström-Gould (MBG) procedure with or without internal brace (IB) augmentation. This study aims to demonstrate the improved outcomes for patients undergoing an MBG procedure with IB augmentation for CLAI. Methodology A retrospective analysis was performed among 40 patients undergoing an MBG procedure with or without IB for CLAI at a large teaching hospital between January 2012 and June 2019. Functional outcomes were measured using the Manchester-Oxford Foot Questionnaire (MOxFQ). Clinic letters were reviewed to assess additional outcomes including postoperative complications, revision surgery rate, time in a plaster cast, and time to full weight-bearing. Results A total of 23 patients were included in the study, with seven undergoing both MBG and IB procedures and 16 undergoing MBG intervention alone. The average age was 37.1 years in the IB group and 35.7 years in the MBG group. The mean MOxFQ overall raw scores (10.9 vs. 33.6, p < 0.016), standing and walking MOxFQ subscale (4 vs. 15.2, p < 0.012), pain MOxFQ subscale (4.86 vs. 10.9, p < 0.042), and social interaction subscale (2 vs. 7.5 p < 0.023) all showed significantly better results for the IB group versus the MBG group. Patients in the IB group had significantly less number of weeks in plaster than the MBG group and were able to fully weight bear sooner (4.14 vs. 6, p < 0.01). The MBG group suffered a postoperative complication in seven patients compared to zero in the IB group (p < 0.057). There were three re-ruptures in the MBG group requiring further revision surgery compared to zero in the IB group (3 vs. 0, p < 0.53). Conclusions MBG surgery with IB augmentation for CLAI appears to have better outcomes in terms of overall function and may have fewer overall complications. The IB group displayed a lower recurrence of pain, less time in a plaster cast, and a quicker return to walking.

Anteromedial Impingement in Chronic Lateral Ankle Instability: A Comparison of MRI and Arthroscopic Findings

Introduction Chronic lateral ankle instability (CLAI) is a known complication of ankle sprains, most commonly involving injury to the anterior talofibular ligament (ATFL). Growing evidence has shown an association between anteromedial (AM) impingement and CLAI. The purpose of this paper is to compare magnetic resonance imaging (MRI) with arthroscopic findings for the incidence of AM impingement in CLAI. Methods A retrospective study was performed by analyzing the radiological and operative reports of all patients who underwent an arthroscopic Broström-Gould procedure for CLAI between 2021 and 2022 at Changi General Hospital, Singapore. All patients who had a pre-operative MRI ankle scan performed and mention of the presence or absence of AM impingement in the operative notes were included in this study. Patients with concomitant fractures or systemic conditions affecting the same ankle were excluded. Results Ninety-seven patients were included in this study, 65 males and 32 females; 6.2% (6 of 97) of patients had a suggestion of AM impingement based on MRI findings, and 77.3% (75 of 97) of patients were noted to have AM impingement based on arthroscopic findings. Conclusion There is a high incidence of AM impingement associated with CLAI. AM impingement is often missed based on MRI findings. Arthroscopic Broström should be considered to address both issues of AM impingement and CLAI in the same setting.

Rehabilitation of a lateral ankle reconstruction in a male professional football player - A narrative case report

OBJECTIVES

Lateral ankle sprains involving the ATFL and CFL are common injuries in football with a high recurrence rate. There is a lack of research to guide post-operative rehabilitation of football players following lateral ligament ankle reconstructive surgery. This narrative case report discusses the management of a lateral ligament reconstruction in a male professional football player.

METHODS

A 25-year-old professional footballer underwent a lateral ankle reconstruction following recurrent lateral ankle sprains leading to an unstable ankle.

RESULTS

Following 11-weeks of rehabilitation the player was cleared to return to full-contact training. The player competed in his first competitive match 13-weeks post-injury and completed a 6-month full-training block, without episodes of pain or instability.

CONCLUSION

This case report illustrates the rehabilitation process of a football player following a lateral ankle ligament reconstruction within a timeframe expected in elite sport.

Lower Extremity Muscle Activation during the Star Excursion Balance Test in Patients with Chronic Ankle Instability and Copers

Background and Objectives: The aim of this study was to assess the impact of ankle muscles on performance of the Star Excursion Balance Test (SEBT) among individuals with stable ankles, a history of ankle sprain, and chronic ankle instability (CAI). Materials and Methods: Sixty subjects (twenty per group) performed the SEBT in each of the anterior (A), posteromedial (PM), and posterolateral (PL) directions. Normalized maximum reach distance (NMRD) and normalized mean amplitude of the tibialis anterior (NMA_TA), fibularis longus (NMA_FL), and medial gastrocnemius (NMA_MG) were measured during performance of the SEBT. Results: Copers have greater NMRD than subjects with stable ankles and those with CAI, and subjects with stable ankles also have greater NMRD than those with CAI in only the PL direction. Subjects with stable ankles and those with CAI showed greater NMA_TA than copers. The A direction showed greater NMA_TA than the PM and PL directions. Copers showed greater NMA_FL than subjects with stable ankles. Subjects with CAI showed greater NMA_MG than copers and subjects with stable ankles. The A and PL directions showed greater NMA_MG than the PM direction. Conclusions: Overall, copers and/or subjects with CAI demonstrated altered neuromuscular function by compensating for their ankle muscles when compared to subjects with stable ankles due to a history of ankle sprain.

Outcomes of a novel all-inside arthroscopic anterior talofibular ligament repair for chronic ankle instability

PURPOSE

This study aimed to introduce a novel all-inside arthroscopic anterior talofibular ligament (ATFL) repair for chronic ankle instability (CAI) with a knotless suture anchor technique-Hugging Repair, evaluate clinical outcomes, and analyze the associated risk factors.

METHODS

A total of 84 patients (42 males and 42 females, mean age: 36.1 ± 11.2 years, range: 19-68 years) who underwent Hugging Repair from January 1, 2016 to December 31, 2018, were enrolled in this retrospective study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), Foot and Ankle Outcome Score (FAOS), Tegner score, and Numerical Rating Scale (NRS) were evaluated pre-operatively and at final follow-up. The potential risk factors such as age, body mass index (BMI), sex, post-injury duration (time from injury to surgery), follow-up time, number of anchors, concomitant injuries [e.g., osteochondral defects (OCD), sinus tarsi syndrome (STS), anterior ankle impingement (AAI)], first-time treatment, and number of ankle sprains were also analyzed through multiple regression analysis.

RESULTS

There were 68 (81%) patients followed up for a mean time of 42 (range: 35-50) months. The median AOFAS score increased from 65 (35-72) to 90 (77-100), KAFS increased from 64 (38-71) to 90 (62-100), FAOS increased from 68 (50-70) to 97 (68-100), Tegner score increased from 1 (1-3) to 4 (2-7), and NRS increased from 3.5 (2-5) to 1 (0-3). No correlation was found between the functional scores and risk factors mentioned above. In the multivariate model, age was significantly negatively associated with KAFS, FAOS, and Tegner activity scale (P = 0.013; P = 0.002; P = 0.000); female was significantly associated with poorer Tegner activity scale (P = 0.004); and the presence of concomitant injuries was significantly negatively associated with AOFAS score (P = 0.033).

CONCLUSION

The novel all-inside arthroscopic ATFL repair for CAI with a knotless suture anchor technique-Hugging Repair is a safe and suitable technique that achieves satisfactory clinical outcomes and provides an effective option for the treatment of CAI. Risk factors for patients who underwent all-inside ATFL repair were older age, female sex, and concomitant injuries.

Peroneal muscle activity during stable and unstable load exercises. A cross-sectional study

OBJECTIVE

To evaluate the muscle activity of the peroneus longus during the execution of different unstable load exercises compared to stable load exercises.

DESIGN

Cross-sectional study.

SETTING

Functional Anatomy Laboratory.

PARTICIPANTS

28 healthy athletes.

MAIN OUTCOME MEASURES

Surface electromyography (sEMG), unstable load (water tank), Stable Load (Sandbag), type of exercise (Isometric single leg stance, single-leg Romanian deadlift, front rack forward lunge and lateral lunge).

RESULTS

The repeated measures ANOVA revealed significant Group ∗ Time interaction in Root Mean Square (RMS) (F = 51.307, P < 0.001, ŋ² = 0.70). In the between-group analysis there were statistically significant differences in RMS isometric single leg stance in favor to unstable load (P < 0.001, ŋ² = 0.07). In the within-group analysis of RMS statistically significant differences were found in the stable load group between isometric single leg stance and single-leg Romanian deadlift (P < 0.001, ŋ² = 0.05).

CONCLUSIONS

Single leg stance exercise with unstable load showed higher peroneus muscle activity than stable load. However, no peroneus muscle activity differences were found between unstable and stable loads for single-leg Romanian deadlift, frontal rack forward lunge and lateral lunge. Single-leg Romanian deadlift with stable load showed higher peroneus muscle activity than isometric single leg stance with stable load.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults

BACKGROUND

Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability.

METHODS

A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine.

RESULTS

Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization.

CONCLUSION

Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

A protocol for a randomized clinical trial assessing the efficacy of hypertonic dextrose injection (prolotherapy) in chronic ankle instability

BACKGROUND

Lateral ankle sprain (LAS) is a common injury. Conservative care is not uniformly effective. Chronic ankle instability (CAI) results in up to 70% of patients with LAS in the physically active population. LAS, together with subsequent osteochondral lesions and pain in many patients, leads to the development of post-traumatic osteoarthritis, resulting in a substantial direct and indirect personal and societal health burden. Dextrose prolotherapy (DPT) is an injection-based therapy for many chronic musculoskeletal conditions but has not been tested for CAI. This protocol describes a randomized controlled trial to test the efficacy of DPT versus normal saline (NS) injections for chronic ankle instability (CAI).

METHODS AND ANALYSIS

A single-center, parallel-group, randomized controlled trial will be conducted at a university-based primary care clinic in Hong Kong. A total of 114 patients with CAI will be randomly allocated (1:1) to DPT and NS groups. The primary outcome will be the Cumberland Ankle Instability Tool scores at 1 year. The secondary outcomes will be the number of re-sprains in 1 year, the Star Excursion Balance Test, the 5-level of EuroQol 5-dimension questionnaire, and the Foot and Ankle Ability Measure. All outcomes will be evaluated at baseline and at 16, 26, and 52 weeks using a linear mixed model.

DISCUSSION

We hypothesized the DPT is a safe, easily accessible, and effective treatment for patients with CAI. This RCT study will inform whether DPT could be a primary non-surgical treatment for CAI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000040213 . Registered on 25 November 2020.

Prevalence of ankle instability in performers of Chinese classical dance: a cross-sectional study of 105 Chinese dancers

Objectives

Foot and ankle injuries are commonly seen in dancers, yet limited studies exist on the injury prevalence of performers of Chinese classical dance. This study aims to determine and assess the prevalence of chronic ankle instability (CAI) in Chinese dancers and correlate the impact of CAI with foot function.

Methods

This is a cross-sectional study of 105 Chinese dancers. CAI was assessed using the Cumberland Ankle Instability Tool and foot function via the Foot and Ankle Outcome Score (FAOS). Both self-reported assessment tools were distributed online between January and February 2021. Subjects were divided into CAI and healthy groups to observe any correlations in demographics, training hours and foot function.

Results

CAI was seen in 28% of Chinese dancers, with most being unilateral instability. The number of training hours, level of expertise, occupation, gender and age showed no statistical significance with CAI. The FAOS showed that subjects with CAI had significantly greater pain and poorer quality of life.

Discussion and conclusion

CAI is a problem affecting 28% of performers of Chinese dance. Future research should investigate the ankle biomechanics in Chinese dance and specific risk factors for CAI to formulate strategies to prevent ankle injuries in Chinese dancers.

Effect of Joint Mobilization in Individuals with Chronic Ankle Instability: A Systematic Review and Meta-Analysis

Sensorimotor and range of motion deficits due to chronic ankle instability (CAI) are abnormalities of the movement system that make postural control difficult. This review aimed to quantify the effect of joint mobilization on the range of motion, dynamic balance, and function in individuals with CAI. Randomized controlled trials in which joint mobilization was performed in individuals with CAI were searched for in five international databases (CENTRAL, CINAHL, Embase, MEDLINE, PEDro). Qualitative and quantitative analyses were performed using the risk of bias tool and RevMan 5.4 provided by the Cochrane Library. Nine studies with 364 individuals with CAI were included in this study. This meta-analysis reported that joint mobilization showed significant improvement in the dorsiflexion range of motion (standardized mean difference [SMD] = 1.02, 95% confidence interval [CI]: 0.41 to 1.63) and dynamic balance (SMD = 0.49, 95% CI: 0.06 to 0.78) in individuals with CAI. However, there was no significant improvement in function (patient-oriented outcomes) (SMD = 0.76, 95% CI: -0.00 to 1.52). For individuals with CAI, joint mobilization has limited function but has positive benefits for the dorsiflexion range of motion and dynamic balance.

A new mouse model of ankle instability induced by multiple mechanical sprains with controlled inversion angle and speed

Ankle sprain occurs by a sudden and extreme inversion and plantarflexion at the ankle joint to cause ligamentous injuries. A portion of ankle sprain patients experience recurrent ankle sprains and develop chronic ankle instability (CAI). The present CAI animal models are single events with severe ligamentous injury using surgical transection of ligaments or manually overextending the ankle.

Purpose: To simulate the mechanical and recurrent sprain injuries in CAI patients, we established a new ankle instability model with multiple ankle injuries using a self-designed machine to sprain the ankle with a controlled inversion angle and speed.

Methods: Male C57BL/6J mice were used and respectively subjected to a sham operation, calcaneofibular ligament (CFL) transection, and mechanical ankle sprains. Three mechanical sprains were performed on the 13th and 185th day after the initial mechanical ankle sprain.

Results: The first mechanical sprain and CFL transection induced ankle injury as indicated by an average of a 62% decrease in ankle pressure pain threshold and a 114% increase in the ankle thickness compared with the contralateral untreated ankle. The second and third mechanical sprains induced recurrent ankle injuries. The foot slips during beam tests were increased after mechanical ankle sprains but not after CFL transection, indicating the induction of motor balance deficits. Multiple mechanical ankle sprains induced significant gait changes in longer duration of stance (an average of 194% increase), swing (134%), and step cycle (147%) compared with CFL transection or sham operation, and slower walking speed (78% reduction) and shorter step distance (91%) after the third sprain.

Conclusion: These results elucidate that multiple mechanical sprains, which induce recurrent ankle injuries, balance deficits, and gait changes, are a good model for investigating the mechanisms of CAI induced by recurrent sprain injuries.

Current concepts in the surgical management of chronic ankle lateral ligament instability

Background/aims

Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI).

Methods

The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI.

Results

Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes.

Conclusion

Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Comparison of Modified Broström Procedure with or without Suture Tape Augmentation Technique for the Chronic Lateral Ankle Instability

Purpose

To compare the clinical outcomes of the modified Broström repair (MBR) with or without suture tape augmentation (STA) for managing the chronic lateral ankle instability.

Methods

72 patients with chronic lateral ankle instability treated at our hospital from January 2018 to July 2019 were included, with 37 patients receiving the MBR and 35 treated by the MBR with STA. The clinical efficacy of the two techniques was assessed in terms of VAS, AOFAS, and Karlsson scores and by physical examination in follow-ups.

Results

In all 72 patients, operations were successful, and the patients were followed up for 29.3 months on average (range, 24-43 months). There were no significant differences in preoperative pain, AOFAS, and Karlsson scores between the two groups. Compared with preoperative findings, all the functional scores were significantly improved in both groups 3 months after the operation and at the last follow-up. Three months after the operation, the STA group had significantly lower VAS and higher AOFAS scores than the isolated MBR group, suggesting that patients in the STA group suffered less pain and achieved better functional improvement. However, the VAS and functional scores at the last follow-up and the Karlsson score at 3 months postoperatively showed no intragroup difference in both groups.

Conclusion

MBR with or without STA could achieve good results for the treatment of chronic lateral ankle instability. Compared with the widely used MBR, combining with STA may be more effective in promoting rehabilitation in early term.

Epidemiology of Ankle Sprain in the Active-Duty Military Population

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Ankle sprain is one of the most prevalent injuries within the military population, resulting in health-care costs, time away from active duty, and negative impacts on overall readiness.

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Female service members appear to be more likely to sustain ankle sprains than male service members.

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There is a need for additional research on prevention methods and rehabilitation programs for ankle sprains in the military population because the rate of ankle sprain in this population exceeds that in populations with less physically demanding lifestyles. Consequently, low-cost prevention strategies could yield substantial benefits.

Modified Broström With and Without Suture Tape Augmentation: A Systematic Review

The Modified Broström has become the gold standard for operative management of chronic lateral ankle instability. Despite overall good clinical outcomes with this procedure, recent biomechanical data have called into question the strength and durability of this technique. Accordingly, the addition of suture tape to the Modified Broström construct has been described in an attempt to more closely recreate the natural biomechanical properties of the ankle lateral ligament complex. We performed a systematic review of the literature was using PubMed, Embase, and CINAHL to identify English-language articles from 2009 to present discussing outcomes with the augmented Modified Broström technique. A total of 4 studies (2 retrospective cohort studies, 2 case series) involving 156 patients with Modified Broström with augmentation met inclusion criteria. Average follow-up time was 13.8 months. Of the 3 studies reporting patient-reported outcome measures both pre- and postoperatively, there was a significant improvement in all measures (p < .05). Two studies compared the Modified Broström directly with and without augmentation, one of which found a statistically significant difference in the Foot and Ankle Ability Measure in favor of the augmentation group (93.1 vs 90.5, p = .027), while American Orthopaedic Foot and Ankle Society score was not significantly different (p > .05) between the 2 procedures across studies. There were no significant differences in complications between techniques. Modified Broström with suture tape augmentation for chronic lateral ankle instability can produce good short-term clinical outcomes with few complications, comparable to the Modified Broström alone.

Ligamentous injury-induced ankle instability causing posttraumatic osteoarthritis in a mouse model

BACKGROUND

This study aims to explore the relationship between surgically-induced ankle instability and posttraumatic osteoarthritis (PTOA) in a mouse model, and to provide reference for clinical practice.

RESULTS

Ligamentectomy was performed on 24 eight-week-old male C57BL/6 J mice, which were divided into three groups. Both the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) were severed in the CFL + ATFL group, while only the CFL was removed in the CFL group. The SHAM group was set as the blank control group. A wheel-running device was used to accelerate the development of ankle osteoarthritis (OA). Balance measurement, footprint analysis, and histological analysis were used to assess the degree of ankle instability and OA. According to the balance test results, the CFL + ATFL group demonstrated the highest number of slips and the longest crossing beam time at 8 weeks postoperatively. The results of gait analysis exhibited that the CFL + ATFL group had the most significant asymmetry in stride length, stance length, and foot base width compared to the CFL and SHAM groups. The OARSI score of the CFL + ATFL group (16.7 ± 2.18) was also much higher than those of the CFL group (5.1 ± 0.96) and the SHAM group (1.6 ± 1.14).

CONCLUSION

Based on the mouse model, the findings indicate that severe ankle instability has nearly three times the chance to develop into ankle OA compared to moderate ankle instability.

Resultados de uma técnica modificada de reconstrução assistida por artroscopia para instabilidade lateral do tornozelo

Objective  The present study assesses the results of a minimally invasive surgical technique for acute and chronic ankle instability management.

Methods  The present case series study retrospectively evaluated 40 patients undergoing arthroscopic-assisted percutaneous ankle ligament reconstruction from 2013 to 2019.

Results  The present study included 17 males and 23 females with an average age of 38.3 years old. Postintervention follow-up using American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores identified improvement of > 30 points in function and pain control. The most frequently occurring associated injuries were osteochondral (35%). No patient required reintervention or had infection during follow-up.

Conclusion  The technique in the present study is easy and achieves satisfactory results for function and pain control.

Level of Evidence IV.

Influence of invertor and evertor muscle fatigue on functional jump tests and postural control: A prospective cross-sectional study

OBJECTIVE

Fatigue of the ankle's stabilizing muscles may influence the performance of functional activities and postural control. The purpose of this study was to evaluate the performance of healthy young adults using functional jump tests and static posturography control under pre- and post-fatigue conditions of the ankle invertor and evertor muscles.

METHODS

Thirty physically active healthy male and female (15 male and 15 female) volunteers (24.3 years) were enrolled in this prospective cross-sectional study. Participants performed tests on one day under a non-fatigued state of invertor and evertor muscles and on the second day in a fatigued state. Tests included static posturography on a force platform in a bipedal stance with eyes open and closed and in one-legged support with eyes open and functional jump tests (figure-of-8, side hop, 6-m crossover hop, and square hop). Fatigue of the ankle invertor and evertor muscles was induced using isokinetic dynamometry with 30 repetitions at 120°/s.

RESULTS

Participants had an average age of 24.3 years (SD ± 2.08), the height of 1.73 m (SD ± 0.08), and a weight of 68.63 kg (SD ± 10.29). The average Body Mass Index (BMI) was 22.88 (SD ± 2.46). A decrease in performance was observed in functional activities and postural control under all conditions after the induction of muscle fatigue, except for the speed at a bipedal stance with eyes open.

CONCLUSIONS

Functional jump tests are low cost and useful for clinical practice and evaluation of the effects of muscle fatigue and could be used in clinical practice.

Sex-Specific Differences Following Lateral Ankle Ligament Repair

BACKGROUND

Chronic ankle instability is a common condition that can be treated with lateral ankle ligament repair. These procedures have a reported success rate greater than 85% in the literature, but little has been reported about the differences in postoperative outcomes between males and females. The purpose of this study was to evaluate sex-specific outcomes following lateral ankle ligament repair.

METHODS

In this systematic review and meta-analysis, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to search for articles on electronic databases and included studies in which study participants underwent primary lateral ligament repair and sex-specific outcomes were evaluated. Functional postoperative outcomes for males and females were recorded and statistically analyzed.

RESULTS

Out of 2768 studies, 7 (0.25%) met inclusion criteria and were analyzed in this review. These studies included 618 patients (402 males [65%] and 216 females [35%]) who underwent primary lateral ligament repair for ankle instability. Karlsson score (P = .1582) and American Orthopaedic Foot & Ankle Society (AOFAS) score (P = .1586) analyses found no statistically significant difference between males and females. Postoperative success rate-defined as a "good" or "excellent" Karlsson score (>81)-was not found to be significantly different between males and females (P = .9374).

CONCLUSION

There was no difference in postoperative mean Karlsson scores, AOFAS scores, or success rates between males and females who underwent primary lateral ankle ligament repair.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Differences in the locomotion biomechanics and dynamic postural control between individuals with chronic ankle instability and copers: a systematic review

An empirical consensus of differences between chronic ankle instability (CAI) individuals and copers (individuals who sprained ankle once and without recurrent symptoms or injury) has not been reported. This study aimed to review the locomotion biomechanics and dynamic postural control between these two populations. Database of ScienceDirect, PubMed and Web of Science was used to search ('chronic ankle instability' OR 'ankle instability') AND ('ankle sprain' OR 'coper*') until 30 November 2020. Articles that made a comparison about changes in biomechanical parameters between Copers and CAI individuals during locomotor or functional tasks were included in this review. Twenty-three articles met the inclusion criteria. CAI individuals exhibited an increased hip flexion to maintain stability, suggesting the adopted hip strategy compared to copers during landing. Dorsiflexion angle and ankle frontal displacement increased considerably compared to copers, which might increase risks of lateral ankle sprain injury. CAI individuals reduced the ankle displacements in the sagittal plane and indicated worse performance of Star Excursion Balance Test in the posterior-lateral direction compared to copers. Identified motion deficits or altered motion strategies provide opportunities for targeted intervention and scheme after index sprain or in CAI individuals.

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.

The fibula and talus position difference in functional and mechanical ankle instability: MRI findings

PURPOSE

This study aimed to use MRI to evaluate the fibula and talus position difference in functional and mechanical ankle stability patients.

METHODS

61 and 68 patients with functional and mechanical instability, and 60 healthy volunteers were involved. Based on the axial MRI images, the rotation of the talus was identified through the Malleolar Talus Index (MTI). The position relative to the talus (Axial Malleolar Index, AMI) and medial malleolus (Intermalleolar Index, IMI) were used to evaluated the displacement of the fibula.

RESULTS

Post hoc analysis showed that the values of malleolar talus index was significantly larger among mechanical instability (89.18° ± 2.31°) than that in functional instability patients (86.55° ±61.65°, P < 0.001) and healthy volunteers (85.59° ± 2.42°, P < 0.001). The axial malleolar index of the mechanical instability patients (11.39° ± 1.41°) were significantly larger than healthy volunteers (7.91° ± 0.83°) (P < 0.0001). There were no statistically significant differences in the above three indexes between the functional instability patients and healthy volunteers.

CONCLUSION

The functional instability patients didn't have a posteriorly positioned fibula and an internally rotated talus. The malleolar talus index was significantly larger among mechanical instability patients than that in functional instability patients. Increased malleolar talus index may become a new indirect MRI sign for identifying functional and mechanical instability patients.

Traditional Modified Broström vs Suture Tape Ligament Augmentation

BACKGROUND

The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB.

METHODS

Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm.

RESULTS

Average RTPAL was 17.5 weeks after MB and 13.3 weeks after ST (P < .001). At 26 weeks, 12.5% of patients in the MB group and 3.6% of patients in the ST group had not managed RTPAL (P = .14). The complication rate was 8.5% in the MB group vs 1.7% in the ST group (P = .12). Four patients in the MB group failed to complete the ARP vs 1 in the ST group (P = .144).

CONCLUSION

Results from this multicenter, prospective, randomized trial suggest that ST augmentation allows for earlier RTPAL than MB alone. ST augmentation may support successful accelerated rehabilitation and did not result in increased complications or morbidity.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Using arthroscopy combined with fluoroscopic technique for accurate location of the bone tunnel entrance in chronic ankle instability treatment

Background

Minimally invasive reconstruction techniques are used for anatomical ligament construction of the lateral collateral ligament complex of the ankle, but the two key elements, the bone tunnel and the appropriate graft tension, for the identification of the anatomic location during the surgery are not clearly stated.

Methods

The patients with chronic ankle instability who received arthroscopic anatomic lateral ligament complex reconstruction were retrospectively analyzed. The anatomical location of the bone tunnel was performed under arthroscopy combined with fluoroscopy for accurate location of the bone tunnel entrance. The graft tension and routing were controlled under arthroscopic visualization. The clinical outcomes were assessed using the Karlsson-Peterson score, Sefton articular stability scale, and Visual Analogue Scale (VAS). The complications were recorded during the follow-up.

Results

A total of 18 patients were enrolled in this study. The mean follow-up was 33.33 ± 3.69 (range from 24 to 36) months. No patient had recurrence of ankle instability after the operation. According to the Sefton articular stability scale, 94.5% of the patients had excellent/good function. The mean value of the anterior drawer tests and the talar tilt angle examination were decreased. The mean of the Karlsson-Peterson score and the Visual Analogue Scale(VAS) score were both improved significantly.

Conclusions

The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopy combined with the fluoroscopic technique could improve the clinical functions, satisfaction, and reduced pain of patients.

Cross-education effect of balance training program in patients with chronic ankle instability: A randomized controlled trial

Chronic ankle instability (CAI) is frequently developed due to failure of the functional rehabilitation after acute ankle sprain. So, there is a need for an alternative way by which we can begin neuro-muscular control retraining sooner.

PURPOSE

This study was conducted to examine the effect of 6-week Single-limb Balance Training Program of the non-affected side on the Overall Stability Index (OASI), Antero-Posterior Stability Index (APSI), and the Medio-Lateral Stability Index (MLSI) of the affected side in females with unilateral CAI.

METHODS

Thirty-two female patients with CAI with mean age 20.96 ± 1.69 years participated in this study. They were randomly assigned into three groups: experimental group A (Cross-Education) (n = 11) performed the exercises for the non-affected side, experimental group B (Traditional Training) (n = 11) performed the exercises for the affected side, and Control group C (n = 10) did not perform any exercises. The randomization was done using statistical random tables. Data were collected using the Biodex Balance system before and after training.

RESULTS

Two-way mixed design MANOVA revealed that there were significant improvements in the mean values of the OASI, APSI and MLSI after training (p < .05) in both the Cross-Education group (A) and Traditional Training group (B) with no significant difference in-between for the OASI, MLSI and APSI after training. There was no significant difference (p > .05) between the pre and post-training mean values of the OASI, MLSI and APSI in the Control group (C).

CONCLUSION

Single-limb balance training for the non-affected side is effective in improving the postural control of the affected side in patients with CAI.

Association between anterior talofibular ligament injury and ankle tendon, ligament, and joint conditions revealed by magnetic resonance imaging

Background

The lateral ankle ligament complex is the most frequently injured ligament secondary to strong ankle inversion movement during lateral ankle sprains (LAS). Among these injuries, anterior talofibular ligament (ATFL) injury is the most frequent condition (present in 66-85% of such injuries). The purpose of this research was to use magnetic resonance imaging (MRI) to determine the association between ankle tendon, ligament, and joint conditions and ATFL injuries.

Methods

A case-control MRI study was carried out to compare the presence of ankle muscle, tendon, ligament, and joint conditions in patients with injured ATFLs (case group; n=25) and non-injured ATFLs (control group; n=25).

Results

Achilles tendinopathy was present in 1/25 (4%) patients with injured ATFLs and 7/25 (28%) non-injured ATFL subjects (P=0.048). Injured calcaneofibular ligaments (CFLs) were present in 19/25 (76%) patients with injured ATFLs and 1/25 (4%) non-injured ATFL subjects (P<0.001). Finally, injured tibiotalar joints were present in 16/25 (64%) patients with injured ATFLs and 5/25 (20%) non-injured ATFL subjects (P=0.002). Other musculoskeletal structure injuries occurred at similar rates between patients with injured ATFLs and those with non-injured ATLFs (P≥0.05).

Conclusions

Patients with ATFL injuries showed a greater presence of CFL and tibiotalar joint injuries than subjects with non-injured ATFLs.

The "Ankle Instability Instrument": Cross-cultural adaptation and validation in French

BACKGROUND

Functional ankle instability affects 20-40% of individuals who have already suffered from a sprain. Such dysfunctions are difficult to diagnose. Therefore, the information provided by self-administered questionnaires is essential. Thus, the Ankle Instability Instrument (AII) was developed and initially validated in English. Our goal is to create a French version of the instrument, named AII-F, by scrupulously respecting the cultural adaptation phases and to make sure the new instrument has good psychometric properties.

METHODS

International recommendations have been rigorously followed for the cultural adaptation and the French-translation phase. Six steps are recommended: I) two initial translations from English to French; II) synthesis of the two versions; III) back-translations from French to English; IV) comparisons between the back-translations and the original questionnaire by the expert committee; V) pretest; and VI) approval of the final French version of the AII. In order to validate this French-translation, 91 subjects suffering from ankle instability matched to 91 healthy subjects were asked to complete the AII-F. The Short Form Health Survey (SF-36) was used as a comparative questionnaire as well as the French Cumberland Ankle Instability Tool (CAIT-F). The psychometric properties of the questionnaire were evaluated by determining the test-retest reliability after a 10-14-day interval, the internal consistency, construct validity, and the floor/ceiling effects.

RESULTS

The French-translation did not pose a problem and could be validated by the expert committee. The AII-F showed a very good test-retest reliability for the total score, with an Intra Class Coefficient of 0.983. The internal coherence is high with an alpha coefficient of Cronbach of 0.861. The association of the AII-F with the CAIT-F was high, for the summary of the physical component of the SF-36, meaning a great convergent validity. The other subscales of the SF-36 (mental health) were weakly correlated with the AII-F, reflecting good divergent validity. An optimal cut-off score was obtained to dissociate pathological patients from healthy subjects: when the subject responded to "yes" 5 times or more, he is considered, with a very high degree of confidence, to be pathological.

CONCLUSION

The AII-F is reliable and valid for evaluating and measuring functional ankle instability.

Effect of Novel Remodeled Bicycle Pedal Training on Balance Performance in Athletes With Functional Ankle Instability

Context

Appropriate training without risk of injury is a critical concern for athletes. Remodeled bicycle pedal training with multi-directional challenges may be effective in improving the balance performance of athletes with functional ankle instability (FAI).

Objective

To evaluate the effects of 6-week modified bicycle pedal training on the balance ability and proprioception of athletes with FAI.

Design

Randomized controlled trial.

Setting

University motion analysis laboratory.

Participants

Fourteen healthy athletes (healthy group) and twenty-six athletes with FAI and an age of 18 to 30 years old. The participants with FAI were randomly distributed to two groups, designated as the training group (AI-T group) and non-training group (AI-NT group), respectively. The athletes in the AI-T group received 6-week remodeled bicycle pedal training, while those in the AI-NT group received no intervention at all.

Intervention

A 6-week training using modified bicycle pedal capable of moving freely during loading cycle vs no intervention.

Main Outcome Measures

The passive ankle joint position sense (JPS) in four angles and the center of pressure (COP) parameters were analyzed during single-leg standing with and without vision, respectively.

Results

A 6-week remodeled pedal training: (1) significantly improved the passive JPS of ankle in all directions (P < 0.05); (2) reduced the excursion of the COP in the medial-lateral (ML) direction (p < 0.05), the velocity of the COP in the ML direction (p < 0.05), and the RMS of the COP in the ML direction (P < 0.05) during single-leg standing both with and without vision.

Conclusion

The remodeled bicycle pedal training improved the passive JPS and reduced the postural sway in single-leg standing both with and without vision. Therefore, remodeled bicycle pedal training can be considered for inclusion in rehabilitation programs for athletes with FAI to restore the proprioception and balance ability.

Open Brostrom for Lateral Ligament Stabilization

PURPOSE OF REVIEW

Lateral ankle ligament sprains are one of the most commonly reported injuries in high-level athletes and the general population. Unfortunately, up to 40% of these can go on to develop chronic lateral ankle instability which in the right circumstances requires surgical intervention. The purpose of this review is to present the gold standard surgical treatment for chronic lateral instability with anatomic ligament repair and to highlight the techniques, outcomes, and importance of anatomy when considering surgical treatment.

RECENT FINDINGS

Recent and remote literature agrees that the initial treatment for chronic ankle instability is non-operative rehabilitation. In the cases where this fails, the gold standard of surgical treatment is open anatomic repair using the Brostrom-Gould technique which stands out as having very good results over the course of time. Recent studies have shown equally good outcomes with arthroscopy as well as with internal brace devices, and both techniques show potential for earlier rehabilitation. In those with contraindications for anatomic repair including innate soft tissue laxity, high BMI, and in the revision setting, anatomic ligament reconstruction is an appropriate surgical option. Open modified Brostrom lateral ligament repair continues to be the preferred method of surgical treatment for chronic lateral ligament instability. In the setting of new modifications and techniques, long-term outcome studies are necessary to identify both their usefulness in long term and to compare them to the open surgery outcomes. It would be useful to standardize rehabilitation protocols as well as return to sport metrics in order to better evaluate outcomes moving forward.

The comprehensive review of the neurovascular supply of the ankle joint: clinical implications

The rupture of ligament in the lateral part of ankle joint is a common injury and can lead to chronic ankle instability and lead to ankle osteoarthritis. Ankle arthroscopy is considered as a standard option to treat various ankle problems due to the need for only minimal incisions and fewer complications when compared to open surgery. However, there are complications associated with arthroscopic surgery e.g. damage to the anatomical structures around the portal placement areas. The present review provides anatomical knowledge of the superficial and deep neurovascular structures in the ankle region. These structures are important when ankle surgery is performed in order to avoid any intraoperative injury and prevent any complication following surgery.

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.

A New Individualized Three-Dimensional Printed Template for Lateral Ankle Ligament Reconstruction

Background

Anatomical reconstruction using a semitendinosus tendon autograft is one of the most widely-used techniques for chronic lateral ankle instability (CLAI), and it can result in good biomechanical recovery for patients. The purpose of this study was to investigate the outcome of a novel individualized three-dimensional printed guide template for lateral ankle ligament reconstruction compared with the traditional surgical methods.

Material/Methods

We retrospectively studied 34 patients with CLAI who required lateral ankle ligament reconstruction. Patients were randomly divided into 2 cohorts: the template group (18 patients) and the conventional group (16 patients). The average operation duration and number of radiation exposures were compared between the 2 cohorts. The displacement of anterior talar and talar tilt angle were recorded at the last follow-up, and Karlsson-Peterson score and American Orthopedic Foot and Ankle Society Score (AOFAS) were also compared.

Results

All patients had satisfactory ankle stability at the last follow-up. The average operation duration was 51.9±3.6 min and the average number of radiation exposures was 1.34±0.6 in the template group, and the average operation duration was 72.4±12.6 min and the average number of radiation exposures was 6.58±1.7 in the conventional group. Difference between the 2 cohorts was statistically significant. However, in AOFAS (95.2±2.5 vs. 94.9±2.2; P>0.01.) and Karlsson Score (94.7±3.6 vs. 93.8±4.1; P>0.01.), no significant differences were found between the 2 cohorts.

Conclusions

Both the template technique and the conventional method provided satisfactory outcomes for CLAI patients. However, the shorter operation duration and low number of radiation exposures in the template cohort suggest it is the better alternative for treatment of CLAI.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review

PURPOSE OF REVIEW

Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options.

RECENT FINDINGS

First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

Ultrasound-Guided Ankle Lateral Ligament Stabilization

PURPOSE OF REVIEW

Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

RECENT FINDINGS

To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Different Cleat Models Do Not Influence Side Hop Test Performance of Soccer Players with and Without Chronic Ankle Instability

The lateral ankle sprain is one of the most common sport injury, representing 10-30% of all musculoskeletal disorders. The lateral ankle sprain is induced by sport gestures involving changes of direction and landing manoeuvres and constitutes a risk factor for the occurrence of chronic ankle instability. Although cleat models and performance have been already explored, no study has evaluated this relationship in athletes with chronic ankle instability. Therefore, the purpose of the study was to analyse the influence of different soccer cleat models on Side Hop Test performance of athletes with and without chronic ankle instability. Thirty-nine athletes were divided into two groups, a chronic ankle instability group (n = 20) and a healthy group (n = 19). Each participant performed the Side Hop Test, executing 10 consecutive jumps on dry artificial grass with 4 cleat models. The Qualisys System and two force platforms were used to analyse the test runtime, the distance travelled and the mean velocity. No statistically significant interaction was observed between the group and the cleat model for all variables evaluated. In addition, no differences were observed between models or groups. In this specific test, performance does not seem to be influenced by different cleat models on dry artificial grass in athletes with and without chronic ankle instability.

Functional Results of Open Broström Ankle Ligament Repair Augmented With a Suture Tape

BACKGROUND

The Broström procedure is the most commonly used lateral ligament repair for chronic instability, but there is concern about the strength of the repair and the risk of reinjury. Currently, the InternalBrace^TM ligament augmentation repair is an accepted augmentation method for management of a Broström procedure. Our hypothesis was that augmentation of the Broström repair with an InternalBrace^TM would allow accelerated rehabilitation and return to activity and would aid in stability of the repair without a tendency to stretch.

METHODS

Eighty-one patients with lateral ankle instability procedures repaired with a Broström and InternalBrace^TM augmentation were evaluated at a one-time postoperative visit between 6 and 24 months. Outcomes included demographics, surgical time, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Veterans Rand 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), satisfaction, and objective clinical measurements. Eighty-one patients were analyzed including 30 males and 51 females. Median age was 34 years (range, 18-62 years) with a median return for follow-up of 11.5 months (range, 6-27 months).

RESULTS

Average postoperative VAS and satisfaction were 0.8 ± 1.4 and 9.1 ± 1.6, respectively. Mean return to sport (n = 68) was 84.1 days. Average AOFAS Ankle-Hindfoot score was 94.3. A score of 90 or higher on the FAAM Sports subscale was seen in 79.0% of the subjects. The single-leg hop test (Limb Symmetry Index %) showed that 86.4% of patients returned to normal or near normal function. The tape measure method and ankle dorsiflexion comparisons showed a significant difference: 9.2 ± 3.3 cm (operative side) and 10.4 ± 3.7 cm (contralateral side) ( P = .034). Ankle plantar flexion comparison (goniometer) was 48.5 ± 11.5 degrees (operative side) and 49.7 ± 11.9 degrees (contralateral side), showing no difference ( P = .506).

CONCLUSION

These results suggest that InternalBrace^TM augmentation of a Broström procedure is a safe and efficacious procedure that produces favorable outcomes in patients in terms of preventing recurrent instability in the ankle in the short term.

LEVEL OF EVIDENCE

Level IV, case series.

Clinical and magnetic resonance imaging assessment of anatomical lateral ankle ligament reconstruction: comparison of tendon allograft and autograft

PURPOSE

To compare the results of anatomical lateral ankle ligament (LAL) reconstruction with tendon allograft and autograft using clinical scores and ultrashort echo time (UTE) sequence of MRI.

METHODS

A total of 26 patients with LAL reconstruction were recruited in this study, including 16 using semitendinosus allografts and 10 using semitendinosus autograft. All of them were diagnosed as chronic ankle instability and accepted anatomic reconstruction. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, and radiological evaluation using MRI UTE scanning were extracted from each patient. The comparative analysis of the clinical assessments and UTE-T2* values were performed between the patients using autografts and allografts.

RESULTS

For the allograft group, the mean AOFAS score improved from 69.9 ± 13.3 to 94.8 ± 5.4 (P = 0.000), and the mean Karlsson score improved from 70.3 ± 12.2 to 93.8 ± 5.6 (P = 0.000). For the autograft group, the mean AOFAS score improved from 68.4 ± 10.0 to 94.7 ± 5.0 (P = 0.000), and the mean Karlsson score improved from 64.5 ± 14.4 to 95.0 ± 5.8 (P = 0.000). No significant differences were found between the allograft and autograft neither before (AOFAS P = 0.756, Karlsson P = 0.285) nor after (AOFAS P = 0.957, Karlsson P = 0.574) surgery. While the UTE T2* values in allograft were higher than those of autograft group both in anterior talofibular ligament (8.3 ± 1.0 vs 7.6 ± 1.1 P = 0.027) and intra-tunnel graft (7.8 ± 0.6 vs 7.2 ± 0.8 P = 0.045).

CONCLUSION

Both allograft and autograft reconstructions could get an ideal patient satisfaction and clinical functional outcomes at the follow-up. Higher T2* values were found in allograft group which indicated that autograft had some superiorities in respect of revascularization process, collagen structure, water content, and tendon properties.