Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, case series.

Juxta-articular myxoma of the knee

Juxta-articular myxoma is a benign lesion usually presenting as a slow-growing, well-circumscribed mass. Occasionally, however, the lesion grows rapidly and is poorly circumscribed, and it is this clinical presentation that arouses suspicion of malignancy. Furthermore, on histology a myxoma can also be confused with a variety of sarcomas. We present a case of juxta-articular myxoma and discuss the possible diagnostic dilemmas involved.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, conservative or surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010.

SELECTION CRITERIA

All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).

AUTHORS' CONCLUSIONS

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

Interventions for treating chronic ankle instability

BACKGROUND

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.

OBJECTIVES

To compare different treatments, conservative or surgical, for chronic lateral ankle instability.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles, all to February 2010.

SELECTION CRITERIA

All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible.Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials.Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).

AUTHORS' CONCLUSIONS

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

Arthroscopic capsular shrinkage for chronic ankle instability with thermal radiofrequency: prospective multicenter trial

The study was designed as a prospective multicenter longitudinal trial. Adult patients with symptomatic mechanical chronic ankle instability, not improving with conservative therapy, were included and underwent surgery. Primary outcome measures were radiological and manually tested mechanical laxity. Secondary outcome measures were number of complications, reoperations and symptoms, range of motion, and functional (ankle) scores (Karlsson and SF-36 score). The latest follow-up was 9 months for each patient. Thirty-nine patients underwent surgery (19 male patients; 16 right ankles; median age, 27 years). Mechanical stability showed no clinically relevant improvement whereas most secondary outcome measures showed a substantial and statistically significant improvement. One surgery-related complication occurred without functional consequences, and 3 patients underwent a secondary procedure. One was considered a treatment failure, requiring an open anatomic ligament reconstruction. The second patient sustained a severe supination trauma by starting intensive training too early, also requiring an open anatomic reconstruction. The third patient had posterior ankle pain, which was successfully treated by posterior ankle arthroscopy. Arthroscopic thermal capsular shrinkage of the ankle is a safe procedure, leading to resolution of symptoms in the majority of patients with chronic ankle instability.

Treatment of subtrochanteric nonunions

The purpose of this retrospective study was to evaluate our results of treating subtrochanteric nonunions with a (AO/ASIF) blade plate. We treated a total of 32 patients (33 hips) with a subtrochanteric nonunion with a blade plate. Outcome measures were time to healing, complications after the index-operation and the Merle d'Aubigne hip score at follow-up. Union was achieved in 32 of the 33 hips after an average of 5 months. Complications were seen in nine patients (nine hips); five complications required re-intervention and four minor complications were treated conservatively. According to the Merle d'Aubigne hip score, 10 patients were rated as excellent, 15 as good and 7 as fair. This study shows that treatment of a subtrochanteric nonunion with a blade plate consistently leads to bony union with a good to excellent hip score in the vast majority of the patients (25 out of 33 hips).