Anatomic Ligament Reconstruction Research Articles

Which tendon graft to choose for anatomical ligament reconstruction in chronic lateral ankle instability? A biomechanical study

BackgroundThe need for anatomic lateral ligament reconstruction of the ankle continues to grow. This procedure usually requires a gracilis autograft or in some cases an allograft. Siegler et al. reported the mechanical characteristics of the collateral lateral ligaments of the human ankle: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL.The objective of this study was to evaluate the mechanical properties of different tendon grafts available for ATFL and CFL reconstruction. We hypothesized that the properties of the tested grafts are not inferior to the published values of those of the original ligaments on the lateral side of the ankle. MethodsThis was a comparative biomechanical study using 6 cadaver specimens (108 grafts): The biomechanical properties of nine types of grafts were determined using validated tensile testing methods: Gracilis, SemiT, EHL, FHL, Plantaris, Peroneus longus and brevis, TA and TP.The main outcome measure was the comparison of the mechanical properties of each single-stranded tendon with each other and with the known values ​​for the ATFL and CFL, during a uniaxial static rupture test. ResultsThe mean load to failure for the gracilis was 257.5 ± 52.9 N. The groups had similar mean values in terms of the maximum load that they could withstand before failing except for the plantaris (137.9 ± 33.7 N) which was statistically lower than all other tested tendons (p < 0,01).The mean load to failure values of the grafts tested were equal or higher than that of the ATFL and CFL reported by Siegler et al. [14]: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL, while the grafts tested here had mean failure load between 258 ± 53 N and 464 ± 136 N. ConclusionThe gracilis, peroneus longus/brevis, EHL, FHL, TA, TP and semiT are legitimate grafts for combined ATFL and CFL reconstruction in the ankle. These tendons have mechanical properties (load to failure, maximum strain at failure and stiffness) that are equal to or higher than the native ligaments on the lateral side of the ankle, except the plantaris. Clinical relevanceThis study validates the current use of the gracilis autograft for the anatomical reconstruction of the ATFL and CFL, and even provides proof that other tendons would be suitable for this anatomical reconstruction of the lateral ankle ligament by auto or even allograft under certain conditions. Level of evidenceDescriptive laboratory study.

Estimation of footprints of the canine stifle ligaments using deformable shape templates of bones

Knowledge regarding the ligament footprints in the canine stifle is essential for biomechanical modeling of the joint and patient-specific surgical planning for anatomical ligament reconstruction. The present study aimed to establish and evaluate deformable shape templates (DSTs) of the femur and tibia with footprints of the cruciate and collateral ligaments embedded for the noninvasive estimation of ligament footprint positions. To this end, a data set of computed tomography (CT)-derived surface models of the femur and tibia were established and used to build statistical shape models (SSMs). The contours of the stifle ligaments were obtained from CT scans of 27 hindlimb specimens with radio-opaque markings on the ligament footprints. The DST, constructed by embedding averaged footprint contours into the SSM, was used to estimate subject-specific ligament footprints in a leave-one-out cross-validation framework. The DST predictions were compared with those derived from radio-opaque-marked footprints. The results showed that the averaged Euclidean distances between the estimated and reference footprint centroids were less than 1.2 mm for the cruciate ligaments and 2.0 mm for the collateral ligaments. The DST appeared to provide a feasible alternative approach for noninvasively estimating the footprints of the stifle ligaments in vivo.

Treatment of chronic instability of the ankle joint caused by lateral ligament complex trauma: review

Background. The incidence of injuries to the lateral ligaments of the ankle joint is up to 22% of all sports injuries and 85% of all ankle sprains. Most of these are effectively managed using nonoperative measures in the acute setting. Approximately 20% of patients will, however, develop chronic lateral ankle instability. A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The aim is to evaluate treatment options for chronic ankle instability and determine the state of the problem of current methods of treatment. Material and methods. For the analysis of the literature, 100 foreign articles were selected on chronic instability of the ankle joint and methods of its treatment, published from 1985 to 2023, as well as 18 domestic publications for the period from 2007 to 2022. 59 most relevant articles were selected. Publications were searched in the PubMed/MedLine and eLIBRARY databases. Results. Recent and remote literature agrees that the initial treatment for chronic lateral 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 and both techniques show potential for earlier rehabilitation. In those with contraindications for anatomic repair including innate soft tissue laxity, high body mass index, and in the revision setting, anatomic ligament reconstruction is an appropriate surgical option. Conclusion. There is limited evidence to support any particular surgical technique over another surgical technique for chronic lateral ankle instability. The open modified Brostrom-Gould collateral ligament repair continues to be the preferred method of surgical treatment for chronic lateral ankle instability. Nonanatomic reconstruction abnormally increases inver-sion stiffness at the subtalar level compared with anatomic reconstruction and shows greater clinical dissatisfaction. Arthroscopic repair can reduce recovery time and improve outcomes in certain populations, but there is a higher complication rate with these surgeries. When using new modifications and techniques, long-term outcome studi-es are needed to determine their long-term usefulness and compare them with the results of open surgery

Publication trends in ligament augmentation techniques: current concepts

ImportanceLigament augmentation techniques (LATs) are surgical procedures, in which an anatomical ligament repair or reconstruction is strengthened with a synthetic material. During the last decade, LATs have increased in prevalence in clinical practice and academic literature. Observing the trends in LAT publications can be used to identify clusters of strong evidence for clinical practice and to highlight areas of the literature which need further development. ObjectiveThis article aims to define ligament augmentation as a technique category, observe anatomical, procedural, and temporal trends in LAT publication, and report on the state of current research in this field. Evidence reviewPrimary literature in the English language, which describes ligament augmentation and reports on human, cadaveric, or biomechanical models, and published prior to May 24th, 2022, was targeted for analysis. PubMed, Embase, and Cochrane CENTRAL databases were explored using a focused keyword search strategy, and the resulting publications were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were collected and analysed using descriptive statistics. FindingsTwo hundred eighty-three publications reporting ligament augmentation techniques, published from May 1989 to May 2022, were included for final analysis. A wide technical and anatomical variety of procedures are reported. 36.8% of LAT publications describe knee ligaments, among which the anterior cruciate ligamenthas the highest focus in ligament augmentation publications (31.8% of articles). LAT literature has recently expanded in anatomical scope, with many contemporary articles describing the usage of a LAT in the ankle syndesmosis and coracoclavicular ligaments. 60.4% of LAT literature has been published since 2017. There has been an 11% average increase in the rate of LAT publication reports since 2015. Novel fixation devices—suture buttons and suture anchors—have gained wide popularity in the literature. Conclusions and relevanceIn this review, we define LATs and quantitatively describe the expansion of LAT use reported in the literature. This data will provide physicians an overview of the history of these methods, as well as illustrate the broad range of applications available for the use of LATs. Level of Evidence3.

Surgical Options for Chronic Lateral Ankle Instability: How Has the Incidence of the Broström-Gould Procedure Evolved in the Past Decade?

Category: Ankle; Trauma Introduction/Purpose: The past 50 years has seen significant development of surgical techniques aimed at treating chronic lateral ankle instability. Surgical procedures currently being performed can be classified as anatomic ligament reconstruction as well as nonanatomic, and more recently, anatomic repair by tenodesis. Anatomic reconstruction is successful at circumventing important shortcomings associated with nonanatomic repair such as impaired ankle kinematics and biomechanics. One variation of the anatomic repairs described in orthopedic literature demonstrating excellent long-term functional outcomes includes the Broström-Gould (BG) modification. However, there is no detailed depiction of the procedural incidence in recent years. We hypothesize that the incidence of this surgical technique has risen in the past decade. Methods: The Truven MarketScan database was queried to identify patients who underwent a BG procedure from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of the BG procedure. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 160,457 BG procedures were identified in the database from 2009 to 2019. Annual volumes have increased by 89.9%, from 10,441 to 19,829 total procedures nationwide. Procedural incidence reported per 1,000,000 people increased by 76.6%, at 61.1 in 2019. Increased incidence was demonstrated in males and females ≤65 years, with the highest annual incidence found &lt;55 years of age. Incidence stratified by region rose in the South, West, and Midwest regions of the United States by 81.7%, 75.4%, and 69.2%, respectively. Conclusion: The epidemiology of operative treatment for chronic lateral ankle instability has yet to be clarified in recent years. Our findings demonstrate that the annual volumes and incidence of the BG procedure has increased in the past 11 years. Growth in incidence was found in both sexes below the age of 65 years whereby the greatest annual incidence was found in ages below 55 years. Incidence significantly rose in all regions of the United States except for the Northeast. The insight provided by epidemiologic studies allows orthopedic surgeons to better adapt their practice to the current trends in the field.

Chronic Lateral Ankle Instability Treated With Tendon Allografting: A Preliminary Comparison of Arthroscopic and Open Anatomic Ligament Reconstruction.

Background:Roughly 30% of patients with chronic lateral ankle instability (CLAI) have long-lasting painful instability requiring surgical intervention. Ligament reconstruction with the traditional open method and using tendon allografts can provide sufficient mechanical stability for severe CLAI. Arthroscopic ligament reconstruction with tendon allograft has recently been introduced to treat CLAI.Purpose:In this study, we describe an arthroscopic ligament reconstruction procedure involving the use of the tendon allograft for patients with CLAI, and we compare the efficacy of this procedure with open ligament reconstruction with tendon allograft.Study Design:Cohort study; Level of evidence, 3.Methods:We enrolled 10 patients (4 men and 6 women) with CLAI (mean age, 37.3 years; range, 16-57 years) who underwent arthroscopic ligament reconstruction with tendon allografting between November 2017 and June 2019. The control group consisted of 10 patients who received open tendon allograft reconstruction. Preoperative and 2-year postoperative functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale (AOFAS), Karlsson Ankle Functional Score (KAFS), pain visual analog scale (VAS), 12-Item Short Form Health Survey (SF-12), and Tegner activity score (TAS).Results:The mean operative time was 118 and 110 minutes in the arthroscopic and open groups, respectively. At 2-year follow-up, scores on the AOFAS improved significantly compared with preoperatively, from 71.3 to 96.4 (P = .006) in the arthroscopic group, and from 68.6 to 96.7 (P = .005) in the open group. The postoperative AOFAS, VAS, KAFS, and SF-12 scores did not differ significantly between the 2 groups; however, the TAS score was significantly higher in the arthroscopic reconstruction group compared with in the open group (7 vs 6.1, respectively; P = .01).Conclusion:Arthroscopic ligament reconstruction with tendon allografting resulted in sufficient ankle stability and no donor-site morbidity. This procedure can yield similar functional outcomes to open reconstruction technique and may be an option for the management of CLAI.

Arthroscopic anatomical reconstruction of lateral collateral ligaments with ligament advanced reinforcement system artificial ligament for chronic ankle instability.

BACKGROUNDRecently, the use of ligament advanced reinforcement system (LARS) artificial ligament, a new graft which has several unique advantages such as no donor-site morbidity, early recovery and no risk of disease transmission which has been a significant breakthrough for anatomical ligament reconstruction. Growing studies suggested that the special design of the LARS ligament with open fibers in its intra-articular part was believed to be more resistant to torsional fatigue and wearing. However, the safety and efficacy of LARS artificial ligament for ankle joint lateral collateral ankle ligament reconstruction has not been defined to date.AIMTo evaluate the clinical results of all-arthroscopic anatomical reconstruction of ankle joint lateral collateral ligaments with the LARS artificial ligament for chronic ankle instability.METHODSTwenty-two patients with chronic lateral instability underwent anatomical reconstruction of the lateral collateral ligaments of ankle with LARS artificial ligament. The visual analogue score (VAS), American Orthopaedic Foot and Ankle Society score (AOFAS score) and Karlsson score were used to evaluate the clinical results before and after surgery.RESULTSA total of 22 patients (22 ankles) were followed up for a mean of 12 mo. All patients reported significant improvement compared to their preoperative status. The mean AOFAS score improved from 42.3 ± 4.9 preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively. The mean VAS score improved from 1.9 ± 2.5 preoperatively to 0.8 ± 1.7 postoperatively.CONCLUSIONAll-arthroscopic anatomical reconstruction of the lateral collateral ligaments with LARS artificial ligament achieved a satisfactory surgical outcome for chronic ankle instability.

GENDER FEATURES OF THE AREAS OF ATTACHMENT OF THE ANTERIOR CRUCIATE LIGAMENT TO THE LATERAL FEMORAL CONDYLE FROM THE POSITION OF SURGICAL ANATOMY

Injury of the anterior cruciate ligament (ACL) remains the most common cause leading to limited knee function and earlier development of gonarthrosis. The results of ACL repair in male and female patients remain heterogeneous. Women have worse results of surgical treatment, as well as higher risks of ACL injuries (from 1,5 to 10 times) when playing sports. It is assumed that the features of the anatomical structure of the knee play the key role in this joint. We have studied 40 unpaired anatomical preparations of the human knee joint obtained from women and men.The morphometry of the distal femoral epiphysis was performed using a digital sliding caliper according to 16 parameters. When examining the areas of femoral ACL attachment, their shape, size, area, and center distance from individual bone structures were assessed. The data obtained were correlated with the type of structure of the knee joint. Were studied the anatomical features characteristic of the "female" type of structure of the knee joint. It was found that the type of structure of the knee joint affects the topography of the femoral attachment area of the ACL, which must be taken into account in anatomical ligament reconstruction.

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

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. 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. 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. 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. Level IV.

Anatomical ligament reconstruction with allograft in chronic acromioclavicular dislocations restores joint stability and function. Short-term outcomes in 14 cases

Objetivo: analizar los resultados a corto plazo de una técnica anatómica que reconstruye los complejos ligamentosos acromioclavicular y coracoclavicular con ayuda de un aloinjerto tendinoso para el tratamiento de las luxaciones acromioclaviculares de más de 3 semanas de evolución. Métodos: estudio longitudinal prospectivo de una serie de casos con luxaciones acromioclaviculares de más de 3 semanas de evolución que fueron tratados con una técnica de reconstrucción anatómica de los complejos ligamentosos acromioclavicular y coracoclavicular con aloinjerto de tendón tibial. Se analizaron los resultados radiológicos y funcionales con las escalas de Constant-Murley, American Shoulder and Elbow Surgeons (ASES)-hombro y Quick-DASH (Disabilities of the Arm, Shoulder and Hand); además, se evaluó la estabilidad de la articulación acromioclavicular y la cinética escapulotorácica. Resultados: se evaluaron 14 sujetos al menos un año tras la cirugía –media: 2,7 (1,1) años–. Hubo mejorías significativas en las 3 escalas clínicas evaluadas: Constant-Murley pasó de 64,4 (13,0) en el preoperatorio a 93,6 (12,6) al finalizar el seguimiento (p

Biomechanical study of autograft anatomic reconstruction in lateral ankle instability

IntroductionThe purpose of this work is perform a biomechanical comparison of anatomic reconstruction of the anterior talofibular ligament (ATFL) with the intact ATFL. Materials and methodsWe studied 18 fresh cadaveric ankles with intact ATFL. Each specimen was clinically assessed with the anterior drawer (AD) and varus tilt (VT) tests and the angular movement in the three spatial planes (axial, coronal and sagittal) was measured with an arthrometer using a sensor located in the talus. ResultsStatistically significant differences were found in the axial plane, between the intact ATFL versus the sectioned ATFL for AD test with p = 0.012, and for VT test with p = 0.013. Regarding the coronal plane, we also observed a statistically significant difference for VT test with p = 0.016. In the sagittal plane, there are no statistically significant differences in both maneuvers.No statistically significant differences were found when comparing the biomechanics of anatomic ligament reconstruction versus the intact ATFL. ConclusionAutograft anatomic reconstruction of the ATFL showed biomechanical properties similar to those of the native ATFL, at the zero moment in a cadaveric model.

Risk factors related to the loss of reduction after acromioclavicular joint dislocation treated with the EndoButton device.

BackgroundAnatomic ligament reconstruction using the EndobutBon device has been proven an effective technique for the management of acute acromioclavicular (AC) joint dislocation. The aim of this study was to analyze the risk factors causing loss of reduction after AC joint dislocation treated with the EndoButton device for open procedures.MethodsA total of 107 patients who met the inclusion and excluded criteria finally were enrolled. We retrospectively analyzed the clinical tests, imaging data, and postoperative rehabilitation of patients in a stable reduction group and a loss of reduction group.ResultsAmong all patients included in the study, the incidence of reduction failure was 14%. Univariate analysis identified that the time between injury to surgery, double or triple EndoButton, coracoid EndoButton position, weight-bearing time of the upper limb, and osteolysis had statistically significant associations with loss of reduction for the AC joint (P=0.022, 0.002, 0.000, 0.000, and 0.000 respectively). By using multivariate logistic regression analysis, we found that coracoid EndoButton position (P=0.002), weight-bearing time of the upper limb (P=0.011), and osteolysis (P=0.036) were the significant independent risk factors related to the loss of reduction after AC joint dislocation treated with the EndoButton device used with open procedures.ConclusionsIn order to reduce the incidence of reduction failure and improve the prognosis of patients, more accurate placement of EndoButton plates in surgery and guidance for patients in completing planned rehabilitation training are needed.

Arthroscopic anatomical reconstruction of the lateral collateral ankle ligament: an examination of the learning curve and the influence of laterality and body mass index

Objectives:Anatomical reconstruction under arthroscopy by gracilis tendon autograft is an innovative technique in full development and requires a learning curve. Our objective was to evaluate this curve and determine the influence of the surgical side and the patient’s body mass index (BMI) on the performance of the procedure.Methods:In this retrospective study, conducted from January 2015 to March 2020, data was collected from 7 centers through 11 operators, and included the surgical side, body mass index and total procedure time. The ankle ligament reconstruction had to be performed entirely under arthroscopy, without any associated procedure, at the expense of the gracilis tendon. The learning curve was calculated over the total operating time.Results:The learning curve showed a logarithmic pattern with an average decrease of 20% in operating time for the 4th patient. In the largest cohort, there was a significant difference in operating time between the right and left sides (35.39 minutes vs. 32.29 minutes, p < 0.002, [CI95] = 1.23; 4.98). In the two largest cohorts, there was a correlation between operating time and BMI (ρ= 0.7022, p < 7.29E-20, [CI95] = 0.6006; 0.7814 and ρ= 0.2749, p < 0.025, [CI95] = 0.0371; 0.4832) for all the patients (ρ= 0.1753, p < 0.0001, [CI95] = 0.0867; 0.2612).Conclusion:Arthroscopic anatomical ligament reconstruction of the ATFL and CFL is a technical intervention with a fast learning curve, with good control of the procedure in less than ten procedures. The surgical side and the patient’s BMI were noted to have an influence on the duration of the procedure.

Estudio biomecánico de la reconstrucción ligamentosa anatómica con autoinjerto en la inestabilidad lateral de tobillo

IntroductionThe purpose of this work is perform a biomechanical comparison of anatomic reconstruction of the anterior talofibular ligament (ATFL) with the intact ATFL. Materials and methodsWe studied 18 fresh cadaveric ankles with intact ATFL. Each specimen was clinically assessed with the anterior drawer (AD) and varus tilt (VT) tests and the angular movement in the three spatial planes (axial, coronal and sagittal) was measured with an arthrometer using a sensor located in the talus. ResultsStatistically significant differences were found in the axial plane, between the intact ATFL versus the sectioned ATFL for AD test with p = 0.012, and for VT test with p = 0.013. Regarding the coronal plane, we also observed a statistically significant difference for VT test with p = 0.016. In the sagittal plane, there are no statistically significant differences in both maneuvers.No statistically significant differences were found when comparing the biomechanics of anatomic ligament reconstruction versus the intact ATFL. ConclusionAutograft anatomic reconstruction of the ATFL showed biomechanical properties similar to those of the native ATFL, at the zero moment in a cadaveric model.

Open Brostrom for Lateral Ligament Stabilization.

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 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.

Outcomes of ossicle resection and anatomic reconstruction of lateral ligaments for chronic ankle instability with large malleolar accessory ossicles

BackgroundMalleolar accessory ossicles can be found in patients with chronic lateral ankle instability (CLAI). Ossicle resection combined with the modified Broström procedure is the most commonly used surgical method. However, an unrepairable gap after ossicle resection often occurs in patients with large ossicles. PurposeThis study analysed the clinical outcomes of ossicle resection and anatomic ligament reconstruction (ALR) for CLAI with large malleolar accessory ossicles. MethodsThis study was a retrospective case series. Since 2014, we have adopted ALR for patients with difficulties using the modified Broström procedure after ossicle resection. Sixteen patients with chronic ankle instability and malleolar accessory ossicles were treated with this method between December 2014 and February 2018. The average age of the patients at the time of surgery was 28.9 (range, 16–65) years. They were followed up for an average time of 26.9 (range, 12–47) months. The clinical outcomes were evaluated using the Visual Analogue Scale, Karlsson–Peterson ankle scoring system, subjective satisfaction of patients, and radiographic parameters. ResultsAll unrepairable cases occurred in patients with ossicles larger than or equal to 10 mm. The VAS score improved from 3.5 ± 1.6 preoperatively to 1.4 ± 1.0 at the final follow-up (p < 0.05), and the Karlsson–Peterson score improved significantly from 52.7 ± 15.1 to 86.4 ± 8.2 (p < 0.05). There was also an obvious change in the varus talar tilt angle (15.4 ± 2.0° vs 6.2 ± 1.6°, p < 0.05) and anterior talar displacement (14.3 ± 2.1 mm vs 6.3 ± 1.4 mm, p < 0.05). Fourteen patients (87.5%) were satisfied (excellent or good) with their clinical outcomes. ConclusionIf modified Broström procedure is difficult to accomplish effectively after ossicle resection for chronic ankle instability with large malleolar accessory ossicles, ALR is a viable option with satisfactory clinical results.

Endoscopic anatomic ligament reconstruction is a reliable option to treat chronic lateral ankle instability.

Anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament is a valid treatment of chronic hindfoot instability. The purpose of this study was to investigate the outcomes of this procedure performed by an all-inside endoscopic technique. This study is a retrospective evaluation of a prospective database. Subjects were all patients who underwent an endoscopic lateral ligament reconstruction between 2013 and 2016. All patients had symptoms of ankle instability with positive manual stress testing and failed nonoperative treatment during at least 6months. At final follow-up the outcome was assessed using the visual analogue score (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and Karlsson-Peterson scores. After an average follow-up of 31.5 ± 6.9months, all patients reported significant improvement compared to their preoperative status. The preoperative AOFAS score improved from 76.4 ± 15 to 94.7 ± 11.7 postoperatively (p = 0.0001). The preoperative Karlsson-Peterson score increased from 73.0 ± 16.0 to 93.7 ± 10.6 postoperatively (p = 0.0001). The VAS score improved from 1.9 ± 2.5 to 0.8 ± 1.7 (p < 0.001). Two patients had complaints of recurrent instability. Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure and produces good clinical results with minimal complications. In addition, the endoscopic approach allows an assessment of the ankle joint and treatment of associated intra-articular lesions. II.

Clinical effects of arthroscopic anatomical anterior cruciate ligament reconstruction with direct insertion technique

Objective To explore the operating methods and clinical effects of arthroscopic anatomical anterior cruciate ligament(ACL) reconstruction with direct insertion technique versus traditional method. Methods From January 2017 to December 2017, totally 52 patients who accepted ACL reconstruction and met the inclusion and exclusion criteria in Beijing Friendship Hospital of Capital Medical University were enrolled in this retrospective study. They were divided into two groups by random sequence software and patients′ selection results. The observation group(27 cases) received direct insertion technique, and the control group(25 cases) received traditional method. At postoperative 1 month, 3 months, 6 months, 1 year, the clinical effect was evaluated by imaging index, subjective and objective indicators. Results All 52 patients were available for follow up with an average of 11.5 months. No postoperative complications such as infection, joint instability and soft legs, with a satisfied recovery of range of motion, pain relieved significantly. The Lysholm score of the observation group was (94.80±4.18)points, which was significantly higher than (91.02±1.96)points of the control group (t=2.674, P 0.05), but the pivot-test of the observation group was better than that of the control group, the difference was statistically significant (P<0.05). The ACL angle of the observation group was (51.52±5.18)°, which was significantly lower than (55.86±2.45)° of the control group (P<0.05). According to modified Lysholm scores classification, in the observation group, 24 cases were excellent, 2 cases were good, 1 case was fair, and the excellent and good rate was 96.3%. In control group, 18 cases were excellent, 5 cases were good, 2 cases were fair, and the excellent and good rate was 92.0%. The difference in the excellent and good rate between the two groups was statistically significant(P<0.05). Conclusion Direct insertion anatomical reconstruction is a safe and effective technique for reconstruction of ACL. It can restore the stability of ACL and rotation of knee joint. Key words: Knee injuries; Anterior cruciate ligament; Arthroscopy; Anatomic reconstruction; Joint instability; Comparative effectiveness research

Analyse 3D scannographique des tunnels d’allogreffe ligamentaire anatomique dans l’instabilité chronique de cheville. À propos de 33 cas

IntroductionAlthough clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results. HypothesisWe hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately. Materials and methodsThirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs. ResultsThe mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about 68 % of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52 % and 20 % of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability. DiscussionAnatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination. Level of evidenceIV, Case-series.

The lateral collateral ligament complex of the elbow: quantitative anatomic analysis of the lateral ulnar collateral, radial collateral, and annular ligaments

Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex. The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured. The mean surface area of the LUCL was 229.3 mm2. The mean origin and insertion footprint areas were 26.0 mm2 and 22.9 mm2, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P < .001). The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.