Anterior Drawer Research Articles

A modified "outside-in" Broström-Gould procedure yielding favorable outcomes for the management of chronic lateral ankle instability-a retrospective study with mid-term follow-up.

Purpose: There are various surgical interventions available for the management of Chronic lateral ankle instability (CLAI). The Broström-Gould procedure has gained widespread recognition among foot and ankle specialists for its favorable surgical outcomes. However, with advancements in anatomical understanding and medical technology, further enhancements to the effectiveness of the Gould procedure are warranted. This study introduces a all-inside modified "outside-in" Broström -Gould procedure as an alternative approach for addressing lateral ankle instability. Methods: From August 2020 to October 2022, 40 patients with lateral ankle instability who underwent arthroscopic repair of the modified "outside-in" Broström-Gould procedure were retrospectively analyzed. All patients received standard non-surgical treatment before surgery for more than 6months without symptom relief. Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) and Karlsson-Peterson score were used to evaluate the postoperative effect. Results: All patients were followed up for (14.62 ± 2.04) months. One year after operation, all patients could walk normally, ankle instability sensation disappeared, varus stress test and anterior drawer test were negative. The VAS , AOFAS and Karlsson-Peterson scores of all patients were significantly better compared with those before operation, and the difference between before and after operation was statistically significant. Conclusions: The modified "outside-in" Broström-Gould procedure can effectively treat CLAI, which can obtain satisfactory results. The procedure is straightforward, the impact is minimal, and the aesthetics are pleasing.

RETROSPECTIVE PROSPECTIVE COMPARATIVE ANALYSIS OF RECONSTRUCTION OF ACL TEAR WITH QUADRUPLED HAMSTRING GRAFT VERSUS QUADRUPLED HAMSTRING GRAFT INTERNALLY BRACED WITH FIBERTAPE

Background: Reconstruction of anterior cruciate ligament is a widely done surgery. The surgical outcome is dependent upon the strength of the graft used. Quadrupled hamstring graft is a commonly used graft as it provides good strength and functional outcomes. However graft re-rupture and laxity of the graftare amongst the known complications which lead to repeat surgeries and unsatisfactory outcomes. Various techniques have been described to strenghthen the graft. This study compares the cumulative effect of internally bracing quadrupled hamstring graft using fibertape with quadrupled hamstring graft alone in terms of functional outcome and laxity. Materials and Method:The study was done at the Department of Orthopaedics at King Georges Medical University in Lucknow on 60 patients with anterior cruciate ligament tears from October 2021 to October 2022. The patients were divided into two groups: Group 1 had quadrupled hamstring graft reconstruction done alone, and Group 2 had quadrupled hamstring graft reconstruction done with fibertapebracedinternally.Lysholm knee score was used as a measure of functional outcome along with standardized Pivot shift test, Lachman testand anterior drawer test to measure and compare the pre- and postoperative variation in laxity. Results:On comparing the improvement in grades at subsequent follow-up, group 2 showed significant improvement in functional outcomes in terms of Lysholm knee score . Conclusion:We concluded that reconstruction of anterior cruciate ligament using quadrupled hamstring graft internally braced with fiber tape gives a better functional outcome in form of Lysholm knee score although there was no significant improvement in grades of Anterior Drawer and Lachman test. Although follow up period of six months was a limiting factor . Further clinical evaluation over a longer period of follow up to evaluate the effect of fibertape on shielding and creeping of graft is essential and also to study the resultant collagen fibretapes clinical behavior.

Comparison of the clinical efficacy of all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure for the treatment of chronic lateral rotational ankle instability

Objective: To compare the clinical efficacy of patients with chronic lateral rotational ankle instability(CLRAI) after all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure. Methods: This is a retrospective cohort study. The clinical and imaging data of 106 CLRAI patients were collected at the Xuzhou Central Hospital from January 2021 to December 2022. The patients included 55 males and 51 females with an age of (32.6±8.2) years (range: 16 to 50 years). All patients were treated under all-inside arthroscopic, and were divided into Broström-Gould surgery group (n=54) and Broström surgery group (n=52) according to different ligament repair methods. At 3, 6, and 12 months after surgery, ankle inversion stress tests and anterior drawer tests were used to examine the stability of the ankle joint and observe gait. The American Orthopedic Foot and Ankle Society ankle hindfoot scale (AOFAS-AH) and Karlsson ankle function score (KAFS) were used to assess ankle function; Tegner score was used to assess the patient's level of exercise; the foot and ankle outcome score(FAOS)(including score of symptoms,pain,function, daily living,function, sports and recreational activities (sport); quality of life (QOL)) was used to assess the patient's daily activity ability. Comparisons of data were made using independent sample t test, repeated measures analysis of variance, LSD multiple comparison method, χ2 test or Mann-Whitney U test. Results: All operations were successfully accomplished. All incisions healed by first intention, without evidence of postoperative complications of implant rejection, ligation reaction, and nerve and vessel injury. All patients were followed up at 3, 6, and 12 months after surgery. Ankle varus stress test and anterior drawer test were negative. No evidence supporting lateral ankle instability was obtained. All patients eventually regained normal gait. No patients underwent revision surgery. Repeated measurement analysis of variance showed that AOFAS-AH, Tegner, KAFS and FAOS scores in the Brostrom-Gould group and the Brostrom group were significantly higher than those before surgery (P<0.01). The change trends of Tegner score and FAOS-sport score were significantly different between the two groups (F=18.839, P<0.01; F=8.169, P=0.005). Multiple comparisons revealed that at 3-, 6-and 12-month follow-up, the Tegner scores ((3 months: 3.7±0.5 vs. 3.3±0.5, t=-3.980, P<0.01; 6 months: 4.4±0.6 vs. 3.8±0.7, t=-4.792,P<0.01;12 months: 5.8±0.9 vs. 5.1±1.0, t=-3.889,P<0.01)), sport scores ((3 months: 82.5±3.7 vs. 79.3±3.8, LSD-t=-4.316, P<0.01; 6 months: 88.5±4.9 vs. 85.7±3.8, LSD-t=-3.312,P=0.001;12 months: 90.1±4.3 vs. 88.2±5.1, LSD-t=-2.112,P=0.037)) in the Broström-Gould surgery group were higher than those in the Broström surgery group, with statistical significances. Conclusions: Both Broström-Gould and Broström procedures under all-inside arthroscopic can make ankle stability and improve ankle function in the treatment of CLRAI. However, the former maybe shorten the time to return to exercise and achieve higher motor function.

Clinical Outcome of Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autograft versus Tibialis Tendon Allograft Allograft

Abstract: Objectives: The present study aimed to examine the clinical outcome of anterior cruciate Ligament (ACL) reconstruction using hamstring tendon autograft versus tibialis tendon Allograft. Materials/Patients and Methods: Local institutional review board approval (Code number 930971) was obtained before the commencement of the study. Thereafter, the patients who had undergone anatomical arthroscopic ACL reconstruction with hamstring tendon autograft and allograft tibialis were retrospectively reviewed. A number of 82 eligible Patients in autograft and 100 patients in the allograft group who met inclusion criteria were examined regarding knee stability by clinical examinations and KT-2000 arthrometer from 2008-2014. Results: Anterior drawer test was reported negative in 23.18% of patients in autograft and 23% of patients in the allograft group which was not statistically meaningful (P=0.870). The mean follow-up time was reported as 36.34 and 38.34 months in autograft and allograft groups, respectively. Final score of Knee Injury and Osteoarthritis Outcome Score (KOOS) in autograft and allograft groups was measured at 70.87±19.76 and 71.83%, respectively. In addition, the mean Lysholm score in autograft And allograft groups was reported to be 90±4.77 and 3.3±92, respectively. Moreover, Mean International Knee Documentation Committee (IKDC) score in the autograft and Allograft groups was estimated as 85±14.11 and 7.03±9, respectively. Furthermore, the Mean Kujala score in autograft and allograft groups was measured at 79±3.07 and 3.75±81, respectively. Conclusions: Apart from the mainstay treatment which is the surgical technique, the Use of quadrupled hamstring tendon autograft and tibialis allograft would yield dramatic Results in ACL reconstruction both subjectively and objectively. Moreover, the use of Hamstring tendon autograft and tibialis allograft is reported to have similar medical Results.

Current diagnostics and treatment of ankle sprains in German

Ankle sprains are one of the most frequent injuries of the musculoskeletal system. The injury pattern determines the treatment and are crucial for the outcome. Nonoperative treatment is commonly recommended for isolated injuries of the lateral ligaments but no standard strategy exists in combined ankle ligament injuries. The goal of this national survey was to achieve an overview about the current diagnostic strategies and common treatment concepts in Germany. All members of the German Society for Orthopaedics and Trauma Surgery (DGOU) were invited to participate in an anonymous survey about the diagnostic and therapeutic approach in cases of ankle sprains. The online survey consisted of 20questions. Besides questions about the speciality and scope of activities the participants were ask to depict their diagnostic and therapeutic strategy. A total of 806 participants completed the survey. Most of them were orthopedic trauma surgeons and worked in ahospital. During the first presentation the anterior drawer test (89.5%) and the inversion/eversion test (81.6%) were most commonly used, 88.1% always make an X‑ray examination and 26.5% an ultrasonography examination. Isolated injuries of the anterior fibulotalar ligament (LFTA) were treated nonoperatively by 99.7% of the participants, 78.8% recommend full weight bearing in an orthesis, 78.8% treat the complete rupture of the lateral ligaments without operation whereas 30.1% stated that they would treat acombined lateral ligaments rupture with an injury of the syndesmosis nonoperatively. Due to the heterogeneity of injury patterns after ankle sprain no consistent recommendations for diagnostics and treatment exist. The Ottawa ankle rules and ultrasonography were not often utilized despite of the good evidence. The isolated rupture of the LFTA is diagnosed and treated according to the national guidelines by most of the participants. In cases of combined injuries of the lateral and medial ankle ligaments the majority choose anonoperative treatment strategy which is justified by the guidelines with alow level of evidence. Combined injuries of the syndesmosis and the lateral ankle ligaments were treated operatively, which also correlates with the recommendations in the literature. The standard care of ankle sprain in Germany is in accordance with the recommendations from the current literature.

Effect of anterior cruciate ligament injury on acceleration response of knee joint.

This study investigated the effect of anterior cruciate ligament (ACL) injury on relative acceleration of the tibia and femur during a number of tests/activities, in order to assess the feasibility of acceleration-based diagnosis of ACL injury using inertial sensors. First, a detailed finite element model of the knee joint was developed to simulate the target tests/activities, and identify those in which a large difference between the maximum acceleration peaks (MAPs) of the healthy and ACL injured knees is likely to be observed. The promising tests/activities were entered in an experimental study, where the relative accelerations of the tibiae and femurs of 20 individuals with unilateral ACL injury, allocated randomly to two groups of conscious and unconscious test conditions, were recorded. Model predictions indicated MAP ratios>1.5 for the ACL-injured to healthy knees, during the anterior drawer, Lachman, and pivot-shift tests, as well as the lunge activity. The experimental MAP results indicated acceptable test-retest reliabilities for all tests (coefficient of variation<0.25), and significant MAP differences (p < 0.05) in the anterior drawer and pivot-shift tests, in both coconscious and unconscious conditions. The individualized MAP results indicated side-to-side differences>2 m/s2 for all subjects during unconscious pivot shift tests, and >0.5 m/s2 for eight cases out of ten during conscious anterior drawer tests. It was concluded that the pivot shift test had a great repeatability and discriminative ability for acceleration-based diagnosis of ACL injury in unconscious condition. For the conscious condition, however, the anterior drawer test was appeared to be most promising.

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature.

Background Anterior cruciate ligament reconstruction (ACLR) is a common operative procedure and many options regarding the type of the selected graft and fixation technique have been described to date. Although many studies have addressed the issue of the optimal femoral fixation device during ACLR with a hamstring tendon (HT) autograft, no clear evidence to indicate one technique over another has been found. Objective The purpose of this study was to compare the long-term postoperative outcomes and complication rates between transfemoral Cross-pin (CP) and Endobutton-Cortical Button (CB) fixation techniques in patients undergoing ACLR with an HT autograft. Methods One hundred and seven consecutive patients underwent ACLR by using a quadruple HT autograft that was stabilized with either a CP (CP Group: 52 patients) or a CB (CB Group: 55 patients) fixation technique. The Lachman test (LT), the Pivot-shift test (PST), the side-to-side difference in anterior translation of the tibia, the International Knee Documentation Committee (IKDC), and the Lysholm knee scoring systems were evaluated before surgery and during long-term follow up. Thefemoral and tibial tunnel diameter was measured in the anteroposterior (AP) and lateral radiographsafter surgery and at the final follow-up. Areview of the literature was also carried out to identify any differences between both techniques. Results Study groups were comparable in terms of patient demographics. The mean follow-up was 10.4 ± 1.3 and 10.6 ± 1.3 years in the CP and CB Groups, respectively (p = 0.47). In the CP Group, improvements after surgery in LT and PST from grade 2 (n=34) or 3 (n=18) to grade 0 (n = 41) or 1 (n = 11) and from grade 2 (n=36) or 3 (n = 16) to grade 0 (n = 44) or 1 (n = 8), respectively, were observed. In the CB Group, similar improvements in LT and PST scores from grade 2 (n = 40) or 3 (n = 15) to grade 0 (n = 46) or 1 (n = 9) and from grade 2 (n = 41) or 3 (n = 14) to grade 0 (n = 47) or 1 (n = 8), respectively, were observed. However, no differences between the groups (p = 0.53 for LT and p = 0.90 for PST) were noted. The mean Lysholm scores were 89.7 ± 6.8 and 90.2 ± 7.2 in the CP and CB groups, respectively (p = 0.59). Side-to-side difference improved from 9.1 ± 2.8 to 1.7 ± 1.5 mm and from 8.6 ± 2.5 to 1.6 ± 1.4 mm in the CP and CB groups, respectively (p = 0.89 between groups). According to IKDC grades, 92.1% and 91.4% of knees in the CP and CB groups, respectively were reported to be Grade A (Normal) or B (Nearly Normal) with a p = 0.7. Femoral and tibial tunnel widening was found in the last follow-up in both groups. However, there was no difference in the degree of tunnel widening among the two techniques.With respect to LT, PST, anterior drawer test, and IKDC score, none of the 15 published comparative studies demonstrated any significant differences between the two techniques and only one study detected a difference regarding the Lysholm score in favor of CP fixation. Conclusion In the long term, both CB and CP femoral stabilization techniques were shown to be associated with similar functional outcomes and low complication rates. Further large multicenter random clinical trials are still required to identify the most effective method of femoral fixation for HT autograft during ACLR surgery.

Clinical Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Controlled Accelerated Rehabilitation.

Background An anterior cruciate ligament (ACL) tear is one of the most common sports injuries in the knee region. Currently, anatomical ACL reconstruction with quadrupled hamstring tendon autograft and controlled accelerated rehabilitation is a frequently used treatment approach. This study aims to add to the literature the early and mid-term clinical results of the controlled accelerated rehabilitation program we implemented in our clinic to enable patients to return to their daily activities faster after ACL reconstruction. Methodology In this retrospective study, 51 patients (50 males, 1 female) diagnosed with ACL tear and undergoing ACL reconstruction with quadrupled hamstring tendon graft were included in our study.In the femoral fixation of the graft, the transfix method was used in 22 patients and the Endobutton-CL method was used in 29 patients. A controlled accelerated rehabilitation program developed by Shelbourne was employed with some modifications to the patients. Clinical evaluation of patients was performed using Lysholm, Cincinnati, Tegner, and International Knee Documentation Committee (IKDC) scoring systems. Results The mean postoperative follow-up period was 18.7 months (range = 6-36 months). During the physical examination, Lachman, anterior drawer, and pivot shift, 49 (96%) patients achieved excellent or good results, while only two (5%) patients experienced fair clinical outcomes. On clinical assessment using the Lysholm and IKDC scoring systems, 50 (98%) patients demonstrated excellent or good results, whereas only one (2%) patient showed fair results. Excellent and good outcomes were observed in all patients using the Cincinnati scoring system. We found a significant decrease in Tegner activity score pre-surgery, which significantly increased post-surgery. Conclusions The combination of Endobutton and cross-pin for femoral fixation and staples and interference screw for tibial fixation is thought to be safe in patients undergoing controlled accelerated rehabilitation after ACL reconstruction. The implementation of controlled accelerated rehabilitation enables patients to return to their social lives earlier without resulting in clinically poor outcomes in grafts and implants applied in the early and middle stages.

Functional knee and ankle outcomes of a peroneus longus tendon autograft for primary reconstruction of the anterior cruciate ligament

Background Peroneus longus tendon (PLT) autograft is commonly used for anterior cruciate ligament (ACL) reconstruction because it is easily harvested and has the same size and strength as the ACL. There are few studies in the literature that discussed donor site complications after ACL reconstruction by PLT. PLT was used as an autograft for reconstructions of the medial patellofemoral ligament and deltoid ligament. We evaluated clinical and functional outcomes for knee, foot, and ankle joints after the use of PLT as an autograft in primary isolated ACL reconstruction. Patients and methods We retrospectively reviewed all patients who were operated for primary ACL reconstruction by PLT autograft from May 2020 to May 2021. Preoperatively and postoperatively, all patients were examined clinically for knee stability by anterior drawer, Lachman, and pivot shift tests, applying the International Knee Documentation Committee as well as the Lysholm score. American Orthopedic Foot and Ankle Score, Foot and Ankle Ability Measure, and ankle range of motion were used for the evaluation of postoperative foot and ankle functions. Return time to the sport was also evaluated. Results Sixty-five patients with ACL-injured knees were included. Their mean age was 29.81 ± 8.33 years and ranged from 20 to 45 years, and males were 54 (83%) and females were 11 (17%). The mean postoperative follow-up period was 32.5 ± 3.1 months. Mean of American Orthopedic Foot and Ankle Score was 99.33 and Foot and Ankle Ability Measure was 99.7 after 12 months. Postoperative Lysholm score mean±SD was 95.30 ± 4.65, and the International Knee Documentation Committee mean±SD was 93.47 ± 9.82 with P value less than 0.001. Return to sport ranged from 4 to 8 months with mean±SD of 5.67 ± 0.75. Conclusion PLT autograft for primary reconstruction of isolated ACL injury did not affect foot and ankle functions with good knee stability and restoration of knee functions postoperatively, which facilitated the return to preoperative sports activity level.

Postoperative Stability in Displaced Ankle Fractures With Concomitant Ligamentous Injuries

Ankle instability, which can be attributed to either the deltoid or lateral ligamentous complex, may be both a cause and a consequence of ankle fractures. This study aimed to assess postoperative ankle instability in patients with displaced ankle fractures. A total of 54 patients with displaced ankle fractures were included. Malleolar fractures were surgically reduced and fixated, and if necessary, the syndesmosis was stabilized. Concomitant deltoid injuries were left unrepaired. Ankle stress radiographs were taken approximately 25.4 months after surgery, with a standard deviation of 20.5 months. Radiographic measurements included the tibiotalar tilt angle (TT) on varus stress view, anterior translation of the talus (AT) on the anterior drawer view, and the medial clear space (MC) and tibiotalar tilt angle on the valgus stress view. These measurements were compared between the injured and the noninjured contralateral ankle for all patients as well as in a subgroup of 19 patients with concomitant deltoid and syndesmosis injuries. There were no significant differences in Varus TT (p = .675, p = .394), AT (p = .516, p = .967), Valgus MC (p = .190, p = 0.498), and Valgus TT (p = .173, p = .442) between the injured and noninjured ankles in the whole group of patients as well as in the subgroup of patients with concomitant deltoid and syndesmosis injuries. Patients with displaced ankle fractures exhibited radiographically stable ankles postoperatively. Syndesmosis fixation without deltoid ligament repair is a viable treatment option for achieving ankle stability postoperatively in fractures with both ligament injuries.

Noninvasive and Reliable Quantification of Anteromedial Rotatory Knee Laxity: A Pilot Study on Healthy Individuals

Background: Anteromedial rotatory instability (AMRI) of the knee is a complex and severe condition caused by injury to the anterior cruciate ligament and/or the medial collateral ligament. Clinical studies dealing with AMRI are rare, and objective measurements are nonexistent. Purpose/Hypothesis: The objectives of this study were, first, to quantify anteromedial rotatory knee laxity in healthy individuals using a noninvasive image analysis software and, second, to assess intra- and interrater reliability and equivalence in measuring anteromedial knee translation (AMT). It was hypothesized that AMT could be reliably quantified using a noninvasive image analysis software. Study design: Cohort study; Level of evidence, 3. Methods: This prospective proof-of-concept study included healthy individuals aged 16 to 40 years with no history of knee injury or surgery. Three adhesive surface markers were placed on predefined landmarks on the medial side of the knee. Three independent investigators examined anteromedial rotatory knee laxity with an anterior drawer test in different tibial rotations (neutral tibial rotation, 15° of external tibial rotation, and 15° of internal tibial rotation). The entire examination of each knee was recorded, and AMT including the side-to-side difference (SSD) was assessed using a freely available and validated image analysis software (PIVOT iPad application). Group comparisons were performed using a 1-way analysis of variance with Bonferroni-adjusted post hoc analysis. Intraclass correlation coefficients (ICCs) were calculated to assess inter- and intrarater reliability of AMT measurements. Equivalence of measurements was evaluated using the 2 one-sided t-test procedure. Results: Anteromedial rotatory knee laxity was assessed in 30 knees of 15 participants (53% male) with a mean age of 26.2 ± 3.5 years. In all 3 raters, the highest AMT was observed in neutral tibial rotation (range of means, 2.2-3.0 mm), followed by external tibial rotation (range of means, 2.0-2.4 mm) and internal tibial rotation (range of means, 1.8-2.2 mm; P < .05). Intrarater reliability of AMT (ICC, 0.88-0.96) and SSD (ICC, 0.61-0.96) measurements was good to excellent and moderate to excellent, respectively. However, interrater reliability was poor to moderate for AMT (ICC, 0.44-0.73) and SSD (ICC, 0.12-0.69) measurements. Statistically significant equivalence of AMT and SSD measurements was observed between and within raters for almost all testing conditions. Conclusion: Anteromedial rotatory knee laxity could be quantified using a noninvasive image analysis software, with the highest AMT observed during neutral tibial rotation in uninjured individuals. Reliability and equivalence of measurements were good to excellent within raters and moderate between raters.

Chronic lateral ankle instability using anterior tibiofibular ligament distal fascicle transfer augmentation repair: an anatomical, biomechanical, and histological study.

Background: The transfer of the anterior tibiofibular ligament distal fascicle (ATiFL-DF) for the augmentation repair of the anterior talofibular ligament (ATFL) shows potential as a surgical technique. However, evidences on the benefits and disadvantages of this method in relation to ankle joint function are lacking. Purpose: This study aimed to provide comprehensive experimental data to validate the feasibility of ATiFL-DF transfer augmentation repair of the ATFL. Methods: This study included 50 embalmed ankle specimens to measure various morphological features, such as length, width, thickness, and angle, for evaluating similarities between the ATiFL-DF and ATFL. Furthermore, 24 fresh-frozen ankle specimens were examined for biomechanical testing of the ATiFL-DF transfer augmented repair of the ATFL. Finally, 12 pairs of ATiFL-DF and ATFL tissues from fresh-frozen ankle specimens were treated with gold chloride staining to analyze mechanoreceptor densities. Results: Anatomical studies found that the lengths and thicknesses of the ATFL and ATiFL-DF are similar. Biomechanical outcomes showed that performing ATiFL-DF transfer for ATFL repair can improve the stability of the talus and ankle joints. This is evident from the results of the anterior drawer, axial load, and ultimate failure load tests. However, performing ATiFL-DF transfer may compromise the stability of the distal tibiofibular joint, based on the Cotton and axial load tests at an external rotation of 5°. Analysis of the histological findings revealed that mechanoreceptor densities for four types of mechanoreceptors were comparable between the ATiFL-DF and ATFL groups. Conclusion: ATiFL-DF transfer is a viable method for augmenting ATFL repair. This technique helps to improve the stability of the talus and ankle joints while compensating for proprioception loss. Although ATiFL-DF transfer augmented repair of the ATFL may negatively affect the stability of the distal tibiofibular joint, this procedure can enhance the stability of the talus and ankle joints.

Anterior Talofibular Ligament Repair in Combination With Anterior Tibiofibular Ligament Distal Fascicle Transfer for The Treatment of Chronic Lateral Ankle Instability: A Finite Element Analysis

In recent years, anterior tibiofibular ligament-distal fascicle transfers for anterior talofibular ligament augmentation repair have proposed. However, a comprehensive biomechanical study on the anterior tibiofibular ligament-distal fascicle transfer is still lacking. We are established four distinct groups, namely the normal, the anterior talofibular ligament rupture, the anterior talofibular ligament repair, and the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer. We assessed the anterior drawer test and varus stress test of the ankle in each group. Moreover, we employed the model to simulate and compute the total displacement and von-Mises stress of the talus cartilage at varying gait phases, including foot strike, tibia vertical, and toe-off phases. The results of the anterior drawer test and varus stress test revealed that the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group exhibited greater closeness to the normal group. Regarding von-Mises stress in cartilage, the three gait instants had higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Nevertheless, regarding total displacement, the toe-off phases exhibited higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Using ATiFL-DF transfer to augment ATFL repair is a potential feasible procedure. However, this procedure could potentially compromise the anterior tibiofibular ligament's contribution to the dynamic stability of the ankle. Therefore, we recommend conducting further in-depth research to ensure the suitability and success of this technique in a clinical environment.

Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. Level III.

Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Background: Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. Purpose: To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. Study Design: Controlled laboratory study. Methods: Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. Results: sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. Conclusion: In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. Clinical Relevance: In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

The effect of the interaction between the exercise method and the level of ankle sprain injury in athletes on ankle stability

Background and purpose The aim of this research is to determine the effect of the interaction between the exercise method and the level of ankle sprain injury in athletes on ankle stability. Material and methods The location of this research was carried out in two places, namely the Bintang Physio Sport Bandung Clinic which is located at Jl. Pudak No. 11, Merdeka, Sumur Bandung District, Bandung City, West Java 40133 and PhysioZone Clinic which is located at Jl. Batununggal Indah IX No.2 (Batununggal Indah Club) Bandung City. This type of research is quantitative research with experimental research methods. The population in this study were athletes with Sprain Ankle conditions with screening that the population was an athlete who was medically diagnosed as suffering from Sprain Ankle by a doctor as proven by medical records and then a specific Physiotherapy examination was carried out using a) Anterior drawer test, b) Talar inversion tilt test, and c) Talar eversion tilt test. After being selected to examine the condition of Sprain Ankle, the athlete becomes part of the population. Purposive random sampling used in this research is sampling that has been adjusted in such a way, however, it is still continued with incidental sampling, namely taking respondents who happen to be present or available with a sample target of 8 people for each group. Results There is an effect of the interaction between the exercise method and the level of Ankle Sprain injury in athletes on ankle stability. Comparative analysis showed differences in ankle stability to Ankle Sprain injury rates with p values = 0.010 (p &lt; 0.05). The results of the Tukey test with values Fcalculate = 5.158) &gt; Ftabel for degrees of freedom 2 and 48 with values 3.819, or Fcalculate &gt; Ftabel show that there is an ankle stability interaction between interventions. Conclusions The results of the hypothesis test proved that there was an interaction of ankle stability between the intervention of Proprioceptive exercise and Theraband exercise with the degree of Ankle Sprain injury in athletes, so it can be concluded that there was an interaction of ankle stability between the intervention of Proprioceptive exercise and Theraband exercise with the degree of severe, moderate, and mild ankle injury. This is evidenced by each intervention where the Proprioceptive exercise intervention at the degree of mild and moderate injury has the same stability value, while the Theraband exercise at the degree of moderate and severe injury has the same stability value. To further clarify the interaction of ankle stability between proprioceptive exercise intervention and theraband exercise with severe, moderate, and mild degrees of injury in athletes with Ankle Sprain.

Chronic Ankle Joint Instability Induces Ankle Sensorimotor Dysfunction: A Controlled Laboratory Study.

Chronic ankle instability (CAI) is a clinical sequela that causes the recurrence of ankle sprain by inducing ankle sensorimotor dysfunction. Animal models of CAI have recently shown that ankle ligament injuries mimicking an ankle sprain result in chronic loss of ankle sensorimotor function. However, the underlying mechanisms determining the pathogenesis of CAI remain unclear. Ankle instability after an ankle sprain leads to the degeneration of the mechanoreceptors, resulting in ankle sensorimotor dysfunction and the development of CAI. Controlled laboratory study. Four-week-old male Wistar rats (N = 30) were divided into 2 groups: (1) the ankle joint instability (AJI) group with ankle instability induced by transecting the calcaneofibular ligament (n = 15) and (2) the sham group (n = 15). Ankle instability was assessed using the anterior drawer test and the talar tilt test at 4, 6, and 8 weeks after the operation (n = 5, for each group at each time point), and ankle sensorimotor function was assessed using behavioral tests, including ladder walking and balance beam tests, every 2 weeks during the postoperative period. Morphology and number of mechanoreceptors in the intact anterior talofibular ligament (ATFL) were histologically analyzed by immunofluorescence staining targeting the neurofilament medium chain and S100 proteins at 4, 6, and 8 weeks postoperatively (n = 5 per group). Sensory neurons that form mechanoreceptors were histologically analyzed using immunofluorescence staining targeting the mechanosensitive ion channel PIEZO2 at 8 weeks postoperatively (n = 5). Ankle sensorimotor function decreased over time in the AJI group, exhibiting decreased ankle instability compared with the sham group (P = .045). The number of mechanoreceptors in the ATFL was reduced (P < .001) and PIEZO2 expression in the sensory neurons decreased (P = .008) at 8 weeks postoperatively. The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction (P < .001). The AJI model demonstrated degeneration of the mechanoreceptors in the ATFL and decreased mechanosensitivity of the sensory neurons, which may contribute to CAI. Ankle instability causes degeneration of mechanoreceptors and decreases the mechanosensitivity of sensory neurons involved in the development of CAI. This finding emphasizes the importance of controlling ankle instability after ankle sprains to prevent recurrence and the onset of CAI.

Evaluation of Long-term Outcome of Arthroscopic Reconstruction of Anterior Cruciate Ligament Injury by Hamstring quadrupled Auto graft fixed by Bio Screws in a tertiary level hospital

Background: Hamstring tendon auto grafts in the form of quadrupled semitendinosus and gracilis (STG) has become an increasingly used alternative for anterior cruciate ligament (ACL) reconstruction. Bio screw avoids complications by decreasing possibility of graft damage. Current study was designed to evaluate arthroscopic ACL reconstruction with quadrupled semitendinosus auto graft and fixation of the graft by two biodegradable screws in both femur and tibia.&#x0D; Objectives: This study was conducted to evaluate the outcome of arthroscopic ACL reconstruction by semitendinosus tendon autograft using biodegradable screws for both tibia and femur. Methods: 300 patients with ACL injury admitted from January 2010 to December 2015 in the then Apollo Hospitals Dhaka (Evercare Hospital Dhaka now) were enrolled. All patients underwent ACL reconstruction surgery by quadrupled semitendinosus or gracilis auto graft fixed by Bio Screws. After discharge, these patients were followed up for 3 weeks, 3 months and final outcome was recorded after 6 years.&#x0D; Results: 270 patients (90%) had an uneventful post-operative period. 200 patients (66.67%) complained of postoperative pain after 3 weeks, 10 patients (3.33%) complained of knee swelling, 10 (3.33%) patients had infections &amp; 20 patients (6.65%) had knee stiffness after 6 months. Postoperatively, Lachman test improved significantly, grade 0 in 93.33% cases (280 patients) and grade I was in 6.67% cases (20 patients). Anterior drawer test was also markedly improved. Grade 0 was in 93.33% cases (280 patients) and grade I was in 6.67% cases (20 patients). According to the Lysholm Knee Scoring, the final long-term outcome was excellent in 76.67% cases (230 patients), good in 20% cases (60 patients) and fair in 3.33% cases (10 patients).&#x0D; Conclusion: Arthroscopic reconstruction of ACL by quadrupled hamstring autograft fixed by biodegradable screws for both tibia and femur, leads good to excellent results in the majority of the cases.&#x0D; Pulse Vol.15, 2023 P: 9-15

Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients

BackgroundTo compare the clinical efficacies of arthroscopic anterior talofibular ligament suture augmentation repair and modified suture augmentation repair in patients with chronic ankle instability (CAI).MethodsFrom October 2019 to August 2020, 100 patients with CAI were enrolled after propensity score matching analysis and observed for two years. Among them, 50 underwent modified suture augmentation repair and the other 50 underwent suture augmentation repair. The clinical efficacies of CAI treatments were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) clinical rating scale, visual analog scale (VAS), and anterior drawer test scores.ResultsThe postoperative AOFAS score of the modified suture augmentation repair group (83.8 ± 11.3) was significantly higher than that of the suture augmentation repair group (76.3 ± 11.3; P = 0.001). The VAS (P = 0.863) and anterior drawer test (P = 0.617) scores were not significantly different between the two treatment groups.ConclusionBoth the modified suture augmentation repair and suture augmentation repair demonstrated good clinical efficacies. The AOFAS score of the modified suture augmentation repair group was superior to that of the conventional suture augmentation repair group. Thus, modified suture augmentation repair is a feasible and practical surgical technique for CAI treatment.

Outcome of combined anatomic reconstruction of the anterior cruciate ligament with anterolateral ligament reconstruction versus with iliotibial band tenodesis

Abstract Background Isolated anterior cruciate ligament (ACL) tears without anterolateral structures injuries are treated successfully by isolated reconstruction of ACL. However, most ACL injuries are associated with the injuries of anterolateral stabilizers of the knee; mainly the iliotibial tract (ITB) and the anterolateral ligament (ALL). If ACL is only reconstructed in such a case, the incidence of postoperative rotational instability reaches 18%. New directions guided towards combined ACL reconstruction with extraarticular anatomical and nonanatomical reconstructions to improve knee rotation and translation and prevent pivot shift phenomena. Patients and methods We retrospectively reviewed all patients operated on for combined injuries of ACL and anterolateral stabilizers from February 2019 to February 2021. Preoperatively and postoperatively, all patients were examined clinically by knee stability tests: anterior drawer, Lachman, and pivot shift tests, applying the International Knee Documentation Committee score and return time to the sport. Results Forty patients were included with a mean age of 28 ± 8.33 years (range, 18–44 years). Patients were divided into two groups, group A 20 patients (18 males and two females) were treated by combined ACL with ALL reconstruction, and group B 20 patients (18 males and two females) were treated by combined ACL with ITB tenodesis. Sports injuries were the cause in 15 patients in group A and 14 in group B, while five injuries were due to nonsport activity in group A and six in group B. The mean follow-up period was 33.5 ± 2.1 months. Median postoperative subjective International Knee Documentation Committee scores in groups A and B were 95.4 and 94.25, respectively, without any statistically significant difference. Group A shows better postoperative improvement in pivot shift and one-leg hop test than group B with a significant difference (P&lt;0.05). Conclusion No significant difference between ALL reconstruction or ITB tenodesis with ACL reconstruction according to subjective knee functions but there was a significant difference according to objective functions, also lateral knee pain was reported in group B and not observed in group A.