Anterior Talofibular Ligament Injury Research Articles

Impact of Chronic Lateral Ankle Instability with Lateral Collateral Ligament Injuries on Biochemical Alterations in the Cartilage of the Subtalar and Midtarsal Joints Based on MRI T2 Mapping.

ObjectiveTo quantitatively assess biochemical alterations in the cartilage of the subtalar and midtarsal joints in chronic lateral ankle instability (CLAI) patients with isolated anterior talofibular ligament (ATFL) injuries and combined calcaneofibular ligament (CFL) injuries using MRI T2 mapping.Materials and MethodsThis study was performed according to regulations of the Committee for Human Research at our institution, and written informed consent was obtained from all participants. Forty CLAI patients (26 with isolated ATFL injuries and 14 with combined ATFL and CFL injuries) and 25 healthy subjects were recruited for this study. All participants underwent MRI scans with T2 mapping. Patients were assessed with the American Orthopedic Foot and Ankle Society (AOFAS) rating system. The subtalar and midtarsal joints were segmented into 14 cartilage subregions. The T2 value of each subregion was measured from T2 mapping images. Data were analyzed with ANOVA, the Student's t test, and Pearson's correlation coefficient.ResultsT2 values of most subregions of the subtalar joint and the calcaneal facet of the calcaneocuboid joint in CLAI patients with combined CFL injuries were higher than those in healthy controls (all p < 0.05). However, there were no significant differences in T2 values in subtalar and midtarsal joints between patients with isolated ATFL injuries and healthy controls (all p > 0.05). Moreover, T2 values of the medial talar subregions of the posterior subtalar joint in patients with combined CFL injuries showed negative correlations with the AOFAS scores (r = −0.687, p = 0.007; r = −0.609, p = 0.021, respectively).ConclusionCLAI with combined CFL injuries can lead to cartilage degeneration in subtalar and calcaneocuboid joints, while an isolated ATFL injury might not have a significant impact on the cartilage in these joints.

The anterior talofibular ligament-posterior talofibular ligament angle decreased after ankle lateral stabilization surgery.

The angle between the anterior talofibular ligament (ATFL) and the posterior talofibular ligament (PTFL) is increased in patients with chronic ATFL injury. This study aimed to compare the AFTL-PTFL angle before versus after ankle lateral stabilization surgery, and to evaluate whether the ATFL-PTFL angle correlates with the ligament injury severity. This retrospective study included 48 patients with mechanical ankle instability treated between 2016 and 2018. After arthroscopic evaluation, all patients underwent ankle lateral stabilization surgery comprising ligament repair (n = 28) or reconstruction (n = 20). The ATFL-PTFL angle was measured in the axial plane on pre- and postoperative MRI. Comparisons were made of the pre- versus postoperative ATFL-PTFL angles, and the ATFL-PTFL angle of the repair versus reconstruction groups. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic performance of the ATFL-PTFL angle in selecting the surgical technique. The postoperative ATFL-PTFL angle was significantly decreased compared with preoperatively. The ATFL-PTFL angle was significantly smaller in the repair group than the reconstruction group preoperatively and postoperatively. The area under the ROC curve was 0.741 (P < 0.01). The optimal cutoff point for the selection of ligament reconstruction was an ATFL-PTFL angle of 89.4° (sensitivity 0.85, specificity 0.61). The ATFL-PTFL angle decreases after ankle lateral stabilization surgery. The ATFL-PTFL angle is related to the severity of the ATFL injury. Ankle lateral ligament reconstruction should be considered when the ATFL-PTFL angle is > 89.4°. Level III.

Diagnosis and Classification of Acute Anterior Talofibular Ligament Injury by High Frequency Two-dimensional Ultrasound Combined with Power Doppler

Diagnosis and Classification of Acute Anterior Talofibular Ligament Injury by High Frequency Two-dimensional Ultrasound Combined with Power Doppler

Anatomic Knot Suture Anchor Versus Knotless Suture Anchor Technique for Anterior Talofibular Ligament Repair: A Biomechanical Comparison.

Background:To date, there are few biomechanical studies comparing the strength between knot repair and knotless repair procedures for anterior talofibular ligament (ATFL) injury.Purpose:To perform a biomechanical comparison of the strength of the arthroscopic ATFL repair technique with knot or knotless suture anchors in a cadaveric model with partial or complete ATFL injuries.Study Design:Controlled laboratory study.Methods:A total of 24 fresh-frozen cadaveric ankles were used. Arthroscopy was used to identify, section, and repair the ATFL on the fibular insertion site. The specimens were then randomly placed into 1 of 4 groups: group A received complete ATFL section and 1–suture anchor repair with knot, group B received complete ATFL section and 1-anchor knotless repair, group C received partial ATFL section and 1–suture anchor repair with knot, and group D received partial ATFL section and 1-anchor knotless repair. After repair, the ATFL tension was measured first with a digitalized tensiometer. Specimens were then mounted on a materials testing system to determine the ultimate load to failure and stiffness.Results:The mean ± SD ligament tension measured during the arthroscopic procedure was 8.6 ± 0.6 N for group A, 9.2 ± 0.5 N for group B, 9.4 ± 1.1 N for group C, and 9.6 ± 0.9 N for group D. No significant difference in tension was detected among groups. In load-to-failure testing, the mean ultimate failure load was 27.9 ± 4.1 N for group A, 26.2 ± 9.3 N for group B, 81.9 ± 26.5 N for group C, and 88.1 ± 41.6 N for group D. The mean ultimate failure loads of the partial repair groups were significantly higher than those of the complete repair groups (C vs A, P = .008; D vs B, P = .002), while there was no significant difference between groups A and B (P > .05) or between groups C and D (P > .05).Conclusion:The results of the present study showed that there was no significant difference in biomechanical properties between knot repair and knotless repair techniques.Clinical Relevance:Biomechanically, the results showed that knot suture anchor and knotless suture repair provide similar biomechanical strength for ATFL injury. Unfortunately, these methods in the complete ATFL section models provided less than half the strength and stiffness in the partial ATFL section models at time zero after surgery. As a result, 1–suture anchor repair is not suitable for complete ATFL injury regardless of the repair method.

Biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation: A finite element analysis

ObjectiveTo determine the biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation. MethodA three-dimensional model was established based on CT images from a healthy volunteer. The simulation of lateral malleolus fracture, and the modeling and assembly of plate were completed by referring to characteristics of Weber B lateral malleolus fractures, as well as the technical characteristics of open reduction and internal fixation of lateral plate. Operating conditions were set up for groups A−D. The proximal end of the model was restrained in all four groups, 200N of upward force and 100N of backward force were applied at anterior of talus head in order to simulate the dorsiflexion of ankle joint. Biomechanical differences of the lateral plate were observed under various conditions of different ligament ruptures. ResultsThe maximum stress value of group A was the smallest, approximately 78.47N, while that of group C was the largest, approximately 238.83N. The maximum stress value of group B was about 91.69N; and that of group D was about 184.08N. Importantly, location of the maximum stress in group D (CUT ATaF) was displaced from the posterior edge to the anterior edge of the plate, which was different from those of the other three groups. ConclusionsThe anterior talofibular ligament injury may be a major contributing factor to the stress of lateral plate fixation following Weber B lateral malleolus fracture. It should be considered as an essential risk factor for evaluation of the stability in these fractures.

Arthroscopic all-inside ATFL and CFL repair is feasible and provides excellent results in patients with chronic ankle instability

Chronic ankle instability has been described as presenting with complete tears of both the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in 20% of cases. Arthroscopic techniques to treat chronic ankle instability are increasingly being reported and in some instances they can be technically demanding. The aim of this study was to describe an arthroscopic all-inside repair of both the ATFL and CFL, and to report the outcomes of a group of patients with chronic ankle instability that underwent the technique. Twenty-four patients [22 male and 2 female, median age 41 (range 22-56) years] with chronic ankle instability and torn ATFL and CFL were treated arthroscopically after failing non-operative management. Median follow-up was 35 (mean 34.7, and range 18-55) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, both fascicles of the ATFL and the CFL were repaired. Arthroscopic examination demonstrated ATFL and CFL injuries in all patients. Subjective improvement in their ankle instability was observed postoperatively. The anterior drawer and the talar tilt tests were negative at follow-up. The median AOFAS score increased from 65 (mean 65, range 52-85) preoperatively to 97 (mean 97, range 85-100) at final follow-up. Chronic ankle instability with concomitant injury of both the ATFL and CFL, can be successfully treated by an arthroscopic all-inside repair. The clinical relevance of the study is the description of the first arthroscopic all-inside ATFL and CFL anatomic repair technique, which offers excellent clinical results and the inherent benefits from minimally invasive surgery. IV, retrospective case series.

Lower Signal Intensity of the Anterior Talofibular Ligament is Associated with a Higher Rate of Return to Sport After ATFL Repair for Chronic Lateral Ankle Instability

Background: The treatment strategy for anterior talofibular ligament (ATFL) injury is usually determined by the ATFL remnant condition during surgery. Preoperative magnetic resonance imaging (MRI)–based signal intensity of the ATFL remnant, represented by the signal/noise ratio (SNR) value, can reveal the ATFL remnant condition. Thus far, there is a lack of evidence regarding the relationship between the ATFL remnant condition and functional outcomes. Purpose/Hypothesis: The purpose was to quantitatively evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. The hypothesis was that a lower preoperative SNR is related to a better clinical outcome, particularly a higher rate of return to sport. Study Design: Cohort study; Level of evidence, 3. Methods: First, a preliminary study was performed to measure the ATFL SNR in preoperative MRI, the results of which suggested that a preoperative SNR >10.4 was indicative of a poor ATFL condition. Then, a cohort study was retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between January 2009 and August 2014. Accordingly, the patients were divided into 2 groups: high SNR (HSNR; ≥10.4) and low SNR (LSNR; <10.4). Functional outcomes based on the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner Activity Scale were then compared between the HSNR group and the LSNR group. Results: Ultimately, 70 patients were available for the final follow-up: 37 in the HSNR group and 33 in the LSNR group. No significant difference was detected between the HSNR group and the LSNR group in terms of the AOFAS score, KAFS, or Tegner Activity Scale (P > .05 for all) preoperatively. At the final follow-up, the mean ± SD AOFAS score in the LSNR group (92 ± 6) was higher than that in the HSNR group (87 ± 12), although no significant difference was detected postoperatively (P = .16). The mean KAFS in the LSNR group (94 ± 7) was significantly higher than that in the HSNR group (88 ± 11) postoperatively (P = .03). At follow-up, the mean Tegner score in the LSNR group (6; range, 3-7) was significantly higher than that in the HSNR group (5; range, 1-8) postoperatively (P = .03). Patients in the LSNR group had a significantly higher percentage of sports participation than those in the HSNR group (91% vs 65%, P = .02) postoperatively. Conclusion: A lower signal intensity in the ATFL ligament based on preoperative MRI is associated with a better clinical outcome, particularly a higher rate of return to sport.

Effect of arthroscopic augmention using suture-tape for Broström-Gould repair of anterior talofibular ligament injury

Objective To evaluate the short-term efficacy of Brostrom-Gould repair combined with Internal Brace artifi-cial ligament reinforcement under arthroscopy for anterior talofibular ligament injury in overweight and poor ligament quality popu-lation. Methods A total of 12 patients with anterior talofibular ligament injury treated by arthroscopy were enrolled from October 2017 to May 2018, involving 7 males and 5 females aged from 16 to 57 years old (mean 32.4 years). Patients were with ankle insta-bility, and their BMI was 28.0-30.7 kg/m2 (average, 28.8±0.91 kg/m2), among which there were 2 cases of poor ligament quality (Beighton score ≥4). The anterior tibiofibular ligament injury and the quality of the ligament stump were intraoperatively evaluated under arthroscopy. A 4.75 mm diameter anchor with Internal Brace artificial ligament was inserted into the fibula insertion site, and non-absorbable suture was placed at the talus under total arthroscopy. Firstly, the non-absorbable line on the anchor was per-formed under the standard Brostrom-Gould procedure to repair the anterior talofibular ligament, and the other end of the ligament was fixed near the distal end of the talus. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and foot and ankle ability measure (FAAM) was compared before and after surgery. Results All the incisions were healed in the first stage after operation, and no operative complications such as infection occurred. All the 12 patients were followed up for 7 to 12 months (average 9.1 months). After 2 weeks, the patient began functional exercise and could walk with ankle braces. At the latest follow-up, the anterior drawer test was negative. The ankle-posterior foot score of AOFAS was increased from 61.3±7.9 (preopera-tive) to 85.0±6.0 (latest follow-up) (t=21.422, P< 0.01), and the FAAM score was increased from 57.5±10.1 (preoperative) to 86.3±4.8 (latest follow-up) (t=15.032, P< 0.01). AOFAS score was excellent in 1 case and good in 11 cases. The excellent and good rate was 100% (12/12). No complications such as infection and re-rupture occurred after operation. Conclusion For anterior talofibu-lar ligament injury patients with overweight or poor quality of ligament, the Brostrom-Gould procedure can be applied to strengthen under arthroscopic Internal Brace ligament without additional tendon reconstruction, which can also obtain good results. Key words: Ankle joint; Joint instability; Ligament; Wounds and injuries; Arthroscopy

Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study

BackgroundThe objective of the current study is to compare reliability, accuracy, sensitivity, and specificity in magnetic resonance imaging (MRI) evaluation of anterior talofibular ligament (ATFL) among the routine axial scanning plane, oblique axial-coronal scanning plane, and oblique axial-sagittal scanning plane.MethodsTwenty cadaveric feet were studied. ATFL was exposed before scanning. Routine axial, oblique axial-coronal, and oblique axial-sagittal MRI scanning of 20 ATFL-intact cadaveric feet were acquired utilizing a 1.5-T MRI unit. The scans were repeated on the 20 cadaveric feet after the ATFL was artificially injured. In total, 120 sets of MR images were obtained and were randomly numbered. Three independent observers who were blinded to the experiment evaluated the images. Interobserver agreement, sensitivity, specificity, and accuracy were calculated and compared between different scanning planes utilizing the McNemar test.ResultsThe interobserver agreement was fair to good (kappa, 0.55 to 0.65) in the routine axial plane, fair to good (kappa, 0.557 to 0.75) in the oblique axial-sagittal plane, and excellent (kappa, 0.85 to 0.95) in the oblique axial-coronal plane. The accuracy was significantly higher when utilizing oblique axial-coronal MRI scanning than routine axial MRI scanning (reader 1: p = .018; reader 2: p = .005).ConclusionsThe diagnostic accuracy of oblique axial-coronal plane MRI was higher than the routine axial plane concerning ATFL injury, and the interobserver agreement was excellent. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury.

The Role of Calcaneofibular Ligament Injury in Ankle Instability: Implications for Surgical Management

Background: Acute inversion ankle sprains are among the most common musculoskeletal injuries. Higher grade sprains, including anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, can be particularly challenging. The precise effect of CFL injury on ankle instability is unclear. Hypothesis: CFL injury will result in decreased stiffness, decreased peak torque, and increased talar and calcaneal motion and will alter ankle contact mechanics when compared with the uninjured ankle and the ATFL-only injured ankle in a cadaveric model. Study Design: Descriptive laboratory study. Methods: Ten matched pairs of cadaver specimens with a pressure sensor in the ankle joint and motion trackers on the fibula, talus, and calcaneus were mounted on a material testing system with 20° of ankle plantarflexion and 15° of internal rotation. Intact specimens were axially loaded to body weight and then underwent inversion along the anatomic axis of the ankle from 0° to 20°. The ATFL and CFL were sequentially sectioned and underwent inversion testing for each condition. Linear mixed models were used to determine significance for stiffness, peak torque, peak pressure, contact area, and inversion angles of the talus and calcaneus relative to the fibula across the 3 conditions. Results: Stiffness and peak torque did not significantly decrease after sectioning of the ATFL but decreased significantly after sectioning of the CFL. Peak pressures in the tibiotalar joint decreased and mean contact area increased significantly after CFL release. Significantly more inversion of the talus and calcaneus as well as calcaneal medial displacement was seen with weightbearing inversion after sectioning of the CFL. Conclusion: The CFL contributes considerably to lateral ankle instability. Higher grade sprains that include CFL injury result in significant decreases in rotation stiffness and peak torque, substantial alteration of contact mechanics at the ankle joint, increased inversion of the talus and calcaneus, and increased medial displacement of the calcaneus. Clinical Relevance: Repair of an injured CFL should be considered during lateral ligament reconstruction, and there may be a role for early repair in high-grade injuries to avoid intermediate and long-term consequences of a loose or incompetent CFL.

Accuracy of Point-of-Care Ultrasonography for Pediatric Ankle Sprain Injuries.

In children with radiograph fracture-negative lateral ankle injuries, the main objective of this pilot study was to explore the accuracy, sensitivity, and specificity of point-of-care ultrasound (POCUS) performed by a pediatric emergency physician in diagnosing anterior talofibular ligament injuries, radiographically occult distal fibular fractures, and effusions compared with reference standard magnetic resonance imaging (MRI). This was a prospective cohort pilot study. Children aged 5 to 17 years with an isolated, acute lateral ankle injury and fracture-negative ankle radiographs were eligible for enrolment. Within 1 week of the injury, enrolled children returned for MRI and POCUS of both ankles. Seven children were enrolled, with a mean age 12.1 (SD, 3.0) years. Overall, POCUS agreed with MRI with respect to anterior talofibular ligament injury in 4 (57%) of 7 cases. Of the 2 cases with MRI-confirmed ligament damage, POCUS accurately identified and graded the extent of ligament damage in 1 case. Point-of-care ultrasound falsely identified ligament injuries in 2 cases. Both imaging modalities confirmed the absence of cortical fractures in all 7 cases. For all findings, POCUS sensitivity and specificity were 57% and 86%, respectively. In this pilot study, we established that POCUS diagnosed the specific pathology of radiograph-negative lateral ankle injuries with poor sensitivity but good specificity. Thus, POCUS could act as a tool to exclude significant ligamentous and radiographically occult bony injury in these cases. A larger study is needed to validate the utility of POCUS for this common injury.

Increased ATFL-PTFL angle could be an indirect MRI sign in diagnosis of chronic ATFL injury.

Magnetic resonance imaging (MRI) has relatively low accuracy in diagnosing chronic anterior talofibular ligament (ATFL) injury. This study's purpose was to evaluate the angle between the ATFL and posterior talofibular ligament (PTFL) as a new indirect MRI sign of chronic ATFL injury in patients with mechanical ankle instability (MAI). This study included 200 participants: 105 patients with MAI and 95 patients seen at our institution for reasons unrelated to ankle instability. MR images of all 200 participants were reviewed. The ATFL-PTFL angle in the axial plane was measured and compared between groups. Receiver operating characteristic curves (ROC) were used to analyze ATFL-PTFL angles in participants with and without ATFL injury. The sensitivity and specificity of this method for diagnosing ATFL injury were calculated. The mean ATFL-PTFL angle was significantly larger among MAI patients than among control patients (81.5° ± 9.8° vs 75.2° ± 8.9°, respectively; P < 0.01). The area under the ROC was 0.789 (P < 0.01). The optimal cut-off point for diagnosing ATFL injury on the basis of the ATFL-PTFL angle was 79.0° (sensitivity 0.89, specificity 0.67). The ATFL-PTFL angle was significantly larger among MAI patients than among those without MAI. Increased ATFL-PTFL angle offers a new indirect MRI sign for diagnosing chronic ATFL injury. The ATFL-PTFL angle can be used not only to improve the accuracy of diagnosis of chronic ATFL injury, but also to evaluate the restoration of normal ankle joint geometry after lateral ligament reconstruction. III.

Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries

BackgroundImaging studies done to evaluate chronic ankle instability (CAI) often fail to accurately detail injuries to the anterior talo-fibular ligament (ATFL) and may, therefore, also fail to provide guidance for selecting the most appropriate surgical procedure. Arthroscopy is now an indispensable tool for accurately diagnosing ATFL injuries. This study looked at agreement between arthroscopy and imaging study assessments of ATFL injuries. The primary objective was to adapt an arthroscopic classification of chronic ATFL lesions to the pre-operative imaging study findings in order to estimate the performance of computed tomography (CT)-arthrography, ultrasonography, and magnetic resonance imaging (MRI) in diagnosing ATFL lesions, using arthroscopy as the reference standard. HypothesisAgreement between arthroscopic and imaging findings of chronic ATFL injuries can be assessed by using a shared classification developed from the arthroscopic evaluation, used as the reference standard. Material and methodsA prospective multicentre study was conducted in 286 patients with arthroscopically-treated CAI. In each patient, the arthroscopic assessment of the ATFL was compared to the pre-operative findings by CT-arthrography, ultrasonography, and MRI. A classification of ATFL lesions based on the arthroscopic assessment was used to analyse the imaging studies. Using this classification, two independent observers compared the findings and evaluated the agreement between arthroscopy and imaging studies. ResultsOf the 286 patients, 157 had complete information on the arthroscopic assessment and on pre-operative imaging studies and were included in the analysis. Imaging studies were CT-arthrography in 49 patients, ultrasonography in 63 patients, and MRI in 45 patients; both ultrasonography and MRI were performed in 3 patients. Agreement with arthroscopy was 82% and 88.5% for CT-arthrography, 66.7% and 76.2% for ultrasonography, 70.5% and 79.5% for MRI, and 73.4% and 81.2% for all imaging studies pooled. DiscussionArthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with CAI, as it supplies far more accurate information than any of the current imaging studies and, in addition, provides a dynamic evaluation of the ligaments and assesses mechanical strength. In the study population, a simple arthroscopic evaluation consistently visualised ATFL lesions, thereby either correcting or confirming the pre-operative imaging study findings. Importantly, the arthroscopic assessment provided more accurate information on the lesions and quality of the ATFL compared to the imaging studies. Arthroscopy has improved our knowledge of chronic ATFL lesions and allowed the development of a simple but accurate four-grade classification of direct relevance to choosing the optimal therapeutic procedure. This classification must be disseminated among radiologists to improve the diagnostic performance of pre-operative imaging studies, assist surgeons in selecting the most appropriate ankle-stabilising procedure, and improve patient information. Further studies are needed to confirm the promising results reported here and the usefulness of this common arthroscopy and imaging-study classification for chronic ATFL lesions. Level of evidenceII.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality.

An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality. Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair. Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up. Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality. IV, retrospective case series.

Investigation of the Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In-situ Force

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle sprains are the most common sports injuries, and anterior talofibular ligament (ATFL) injury comprised 85% of all ankle sprains. Most patients recover with conservative treatment, but 20% of them progress to chronic ankle instability. Some studies have reported that anatomic reconstruction using a tendon graft is one of the best procedures to restore the ankle to its condition before symptom development. However, the effect of initial graft tension during ATFL reconstruction is still unclear. Therefore, the objective of this study was to investigate the effect of the initial graft tension during ATFL reconstruction. Methods: Eight fresh-frozen cadaveric ankle specimens were subjected to passive plantarflexion (PF)-dorsiflexion (DF) movement from 15° DF to 30° PF using the 6-degree-freedom robotic system. In addition, 60 N of anterior-posterior load, 1.7 Nm of inversion-eversion (IV-EV) torque, and 1.7 Nm of internal-external rotation (IR-ER) torque were applied to the ankle. During testing, 3-dimensional paths of the ankle were recorded simultaneously. Furthermore, in-situ forces of the ATFL and reconstructed graft were calculated using the principle of superposition. A repeated experiment was designed with the intact condition (intact), ATFL transection, and ATFL reconstruction with four different initial graft tensions (10 N, 30 N, 50 N, and 70 N). Results: AP laxity, IV-EV laxity and IR-ER laxity with ATFL transection was significantly greater than those with intact. In ATFL transection, the talus was significantly translated anteriorly with inversion and internal rotations under passive PF-DF motion compared with intact. Kinematic patterns and laxity in ATFL reconstruction with initial tension of 10 N and 30 N almost imitated intact, but in ATFL reconstruction with initial tension 70 N, the talus was significantly translated with external rotation compared with intact. As the initial graft tension during ATFL reconstruction increased, in-situ force of the reconstructed graft tended to increase during PF-DF motion. In-situ force of the reconstructed graft tension was significantly greater with initial tensions of 50 N, and 70 N than with intact during PF-DF motion (Figure 1). Conclusion: ATFL deficiency altered ankle kinematics and laxity. Although the optimal initial graft tension during ATFL reconstruction might restore ankle kinematics and laxity, excessive initial graft tension caused abnormal kinematics and laxity. Furthermore, the reconstructed graft tension increased as the initial tension increased. Initial tension during ATFL reconstruction has the important effect of imitating the normal ankle condition. We suggest that over-tensioning during ATFL reconstruction should be avoided in order to imitate the conditions of a normal ankle.

2-3 Year Retrospective Audit of Arthroscopic ‘Internal Brace’ For Chronic ATFL Injury

Category: Arthroscopy Introduction/Purpose: The aim of this audit is to present the surgical technique and medium term outcomes (2-3 years) of arthroscopic reconstruction of the anterior talo-fibular ligament (ATFL) using the Arthrex InternalBraceTM system. Acute lateral ligament injuries of the ankle respond well to early functional rehabilitation with physiotherapy and can have excellent results. For patients who develop chronic lateral ligament, the morbidity can be significant. Multiple surgical techniques for repair or reconstruction of the anterior talo-fibular ligament (ATFL) have been described. Protracted immobilization is often required in the post-op protocol. Short term outcomes (six months), for arthroscopic reconstruction of the anterior talo-fibular ligament (ATFL) using the Arthrex InternalBraceTM system, have previously been presented. The majority of patients reported good or excellent recovery. Methods: A similar cohort of patients to the short term (six months group) were identified. Adults aged between 18 and 65, average age 42. Exhausted conservative treatment. Clinical assessment and MRI scan confirmed torn/stretched/abnormal ATFL and no other significant pathology. Surgery was performed by a single surgeon Pre-operative questionnaire was completed on the day of surgery. (AOFAS, MOXFQ, EDQ-5, Visual Analogue Score) Surgery was performed as Day case with General anaesthetic and popliteal block. Antibiotics were given at induction. Anterior ankle arthroscopy performed through 2 standard anterior portals. +ve drive through confirmed. Arthroscopic stabilisation with Arthrex InternalBraceTM System:- 3.5 mm BioComposite SwiveLock with FiberTape placed into fibula with the distal end of FiberTape passed through 4.75 mm BioComposite SwiveLock / FibreTape (InternalBraceTM) placed into the talar neck. Post-op mobilisation in a moonboot for 7-10 days. Commence physiotherapy at 10 days. Biomechanical podiatric assessment at 6 weeks. Called for FU assessment at 2 years. Results: In the short term FU group, the majority of patient (13 of 17) reported that they were satisfied or very satisfied with the results of there surgery, with 10 of 16 stating that the surgery gave good, very good or excellent pain relief. The majority of patients (12 of 16) would definitely have the surgery again. Review at two years of clinical notes for patients who previously had surgery for ATFL injury with InternalBraceTM. Patients with other pathologies were excluded. This gave a similar cohort to the six month review patients. All patients were contacted for FU by an ESP Podiatrist and invited to come for clinical review. Only 3 patients reported on-going issues with pain, 1 of which requires revision surgery. Conclusion: Arthroscopic ATFL repair using an InteralBraceTM allows early post-operative rehabilitation with accelerated fully weight bearing rehabilitation. This audit would suggest that the short-term positive results are maintained into the medium term at 2-3 years. The long term outcome is currently not known due to this being a relatively new procedure. This method of ATFL repair could have great potential for elite athletes but also for ‘every day’ patients who still desire to have a rapid return to normal function.

Influence of ankle joint plantarflexion and dorsiflexion on lateral ankle sprain: A computational study.

Understanding the mechanism of injury involved in lateral ankle sprain is essential to prevent injury, to establish surgical repair and reconstruction, and to plan reliable rehabilitation protocols. Most studies for lateral ankle sprain posit that ankle inversion, internal rotation, and plantarflexion are involved in the mechanism of injury. However, recent studies indicated that ankle dorsiflexion also plays an important role in the lateral ankle sprain mechanism. In this study, the contributions of ankle plantarflexion and dorsiflexion on the ankle joint were evaluated under complex combinations of internal and inversion moments. A multibody ankle joint model including 24 ligaments was developed and validated against two experimental cadaveric studies. The effects of ankle plantarflexion (up to 60°) and dorsiflexion (up to 30°) on the lateral ankle sprain mechanism under ankle inversion moment coupled with internal rotational moment were investigated using the validated model. Lateral ankle sprain injuries can occur during ankle dorsiflexion, in which the calcaneofibular ligament and anterior talofibular ligament tears may occur associated with excessive inversion and internal rotational moment, respectively. Various combinations of inversion and internal moment may lead to anterior talofibular ligament injuries at early ankle plantarflexion, while the inversion moment acts as a primary factor to tear the anterior talofibular ligament in early plantarflexion. It is better to consider inversion and internal rotation as primary factors of the lateral ankle sprain mechanism, while plantarflexion or dorsiflexion can be secondary factor. This information will help to clarify the lateral ankle sprain mechanism of injury.

Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability.

When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. Level IV, retrospective case series.

The Role of Calcaneofibular Ligament (CFL) Injury in Ankle Instability

Category: Ankle Introduction/Purpose: Acute inversion ankle sprains are among the most common musculoskeletal injuries. Higher grade sprains, which include anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, can be particularly problematic and often require surgical repair. The implications of CFL injury on ankle instability are unclear. We aim to evaluate the impact of CFL injury on ankle stability and subtalar joint biomechanics. We hypothesized that CFL injury will result in decreased stiffness and torque, and alteration of ankle contact mechanics compared to the uninjured ankle in a cadaveric model. Methods: Twenty matched cadaveric ankles dissected of skin and subcutaneous tissue were mounted to an Instron with 20° of ankle plantar flexion and 15° of internal rotation. Intact specimens were axially loaded to body weight, then underwent inversion stress along the anatomic axis of the ankle from 0 to 20° (simulating inversion injury) for three cycles. ATFL and CFL were sequentially sectioned, and inversion testing repeated for each condition. Stiffness and change in torque were recorded using an Instron, and pressure and contact area were recorded using a calibrated Tekscan sensor system. Inversion angle of the talus and calcaneus relative to the ankle mortise were recorded using a three-dimensional motion capture system. Paired t tests were performed for inter and intra-group comparisons. Results: Stiffness and torque did not significantly decrease after sectioning of the ATFL, but did decreased significantly after sectioning of CFL. Peak pressures in the tibiotalar joint decreased significantly following CFL release compared to both the uninjured ankle and ATFL-only release. Mean contact area significantly increased following CFL release compared to both the uninjured ankle and ATFL release. There was a concentration of force in the anteromedial ankle joint during weight-bearing inversion. However, the center-of-force shifts 1.22 mm posteromedial after CFL release relative to an intact ankle. Motion capture showed a significant and sequential increase in inversion angle of both the calcaneus and talus, after release of each ligament. There was significantly more inversion in the subtalar joint than the tibiotalar joint with weight-bearing inversion. Conclusion: There is significantly lower stiffness and torque with weight-bearing inversion of the ankle joint complex following injury to both ATFL and CFL, and sequentially greater inversion of the talus and calcaneus with progressive ligament injury. This corresponds to a significant shift in the center of force in the tibiotalar joint. CFL contributes considerably to lateral ankle stability, and sprains that include CFL injury result in substantial alteration of contact mechanics at the ankle and subtalar joints. Repair of CFL may be beneficial during lateral ligament reconstruction, potentially mitigating long-term consequences (e.g., articular damage) of a loose or incompetent CFL.

Is there a Relationship between Bone Morphology and Injured Ligament on Imaging Studies and Laxity on Ankle Stress Radiographs?

Category: Ankle, Sports Introduction/Purpose: We hypothesized that the bony configuration of the ankle could also be associated with ankle stress radiographs, in addition to ligament injury of the ankle. Therefore, this study aimed to investigate the relationship between bone morphology and injured ligament on imaging studies and laxity on ankle stress radiographs in patients with lateral ankle instability. Methods: In total, 115 patients who had undergone ankle MRI, ankle radiography, and stress radiography were included. Distal tibial articular surface angle, bimalleolar tilt, medial and lateral malleolar relative length, medial malleolar slip angle, anterior inclination of the tibia, and fibular position were measured on ankle radiographs. Tibiotalar tilt angle and anterior translation of the talus were measured on ankle stress radiographs. Degree of ligament injury was evaluated on ankle MRIs. Multiple regression analysis was performed using the following independent variables: age, sex, and factors significantly associated with ankle stress view on univariate linear regression analysis. Results: Age (p = 0.041), sex (p = 0.014), degree of anterior talofibular ligament injury (p &lt; 0.001), and bimalleolar tilt (p = 0.016) were correlated with tibiotalar tilt angle (Table). Younger patients demonstrated a larger tibiotalar tilt angle than older patients, and the angle decreased by 0.07° per year of age. Tibiotalar tilt angle in female patients was 2.2° larger than that in male patients. Fibular position and degree of posterior talofibular ligament injury were factors significantly related to anterior translation of the talus. Conclusion: Differences in patient characteristics might predispose ankle stress radiograph results. Comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side, in order to reduce the influence of patient factors.