Anterior Talofibular Ligament Injury Research Articles

Influence of anterior talofibular ligament injury and mechanical ankle anterior displacement on symptoms in individuals with chronic ankle instability.

Repeated ankle sprains can lead to injuries, including those of the anterior talofibular ligament; however, the extent to which these ligament injuries are associated with symptoms of chronic ankle instability remains unclear. To examine the influence of anterior talofibular ligament injury and ankle anterior displacement on symptoms of chronic ankle instability. Case-Control Study. A university laboratory. A total of 426 college students completed a questionnaire survey on the history of ankle sprain. Thirty-four (24 males, 10 females; age = 20.6 ± 0.5 years), 49 (38 males, 11 females; age = 20.2 ± 1.2 years), and 39 (24 males, 15 females; age = 20.1 ± 1.1 years) participants were enrolled in the healthy, coper, and chronic ankle instability groups, respectively. One examiner measured the anterior talofibular ligament delineation using ultrasound and anterior ankle displacement using a capacitance-type sensor device. The Cumberland Ankle Instability Tool was applied to assess pain and perceived instability. The anterior talofibular ligament was normal significantly more frequently in healthy participants and abnormal significantly more frequently in patients with chronic ankle instability (p < 0.001). Anterior ankle displacement was significantly greater in the coper and chronic ankle instability groups than in healthy individuals (p < 0.001), but no significant difference was observed between the coper and chronic ankle instability groups. There was no significant correlation between the anterior ankle displacement and Cumberland Ankle Instability Tool scores (p = 0.709) in participants with previous ankle sprains. Observation of an abnormal anterior talofibular ligament on ultrasonography is associated with anterior displacement of the ankle joint. However, it is assumed that the influence of anterior ankle displacement due to damage to the anterior talofibular ligament on the pain and perceived instability in chronic ankle instability is small.

Enhancing the Diagnosis of Lateral Ankle Sprains: The Role of MSK Diagnostic Ultrasound in Evaluating ATFL and CFL.

Lateral ankle sprains, predominantly involving the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), constitute a significant portion of sports-related injuries, with a notable rate of recurrence and progression to chronic instability. Precise diagnosis and effective treatment of the ATFL and CFL injuries are crucial in preventing long-term complications. Musculoskeletal (MSK) diagnostic ultrasound has emerged as a pivotal tool in the rehabilitation sector, particularly in assessing lateral ankle ligament injuries. This article will highlight its benefits over traditional diagnostic methods and the emerging role of MSK diagnostic ultrasound as a superior tool for accurate, cost-effective, and comprehensive assessment of these injuries. We discuss the technology's ability to provide objective, real-time imagery, facilitating accurate diagnosis, treatment planning, and injury monitoring emphasizing the need for a standardized approach to ultrasound evaluation to improve diagnostic accuracy and patient outcomes.

Optimal assessment for anterior talofibular ligament injury utilizing stress ultrasound entails internal rotation during plantarflexion

ObjectivesAn optimal load and ankle position for stress ultrasound of the injured anterior talofibular ligament (ATFL) are unknown. The objectives of this study were to compare stress ultrasound and ankle kinematics from a 6 degree-of-freedom (6-DOF) robotic testing system as a reference standard for the evaluation of injured ATFL and suggest cut-off values for ultrasound diagnosis. MethodsTen fresh-frozen human cadaveric ankles were used. Loads and ankle positions examined by the 6-DOF robotic testing system were: 40 N anterior load, 1.7 Nm inversion, and 1.7 Nm internal rotation torques at 30° plantarflexion, 15° plantarflexion, and 0° plantarflexion. Bony translations were measured by ultrasound and a robotic testing system under the above conditions. After measuring the intact ankle, ATFL was transected at its fibular attachment under arthroscopy. Correlations between ultrasound and robotic testing systems were calculated with Pearson correlation coefficients. Paired t-tests were performed for comparison of ultrasound measurements of translation between intact and transected ATFL and unloaded and loaded conditions in transected ATFL. ResultsGood agreement between ultrasound measurement and that of the robotic testing system was found only in internal rotation at 30° plantarflexion (ICC ​= ​0.77; 95% confidence interval 0.27–0.94). At 30° plantarflexion, significant differences in ultrasound measurements of translation between intact and transected ATFL (p ​< ​0.01) were found in response to 1.7 Nm internal rotation torque and nonstress and stress with internal rotation (p ​< ​0.01) with mean differences of 2.4 ​mm and 1.9 ​mm, respectively. ConclusionBased on the data of this study, moderate internal rotation and plantarflexion are optimal to evaluate the effects of ATFL injury when clinicians utilize stress ultrasound in patients. Level of evidenceIII.

Comparison of Knot-Tying Techniques During the Arthroscopic Broström-Gould Procedure: Semiconstrained Freehand Versus Knot Pusher Techniques.

The arthroscopic Broström technique with or without Gould modification has been used to treat patients with anterior talofibular ligament injury who failed nonoperative management and progressed to chronic lateral ankle instability. However, some patients develop limited range of motion over the ankle joint postoperatively. To compare the clinical outcomes and midterm functional performance of knot-tying techniques between using a knot pusher and a semiconstrained freehand tie during arthroscopic Broström-Gould procedure with inferior extensor retinaculum (IER) augmentation. It was hypothesized that the semiconstrained freehand tie would provide better plantarflexion of the ankle joint compared with the knot pusher. Cohort study; Level of evidence, 3. Included were 135 consecutive patients with mild-to-moderate lateral ankle instability (mean age, 42.7 years; range, 16-78 years) who underwent an arthroscopic Broström-Gould procedure from March 1, 2016, to April 30, 2022. The patients were divided into 2 groups according to the tying technique used in the Gould modification: surgical tie using a knot pusher (KP group; n = 30) or a semiconstrained freehand tie (FT group; n = 105). Radiographic parameters and ultrasound dynamic testing were examined during the preoperative assessment. Preoperative and 2-year postoperative assessments comprised American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale for pain, and 12-Item Short Form Survey (SF-12) scores. The 2 groups had no differences in age, sex, or severity distribution in the preoperative assessment. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, visual analog scale pain, and SF-12 scores were significantly better at the postoperative evaluation (all P < .05) in both groups. No significant difference was noted between groups in outcome scores. In the KP group, however, 7 out of 30 patients (23.3%) developed ankle stiffness with tightness when performing plantarflexion movement. No patients in the FT group reported similar symptoms. For mild-to-moderate chronic lateral ankle instability, we propose an arthroscopic Broström procedure with the addition of IER augmentation using a semiconstrained freehand tie to avoid overtightening the IER. This ensures favorable patient satisfaction and clinical outcomes without limitation of plantarflexion of the ankle joint and avoids the possible complication of stiffness with plantarflexion.

Construction of an Artificial Neural Network Model for Predicting Ankle Ligament Injury Based on the Results of Ultrasonic Shear Wave Technology and Magnetic Resonance Imaging

We aimed to study the factors influencing the extent of anterior talofibular ligament (ATFL) and calcaneal ligament (CFL) injuries in acute ankle fractures based on construction of an Artificial Neural Network (ANN) Model. Differences in various baseline data, including personal data, anthropometric data, disease history, and life history, were compared among patients with ATFL injury, ATFL+CFL injury, and ATFL fracture. Factors influencing the ATFL injury/ATFL+CFL injury/ATFL fracture were analyzed using logistic regression, and an artificial neural network (ANN) model for predicting ATFL fracture was constructed using the tensor flow framework. Advanced age (OR= 36.33, 95%CI (15.72, 60.62)), male (OR = 21.21, 95%CI (5, 39.92)), high BMI (OR = 0.03, 95%CI (−0.31 0.37)), exercise duration (OR = 0.48, 95%CI (−14.66, 18.3)), and history of diabetes (OR = 16.98, 95%CI (−76.44, 480.78)) may all be influential factors in the ATFL and CFL injury/ATFL rupture. We constructed three neural layers, the first containing 11 ganglia, the second containing 7 ganglia, and the third containing 5 ganglia, and after 10 iterations the ANN model LOSS values were reduced to the lowest and scatter plots were made of the true and predicted values with some linear trend and better prediction. Advanced age, male, high BMI, length of exercise, and history of diabetes may be influential factors in the ATFL and CFL injuries/ATFL rupture. Applying the tensor flow framework, the ANN algorithm was constructed to predict the occurrence of ATFL fracture with good results.

A biomechanical comparison of the double-row suture fixation and compression screw techniques in the treatment of lateral malleolar avulsion fracture

BackgroundAvulsion fractures of fibula occur with ankle sprains. The purpose of this study was to compare the biomechanical characteristics of double-row suture versus compression screw techniques in treatment of lateral malleolar avulsion fracturelarger than 10 mm in size, which is typically not associated with an anterior talofibular ligament injury. MethodsWe simulated lateral malleolus avulsion fractures in six matched pairs of 12 human cadaveric ankles. These were then randomly divided into two groups: a double-row fixation group and a compression screw group. Biomechanical testing was performed after surgical fixation. The foot was rotated from the neutral position toward inversion at a rate of 1°/s until 12.5 N-m or structural failure was reached. The final rotation torque, rotation angle, stiffness, and displacement of the ossicles were recorded. ResultsNo significant difference was found in the final rotation torque (7.60 ± 3.70 vs 7.23 ± 2.06 N-m, p = 0.87), rotation angle (43.61 ± 14.77° vs 40.93 ± 10.94°, p = 0.56), stiffness (0.19 ± 0.08 vs 0.13 ± 0.07, p = 0.33), or displacement (6.11 ± 5.23 vs 7.09 ± 5.93 mm, p = 0.77) between the two groups. Conclusions: The stability of the double-row suture fixation was equivalent to compression screw fixation in treating a lateral malleolar avulsion fracture larger than 10 mm in size with ligament injury, as determined by our biomechanical testing.

Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side

AbstractPurposeTo evaluate the clinical outcomes of anatomic repair procedure for chronic anterior talofibular ligament (ATFL) injury at the talar side, and to compare the outcomes between patients with and without concomitant avulsion fractures. It was hypothesized that anatomic repair procedure could produce similarly satisfactory outcomes for those two groups.MethodsThirty‐nine consecutive patients with chronic ATFL injuries at the talar side who underwent anatomic repair procedure at the department of sports medicine at Peking University Third Hospital between 2013 and 2018, were retrospectively evaluated. The pain visual analogue scale (VAS), American Orthopaedic Foot &amp; Ankle Society (AOFAS) score, Tegner score, and Foot &amp; Ankle Outcome Score (FAOS) were recorded as the primary outcomes. Time to return to sports (RTS), surgical satisfaction, deficiency of ankle range of motion (ROM), recurrent sprain, and postoperative complications were recorded as the secondary outcomes. Outcomes were compared between patients with (Group A, 16 cases) and without (Group B, 23 cases) concomitant avulsion fractures.ResultsThe mean follow‐up time was 79.4 ± 17.0 and 76.6 ± 18.5 months for Group A and B, respectively. VAS, AOFAS, Tegner, FAOS, and all subscale scores of FAOS were significantly improved in both groups at the final follow up. Patients in group A had inferior postoperative VAS, AOFAS, FAOS, and pain score of FAOS compared to group B (1.1 ± 1.1 vs. 0.4 ± 0.5, 89.1 ± 10.1 vs. 95.2 ± 5.2, 87.2 ± 7.2 vs. 91.5 ± 4.1, and 88.4 ± 11.3 vs. 96.7 ± 3.5, respectively).The mean time to RTS, rate of satisfaction and recurrent sprain had no significant differences between group A and B (6.1 ± 2.8, 93.8%, and 18.8% vs. 5.2 ± 2.2, 100.0%, and 13.0%, respectively), and the rate of ROM deficiency was significantly higher in group A (37.5 vs. 8.7%). Avulsion fracture was identified as an independent risk factor for inferior pain score of FAOS.ConclusionAnatomic repair procedure for chronic ATFL injuries at the talar side produces favourable results for patients with and without avulsion fractures at 5 to 10 years follow‐up, however, avulsion fracture is associated with more pain.Level of evidenceIII.

Magnetic Resonance Imaging Characteristics of a Lateral Ligament Injury in Acute Ankle Sprains Among Athletes

Background: It is important to identify the location and pattern of lateral ligament injuries that are related to the development and prognosis of chronic ankle instability in athletes with ankle sprains. Purpose: To describe the location and pattern of lateral ligament injuries on magnetic resonance imaging (MRI) in elite-level or amateur athletes with acute ankle sprains and to further assess the risk of associated concomitant injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) of 110 athletes with an ankle lateral ligament injury (mean age, 24.7 years) were evaluated. MRI scans were evaluated for the location and pattern of ATFL and CFL tears such as sleeve avulsions as well as concomitant deltoid ligament injuries, bone contusions, and osteochondral lesions of the talus (OLTs). Results: On MRI, 52 (47.3%) athletes had an isolated ATFL tear, 56 (50.9%) athletes had both ATFL and CFL tears, and 2 (1.8%) athletes had an isolated CFL tear. ATFL injuries occurred at the fibula, midsubstance, and talus in approximately equal numbers, whereas the majority of CFL injuries occurred at the calcaneal insertion. Concomitant deltoid ligament injuries were identified in 18 (16.4%) athletes. In addition, concomitant bone contusions and OLTs were identified in 38 (34.5%) and 6 (5.5%) athletes, respectively. Using linear-by-linear analysis, CFL injuries correlated with concomitant deltoid ligament and bone injuries ( P = .023 and P = .001, respectively) and a sleeve injury pattern ( P = .005). Conclusion: After an acute ankle ligament rupture, almost all athletes involved in this study had injured their ATFL, and approximately 50% had a concomitant injury to the CFL. The rate of sleeve-type CFL injuries at the calcaneal insertion was high, and concomitant deltoid ligament injuries and OLTs were associated with this pattern of injury.

Immediate Weight Bearing after Modified-Brostrom Reconstruction: A Retrospective Review of an Accelerated Rehab Protocol

Category: Ankle; Sports Introduction/Purpose: Majority of injuries to the anterior talofibular ligament (ATFL) will go on to heal with non-operative management. Nearly a third of these injuries, however, will go on to develop chronic pain and instability; in these cases, operative reconstruction is indicated. An anatomic modified Broström reconstruction has replaced a traditional tenodesis as the standard of care. This reconstruction is often limited by damage to the native tissue and the time required for ligamentous healing, restricting the benefits of early weight bearing. In order to maximize the benefits of early range-of-motion exercises and weight bearing while protecting the repair, a suture-tape augmented Broström procedure has been suggested. We hypothesized that a suture-tape augmented Broström procedure would allow early weightbearing while preventing early failure. Methods: A retrospective chart review of patients who underwent a suture-tape augmented Broström procedure from August, 2020 to January, 2023 was conducted. Our inclusion criteria consisted of MRI confirmation of ATFL injury, a positive anterior drawer, failure of non-operative management, and post-operative physical exam consisting of a single leg hop and single leg heel raise at six weeks. Patients who had concomitant cartilage injuries with allograft repair, posterior arthroscopic debridement, peroneal tendon repair, syndesmosis repair, or calcaneal osteotomies were excluded. All patients participated in our accelerated rehab protocol which included immediate post-operative weightbearing as tolerated (WBAT) in a boot for two weeks followed by WBAT in an ankle brace for four weeks. Physical therapy was initiated two weeks post-op. Our primary outcome was the ability of patients to perform a single leg hop and single leg heel rise at six weeks. Secondary outcomes included visual analog scores (VAS) and post-operative complications. Results: 128 patients met our inclusion criteria. Our mean follow up was 11 (range, 6-52) weeks. At 6 weeks postoperatively, 88 (90%) of the patients asked could perform a single-leg heel raise and 73 (80%) of the patients asked could perform a single-leg hop. The average VAS at the final follow up visit was 1.03+1.9 (range, 0-8). No patients required a revision surgery. Post-operative complications were peroneal or sural neuritis (6 patients) and persistent pain (4 patients). There was no difference in primary and secondary outcomes in patients who had concomitant cartilage injuries not treated with grafting. Male patients were more likely to be able to complete a single leg hop at 6 weeks postoperatively (p = .04). No difference was found amongst other demographic factors. Conclusion: This study demonstrated that a modified-Broström procedure with suture-tape augmentation allowed for immediate weight bearing without reconstruction failure. The vast majority of patients had an excellent functional outcome at six weeks post- operative with minimal complications being recorded. There were no cases of revision surgery, DVTs, post-operative infections, and no patients reported residual instability.

Comparative clinical study of the modified Broström procedure for the treatment of the anterior talofibular ligament injury—outcomes of the open technique compared to the arthroscopic procedure

PurposeTo observe the clinical efficacy and safety of arthroscopic-modified Broström surgery for the treatment of anterior talofibular ligament injury.MethodsThe clinical data of 51 cases with anterior talofibular ligament injury were retrospectively analyzed, in which 23 patients were treated by arthroscopic-modified Broström surgery (arthroscopic surgery group) and 28 patients were treated by open-modified Broström surgery (open surgery group). The time to surgery, hospital stay, visual analog scale (VAS) scores of ankle pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and incidence rate of complications were compared between the two groups.Results(1) General results: compared with open surgery group, arthroscopic surgery group had shorter time to surgery and hospital stay ((33.8 ± 6.7) min, (42.1 ± 8.5) min, t = 1.468, P = 0.001; (2.2 ± 1.4) d, (5.8 ± 1.6) d, t = 1.975, P = 1.975, P = 0.002). (2) VAS scores of ankle pain: there was an interaction effect between the time and group factors (F = 0.378, P = 0.018); overall, there was no statistically significant difference in VAS scores of ankle pain between the two groups, i.e., there was no grouping effect (F = 1.865, P = 0.163); there was statistically significant difference in VAS score of ankle pain at different time points before and after operation, i.e., there was a time effect (F = 1.675, P = 0.000); the VAS scores of ankle pain showed a decreasing trend with time in both groups, but the decreasing trend was not completely consistent between the two groups ((7.78 ± 1.23), (1.23 ± 1.24), (1.03 ± 0.35), (1.01 ± 0.28), F = 0.568, P = 0.000. (7.45 ± 1.43), (1.45 ± 1.87), (1.23 ± 0.55), (1.04 ± 0.37), F = 1.358, P = 0.000); there was no statistically significant difference in VAS score of ankle joint pain between the two groups six and 12 months before and after surgery (t = 2.987, P = 0.055; t = 1.654, P = 2.542; t = 0.015, P = 0.078); the VAS scores of ankle pain in the arthroscopic surgery group was lower than that in the open surgery group three months after operation (t = 1.267, P = 0.023). (3) AOFAS ankle and hindfoot scores: there was an interaction effect between time and grouping factors (F = 2.693, P = 0.027); overall, there was no statistically significant difference in the AOFAS ankle and hindfoot scores between the two groups, i.e., there was no grouping effect (F = 1.983, P = 0.106); there was statistically significant difference in the AOFAS ankle and hindfoot scores at different time points before and after surgery, i.e., there was a time effect (F = 34.623, P = 0.000); the AOFAS ankle and hindfoot scores of the two groups showed an increasing trend with time, but the increasing trend of the two groups was not completely consistent ((48.19 ± 12.89), (89.20 ± 8.96), (90.24 ± 7.89), (91.34 ± 9.67), F = 25.623, P = 0.000; (49.35 ± 13.28), (86.78 ± 12.34), (88.78 ± 9.78),(91.43 ± 7.98), F = 33.275, P = 0.000); there was no statistically significant difference in the AOFAS ankle and hindfoot scores between the two groups 12 months before/after surgery (t = 2.145，P = 0.056；t = 2.879，P = 0.389); compared with open surgery group, the arthroscopic surgery group had higher AOFAS ankle and hindfoot scores 3/6 months after surgery (t = 1.346, P = 0.014; t = 1.874, P = 0.028).ConclusionFor the treatment of anterior talofibular ligament injury, arthroscopic surgery group is superior to open surgery group in ankle pain relief and functional recovery and has shorter operation time and hospital stay compared with open surgery group.

Comparative Evaluation of Metallic and Biodegradable Suture Anchors in Arthroscopic Repair of Anterior Talofibular Ligament Injury: A Short-term Study on Clinical and Functional Outcomes.

BACKGROUND With the development of arthroscopy and suture anchor, the modified Brostrӧm technique has made remarkable progress. However, it is unclear which material is most suitable for treating anterior talofibular ligament injury (ATFL). This study evaluated the short-term efficacy of 2 suture anchors (metal vs biodegradable materials) in arthroscopic ATFL repair. MATERIAL AND METHODS From January 2018 to December 2019, 82 patients with ankle disorders (51 men and 31 women) with ATFL injury received arthroscopic repair with suture anchor through the Brostrӧm-Gould procedure. The mean age was 38.70±9.35 years (range, 18-54 years). Each patient was followed up. American Orthopedic Foot and Ankle Society score (AOFAS), Karlsson Ankle Functional Score (KAFS), and the Visual Analogue Scale (VAS) were used to evaluate functional status and pain. RESULTS All patients were followed up for 21.21±2.19 months (range, 18-25 months). No complications were found either group. Preoperative clinical and functional scores in both groups had no significant difference (P>0.05). The functional score increased significantly in both groups (P<0.001). At the last follow-up, the mean AOFAS score was 93.00 (90.00, 96.00) in the Biodegradable group and 93.50 (91.00, 96.00) in the Metallic group (P=0.31). The mean KAFS score was 91.50 (85.00, 95.00) in the Biodegradable group and 93.00 (90.00, 95.50) in the Metallic group (P=0.10); the mean VAS score was 1.50 (1.00, 1.80) in the Biodegradable group and 1.30 (0.98, 1.70) in the Metallic group (P=0.22). CONCLUSIONS Arthroscopic repair of ATFL injury with suture anchors can improve the prognosis of CAI. There were no statistically significant differences in clinical and functional outcomes with metal or biodegradable suture anchors at short-term follow-up.

Prevalence and Injury Patterns of CFL Injury in Chronic Lateral Ankle Instability: An Observational Cross-Sectional Study Using Ultrasound

The purpose of this paper is to assess the prevalence and injury patterns of the calcaneofibular ligament (CFL) in chronic lateral ankle instability (CAI) patients using ultrasound imaging. This retrospective study included 938 ankle ultrasound images from January 2016 to May 2018. The patients' demographic data and the injury pattern classified by the injury location and the remnant quality were recorded and correlated using t tests, Fisher's exact tests, and post hoc tests accordingly. Of the 938 CAI patients, CFL injury was found in 408/938 (44%). Among the 408 anterior talofibular ligament (ATFL) and CFL complex injury patients, 71/408 (17%) presented with a completely absorbed ATFL, whereas 13/71 (18%) presented with an absorbed CFL. The total CFL absorption proportion in all patients was relatively low (30/938=3%). Post hoc tests indicated a negative association between thickened ATFLs and complex injuries. In addition, a positive association existed between absorbed ATFLs and complex injuries as well as absorbed ATFLs and absorbed CFLs. Thus, the results indicated that total tearing and absorption injury patterns of the CFL in CAI are not common. Even when the ATFL is absorbed, only approximately one-fifth (13/71=18%) of CFLs require reconstruction, suggesting that it is unnecessary to routinely repair or reconstruct CFLs in all lateral ligament surgeries.

Anatomical study of the bone morphology of the anterior talofibular ligament attachment.

Anterior talofibular ligament (ATFL) injuries are the most common cause of ankle sprains. To ensure anatomically accurate surgery and ultrasound imaging of the ATFL, anatomical knowledge of the bony landmarks around the ATFL attachment to the distal fibula is required. The purpose of the present study was to anatomically investigate the ATFL attachment to the fibula with respect to bone morphology and attachment structures. First, we analyzed 36 feet using microcomputed tomography. After excluding 9 feet for deformities, the remaining 27 feet were used for chemically debrided bone analysis and macroscopic and histological observations. Ten feet of living specimens were observed using ultrasonography. We found that a bony ridge was present at the boundary between the attachments of the ATFL and calcaneofibular ligament (CFL) to the fibula. These two attachments could be distinguished based on a difference in fiber orientation. Histologically, the ATFL was attached to the anterodistal part of the fibula via fibrocartilage anterior to the bony ridge indicating the border with the CFL attachment. Using ultrasonography in living specimens, the bony ridge and hyperechoic fibrillar pattern of the ATFL could be visualized. We established that the bony ridge corresponded to the posterior margin of the ATFL attachment itself. The ridge was obvious, and the superior fibers of the ATFL have directly attached anteriorly to it. This bony ridge could become a valuable and easy-to-use landmark for ultrasound imaging of the ATFL attachment if combined with the identification of the fibrillar pattern of the ATFL.

Modified classifications and surgical decision-making process for chronic anterior talofibular ligament injuries based on the correlation of imaging studies and arthroscopic findings.

Surgical treatment of chronic ankle instability (CAI) typically includes ligament repair or reconstruction. Using preoperative ultrasonography or magnetic resonance imaging (MRI) to choose an appropriate arthroscopic procedure is still difficult. The aim of this study was to evaluate the correlation of imaging studies with arthroscopic findings and support the arthroscopic surgical decision-making process. One hundred twelve patients with chronic anterior talofibular ligament (ATFL) injuries were treated using the arthroscopic surgical decision-making process from November 2018 to August 2020. Preoperative imaging assessments using dynamic ultrasonography, MRI, and combined methods were applied to categorize the ATFL remnants into three quality grades ("good," "fair," and "poor"). Arthroscopic findings were classified into 6 major types (7 subtypes) and used to select an appropriate surgical procedure. Correlations between imaging studies, arthroscopic findings, and surgical methods were evaluated. Diagnostic parameters, clinical outcomes, and complications were also assessed. There was a significant interobserver agreement in the evaluation of dynamic ultrasonography (0.954, P < 0.001), MRI (0.958, P < 0.001), and arthroscopy diagnosis (0.978, P < 0.001). There was a significant correlation between the modified imaging classifications, arthroscopic diagnostic types, and surgical procedures. The mean follow-up period was 33.58 ± 8.85 months. Significant improvements were documented in postoperative ankle functions when assessed with Karlson-Peterson scores and Cumberland Ankle Instability Tool scores. The risk of complications is also very low. The modified classifications and surgical decision-making process based on dynamic ultrasonography, MRI, and arthroscopic findings, as proposed in this study, might help in selecting an appropriate arthroscopic surgical procedure for chronic ATFL injuries.

Incidence of Injuries Associated With Anterior Talofibular Ligament Injury Based on the Reporting of Magnetic Resonance Imaging.

Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan doneor hadankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDsfound in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

Ultrasound or MRI in the Evaluation of Anterior Talofibular Ligament (ATFL) Injuries: Systematic Review and Meta-Analysis.

Ankle sprains represent the second most common cause of emergency department access for musculoskeletal injury and lateral ankle ligament complex tears account for 850,000 cases annually in the United States with a relapse rate of 70%. Clinical examination is limited due to its subjectivity and the difficulty of identifying a specific involvement of the ligament; therefore, US and MRI are frequently requested. Therefore, the goal of this study is to analyze the available literature on the use of ultrasound (US) and magnetic resonance imaging (MRI) to diagnose injuries to the anterior talofibular ligament (ATFL) with a meta-analytic approach. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, all studies regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging ATFL injuries were searched and assessed. The data were obtained from two independent reviewers with 12 and 3 years of experience in meta-analysis. A QUADAS-2 (Quality Assessment of Studies of Diagnostic Accuracy Studies) checklist was carried out to assess the risk of biases. From the selected studies, the sensitivity, specificity, and accuracy data were extracted. Nine studies were included. The results of the meta-analysis demonstrate a greater sensitivity for ultrasound [96.88 (95% CI: 94-99) (fixed effects); 97 (95% CI: 94-99) (random effects)] compared to MRI [88.50 (95% CI: 85-91) (fixed effects); 86.98 (95% CI: 77-94) (random effects)], p < 0.05. The result of this meta-analysis shows that the less expensive diagnostic technique is also the most sensitive for the diagnosis of ATFL tears. Ultrasound articles resulted to have non-heterogeneity [(p = 0.2816; I° = 21.4607%)]. This meta-analysis demonstrates that US appears to be a highly sensitive diagnostic technique for diagnosing tears of the ATFL. Compared to MRI, the sensitivity of US result was higher.

Use of a comprehensive systemic ultrasound evaluation in the diagnosis and analysis of acute lateral region ankle sprain

BackgroundFor the diagnosis of acute lateral ankle sprain, many clinicians use ultrasound; they typically focus on the lateral ligament complex, which is the most common site of lesions in ankle sprain. However, this approach risks missing other foot and ankle lesions. The present study aimed to provide and analyze the results of a new ultrasound method of diagnosis for acute lateral ankle sprain which can thoroughly investigate overall lesions of the foot and ankle.MethodsRetrospective cross-sectional cohort study of 123 patients who underwent diagnostic ultrasound within 1 week of acute lateral ankle injury was performed. Causes of ankle sprain, incidence and severity of each ligament injury, location of anterior talofibular ligament (ATFL) injury, accompanying ligament injury, and occult fracture were analyzed.ResultsAmong the 102 cases of ATFL injuries, 60 (58.5%) had islolated ATFL injury, 28 (27.5%) had accompanying calcaneofibular ligament injury (CFL), and 14 (13.7%) had accompanying midtarsal or syndesmosis injury. ATFL injuries occurred on the fibula attachment in 48 (47.1%) cases, ligament mid-substance in 24 (23.5%) cases, and talus attachment in 30 (29.4%) cases. Among the 165 lesions from 123 cases, injuries of the fourth or fifth dorsal tarsometatarsal (12 cases, 7.3%), bifurcate (11 cases, 6.7%), and anterior tibiofibular (11 cases, 6.7%) ligaments were not rare.ConclusionThese findings suggest that an ultrasound examination involving investigation of the midtarsal joint and syndesmotic ligament, as well as the ATFL and CFL, is useful for comprehensive, systemic diagnosis of acute lateral ankle sprain.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years.

An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation. Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used. Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability. At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone. Level II, retrospective cohort study.

The effect of thickness and elastic modulus of the anterior talofibular ligament on anterior ankle joint stiffness: A subject-specific finite element study.

Ankle sprain is a frequent type of sports injury leading to lateral ligament injury. The anterior talofibular ligament (ATFL) is a primary ligamentous stabilizer of the ankle joint and typically the most vulnerable ligament injured in a lateral ankle sprain (LAS). This study aimed to quantitively investigate the effect of the thickness and elastic modulus of ATFL on anterior ankle joint stiffness (AAJS) by developing nine subject-specific finite element (FE) models under acute injury, chronic injury, and control conditions of ATFL. A 120N forward force was applied at the posterior calcaneus leading to an anterior translation of the calcaneus and talus to simulate the anterior drawer test (ADT). In the results, the ratio of the forward force to the talar displacement was used to assess the AAJS, which increased by 5.85% in the acute group and decreased by 19.78% in the chronic group, compared to those of the control group. An empirical equation described the relationship between AAJS, thickness, and elastic modulus (R-square 0.98). The equation proposed in this study provided an approach to quantify AAJS and revealed the effect of the thickness and the elastic modulus of ATFL on ankle stability, which may shed light on the potential diagnosis of lateral ligament injury.

Deep Learning Approach for MRI in the Classification of Anterior Talofibular Ligament Injuries.

Diagnosing anterior talofibular ligament (ATFL) injuries differs among radiologists. Further assessment of ATFL tears is valuable for clinical decision-making. To establish a deep learning method for classifying ATFL injuries based on magnetic resonance imaging (MRI). Retrospective. One thousand seventy-three patients from a single center with ankle MRI within 1 month of reference standard arthroscopy (in-group dataset), were divided into training, validation, and test sets in a ratio of 8:1:1. Additionally, 167 patients from another center were used as an independent out-group dataset. Fat-saturation proton density-weighted fast spin-echo sequence at 1.5/3.0 T. Patients were divided into normal, strain and degeneration, partial tear and complete tear groups (groups 0-3). The complete tear group was divided into five sub-groups by location and the potential avulsion fracture (groups 3.1-3.5). All images were input into AlexNet, VGG11, Small-Sample-Attention Net (SSA-Net), and SSA-Net + Weight Loss for classification. The results were compared with four radiologists with 5-30 years of experience. Model performance was evaluated by the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and so on. McNemar's test was used to compare performance among the different models, and between the radiologists and models. The intraclass correlation coefficient (ICC) was used to assess the reliability of the radiologists. P < 0.05 was considered statistically significant. The average AUC of AlexNet, VGG11, SAA-Net, and SSA-Net + Weight Loss was 0.95, 0.99, 0.99, 0.99 in groups 0-3 and 0.96, 0.99, 0.99, 0.99 in groups 3.1-3.5. The effect of SSA-Net + Weight Loss was similar to SSA-Net but better than AlexNet and VGG11. In the out-group test set, the AUC of SSA-Net + Weight Loss ranged from 0.89 to 0.99. The ICC of radiologists was 0.97-1.00. The effect of SSA-Net + Weight Loss was better than each radiologist in the in-group and out-group test sets. Deep learning has potential to be used for classifying ATFL injuries. SSA-Net + Weight Loss has a better diagnostic effect than radiologists with different experience levels. 4 TECHNICAL EFFICACY: Stage 2.