Anterior Talofibular Ligament Tear Research Articles

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.

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.

Tibialis Anterior Tendon Intrasubstance Tear Associated with Anterior Talofibular Ligament Tear: A Rare Encounter

Tibialis anterior (TA) tendon injury is an uncommon condition among other foot and ankle tendon pathology and there is insufficient literature on incomplete or intrasubstance TA tendon tear. To date, no cases of TA tendon injury with concurrent anterior talofibular ligament (ATFL) tear has been documented. This is a rare case of a 22-year-old gentleman with ankle injury following sports activity and magnetic resonance imaging (MRI) ankle showed incomplete TA tendon tear with concurrent ATFL tear. We proceeded with TA tendon direct repair and ATFL reconstruction. Patient showed good recovery and at third months, sixth months and 1-year post-surgery, American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot scores were 86%, 90% and 96%, respectively. In TA tendon injury, incomplete tear or longitudinal split is reported mostly due to TA tendinopathy or degeneration. Early diagnosis followed by surgical treatment is shown to give better results, which can be either direct primary repair, tendon transfer or tendon reconstruction.

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.

Effectiveness of Ultrasound-Guided Platelet-Rich Plasma Injection in Comparison with Standard Conservative Treatment on Improving Pain and Function Among the Athletes with Partial Tear of Anterior Talofibular Ligament of Ankle: A Randomized Controlled Trial

Background: Ankle sprain is the most common injury in the world of sports and anterior talofibular ligament (ATFL) is most commonly affected. It is often underestimated, mismanaged and often result in delayed treatment, prolonged recovery times and long-term sequela. PRP may have enhancing effect on healing of partial tear of ATFL. Thus, the purpose of this study is to determine the role of PRP on partial tear of ATFL. Methods: A randomized controlled trail was done among athletes with partial tear of ATFL who visited Department of Sports Medicine, RIMS, Imphal during January 2021 – June 2022. Patients with MRI diagnosed partial tear of ATFL (N=48) randomized into PRP injection plus rehabilitation, (n=24) and rehabilitation alone, (n=24) groups. The outcomes were compared using Foot and Ankle Disability Index (FADI) score for function and Visual analogue scale for pain at baseline, 2nd, 6th, 12th and 24th weeks respectively. Results: Baseline characteristics were not statistically significant. There was statistically significant improvement seen in within the group comparison from baseline to 2nd, 6th, 12th and 24th weeks in both FADI and VAS in both the groups. There were statistically significant difference in mean changes of VAS and FADI score between the two groups from baseline to 2nd (p=0.007);(p=0.012), 6th (p=0.018);(p=0.009) and 12th (p=0.004); (p=0.001) follow-ups respectively with PRP group having more improvement however no significant difference at 24th weeks. Conclusion: Ultrasound guided PRP injection along with standard rehabilitation program might be a treatment of choice for partial ATFL tear. Keywords: ATFL tear, PRP, FADI, VAS, USG-guided.

A Study Of Spectrum Of Findings Of Magnetic Resonance Imaging In Ankle Joint Pathologies

Aims & Objectives: This study is being carried out to describe various MRI features in the pathologies of ankle joint. Trauma to the ankle joint is a significant cause of morbidity in the young & active individuals especially amongst labourer’s, road traffic accident patients and athletes. A correct diagnosis regarding traumatic/ non traumatic ankle joint pathologies is essential for early operative as well as non-operative treatment. Magnetic resonance imaging (MRI) has now been accepted as the best modality for non-invasive evaluation of ankle pathologies. This study was undertaken to study different pathologies of ankle joint and its incidence by MR imaging.MATERIALS AND METHODS:A total of 50 cases of clinically suspected & diagnosed of having any pathology of ankle joint by MR imaging of the ankle, at the department of Radiodiagnosis, AMC MET Medical college, L.G hospital, Maninagar, Ahmedabad. Study was performed between December 2018 to December 2019. MRI was carried out on SIEMENS 1.5 T MAGNETOM_ESSENZA machineResults:Of the total50 patients evaluated, most common pathology of ankle joint being anterior talofibular ligament tear & tenosynovitis,20(40%) cases of each, followed by stress fractures 17(34%) & contusions 16(32%). Associated findings include joint collection, marrow edema &soft tissue changes.Interpretation and Conclusions:From these observations, it is found that MRI is an excellent, noninvasive, radiation free imaging modality with multiplanar capabilities and better soft tissue delineation. It can accurately detect, localize and characterize various ligamentous, tendinous, bony & soft tissue pathologies related to ankle joint and thereby guiding in further management of the patient.

Arthroscopic anterior talofibular ligament reconstructin in chronic ankle instability: Two years results

PurposeIn chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability. MethodsEleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure. ResultsAt 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel. ConclusionsArthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity. Study designCase series

The correlation between clinical and ultrasound evaluation of anterior talofibular ligament and calcaneofibular ligament tears in athletes

The objectives of this study were to find correlation between the clinical and ultrasound grading in anterior talofibular ligament and calcaneofibular ligament tear, and to determine the sensitivity and specificity of the two stability tests among the athletes. Subsequently, we would like to propose a new grading criterion for an ultrasound examination. Two blinded assessors examined thirty-five patients with a history of recent lateral ankle sprain. The first assessor performed physical examination on the injured ankle by using the anterior drawer test and talar tilt test, and the second assessor performed dynamic and static ultrasound assessment for anterior talofibular ligament and calcaneofibular ligament. The clinical laxity grading and sonographic extent of ligamentous injury was graded into a three-point scale. There was a moderate positive correlation between clinical test and ultrasound grading of anterior talofibular ligament and calcaneofibular ligament with Spearman's correlation coefficient values of 0.58 and 0.66 respectively. Clinical grading of anterior drawer test had 59.1% sensitivity (95% CI: 0.36-0.79) while ultrasound grading had 100.0% specificity (95% CI: 0.75-1.00), with positive likelihood ratio of 0.77 and negative likelihood ratio of 0.44 in detecting a complete (grade 3) anterior talofibular ligament tear (P<0.05). Meanwhile, the clinical grading of talar tilt test had 54.5% sensitivity (95% CI: 0.23-0.83) and ultrasound grading had 100.0% specificity (95% CI: 0.85-1.00), with positive likelihood ratio of 1.0 and negative likelihood ratio of 0.45 in detecting a complete grade 3 calcaneofibular ligament tear (P<0.05). The dynamic ultrasound is recommended to determine the actual degree of disruption of the ligament especially when clinical grading under-grades the degree of tear. Grade 2 tears can vary from 10% tear to 90% tear causing the clinical correlation to become less strong. We recommend a new classification for ultrasound grading of grade 2 tears, which could result in a stronger correlation between clinical and ultrasound grading.

Ankle ultrasound for detecting anterior talofibular ligament tear using operative finding as reference standard: a systematic review and meta-analysis.

To evaluate the diagnostic accuracy of ankle ultrasound for detection of anterior talofibular ligament (ATFL) tear with a reference standard of operative finding. A computerized search of PubMed and EMBASE databases was performed to identify relevant original articles on ankle ultrasound for ATFL tear. The pooled proportions of the diagnostic accuracy estimates were assessed using random-effects modeling. We also assessed pooled proportions of the diagnostic accuracy according to injury stage (acute or chronic) and severity of injury (complete or partial). Heterogeneity among studies was determined using the inconsistency index (I2). Meta-regression analyses were performed to evaluate the potential sources of heterogeneity. Ten studies were included. The pooled proportion of the diagnostic accuracy of ankle ultrasound for ATFL was 0.95 (95% confidence interval [CI] 0.88-0.98). In subgroup analysis, the pooled proportion of the diagnostic accuracy of ankle ultrasound for acute ATFL tear was 0.92 (95% CI 0.85-0.95). The pooled proportion of the diagnostic accuracy of ankle ultrasound for chronic ATFL tear was 0.96 (95% CI 0.84-0.99). The pooled proportions of the diagnostic accuracy for complete and partial ATFL tear were 0.82 (95% CI 0.72-0.89) and 0.88 (95% CI 0.70-0.96), respectively. In the meta-regression analyses, the inclusion of pediatric patients was only significantly different (p = 0.007). Ankle ultrasound may be a useful diagnostic modality in the detection of ATFL tear in adults and children, regardless of injury stage and severity. For correct diagnosis of ATFL tear, a high-frequency ultrasound probe and sufficient experience of the examiner are mandatory.

Comparison of the diagnostic efficacy of arthroscopy and magnetic resonance on acute injury of the lateral ankle liga-ment complex

Objective To compare the diagnostic consistency and efficacy of arthroscopy and MRI on the severity of acute lateral ligament complex (LLC) injury, and to find an effective method to diagnose acute LLC injury accurately in early stage. Methods Data of 37 patients (27 males, 10 females), with acute lateral ligament complex injury who were treated from February 2015 to December 2016 were retrospectively analyzed. The average age was 28.6±6.2 years (range, 18-42 years) and duration from injury to operation was 4.6±3.3 days (range, 0.3-8 days). The results of MRI and ankle arthroscopy for detecting LLC injury were compared, and the consistency between the two examination results was analyzed. Results Different consistencies were found between the two examination methods according to different parts of LCC injuries. The consistency of injuries (partial tear,complete tear) at the starting point of anterior talofibular ligament and complete tear at the starting point of calcaneofibularliga-ment was ordinary (kappa=0.641, 0.624, 0.680), while the consistency of damage in other parts of LLC was poor (kappa< 0.4). Compared with arthroscopy, MRI has a diagnostic accuracy of 62% (23/37) for partial tear of anterior talofibular ligament, and 62% (23/37) for complete tear. And that of the calcaneofibularligament complete tear was 78% (29/37). Conclusion MRI had low capability in detecting the severity of acute LLC injury accurately and the diagnosing efficacy was insufficient, while ar-throscopic exploration had a high diagnostic value for acute ankle joint injuries. Key words: Lateral ligament, ankle; Arthroscopy; Magnetic resonance imaging

The Sensitivity of Computed Tomography in the Determination of Anterior Talofibular Ligament Tears

The Sensitivity of Computed Tomography in the Determination of Anterior Talofibular Ligament Tears

Differences Between Subtalar Instability and Lateral Ankle Instability Focusing on Subtalar Ligaments Based on Three Dimensional Isotropic Magnetic Resonance Imaging.

The purpose of this study was to assess the differences between subtalar instability (STI) and lateral ankle instability (LAI) focusing on subtalar ligaments using 3-dimensional (3D) isotropic magnetic resonance imaging (MRI). Preoperative MRIs of 10 patients with STI who failed nonoperative treatment and consequently underwent arthroscopic subtalar reconstruction were compared with preoperative MRIs of 23 patients with LAI who underwent ligament repair or reconstruction. Dimensions of anterior capsular ligament (ACL), interosseous talocalcaneal ligament (ITCL), calcaneofibular ligament (CFL), and anterior talofibular ligament (ATFL) were measured. Tears of ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed. Patients with subtalar instability had significantly lower ACL thickness and width than patients with LAI (thickness: 1.48 vs 2.12 mm, P = 0.045; width: 7.30 vs 8.64 mm, P = 0.029). An ACL thickness of 1.8 mm or less had sensitivity and specificity both at 75.0%, and an ACL width of 8 mm or less had sensitivity of 75.0% and specificity of 85.0% for discriminating STI from LAI. Absence or complete tear of ACL was more frequent in patients with STI than in patients with LAI (60.0% vs 13.0%, P = 0.010). The ATFL thickness was significantly greater in patients with LAI (P = 0.001). Complete tear of ATFL was more common in patients with LAI (P = 0.008). Complete tear of CFL was common in both the STI and LAI groups without significant difference (20.0% vs 21.7%). There was no significant difference in thickness and width of ITCL and in CFL thickness. Complete tear of ITCL, cervical ligament, and inferior extensor retinaculum were rare without significant difference. In patients with STI, the ACL is thin and narrow and more commonly absent or torn compared with patients with LAI. Complete tear of ATFL was more common in patients with LAI. Complete tear of CFL was commonly encountered in both the STI and LAI groups.

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.

Subtalar instability: imaging features of subtalar ligaments on 3D isotropic ankle MRI

BackgroundMRI analysis of subtalar ligaments in the tarsal sinus has not been well performed. We retrospectively investigated the appearance of subtalar ligaments using 3D isotropic MRI and compared imaging findings of subtalar ligaments between patients with subtalar instability (STI) and controls.MethodsPreoperative MRIs of 23 STI patients treated with arthroscopic subtalar reconstruction were compared to MRIs of 23 age- and sex-matched control subjects without STI. Thickness and width of anterior capsular ligament (ACL) and interosseous talocalcaneal ligament (ITCL) as well as thickness of calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) were measured. Abnormalities in ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed.ResultsSTI patients had significantly smaller ACL thickness and ACL width than controls (ACL thickness: 1.73 mm vs. 2.22 mm, p = 0.007; ACL width: 7.21 mm vs. 8.80 mm, p = 0.004). ACL thickness of ≤2.1 mm had a sensitivity of 66.7% and a specificity of 66.7% for diagnosis of STI. ACL width of ≤7.9 mm had a sensitivity of 80.0% and a specificity of 76.2% for the diagnosis of STI. However, thickness and width of ITCL, thickness of CFL, or thickness of ATFL was not significantly different between the two groups. Absence or complete tear of ACL was significantly more frequent in STI patients than that in controls (34.8% vs. 8.7%, p = 0.035). Complete tear of CFL and ATFL was more common in STI patients than that in controls, although the difference between the two groups was not statistically significant. Abnormalities of ITCL, cervical ligament, or inferior extensor retinaculum were not significantly different between the two groups.ConclusionsMRI features of thin or narrow ACLs may suggest STI. Absence or complete tear of ACL was significantly more common in STI patients than that in controls.

T2‐Mapping evaluation of early cartilage alteration of talus for chronic lateral ankle instability with isolated anterior talofibular ligament tear or combined with calcaneofibular ligament tear

To quantitatively evaluate the cartilage alteration of talus for chronic lateral ankle instability (LAI) with isolated anterior talofibular ligament (ATFL) tear and combined ATFL and calcaneofibular ligament (CFL) tear using T2 -mapping at 3.0T. In all, 27 patients including 17 with isolated ATFL tear and 10 with ATFL+CFL tear, and 21 healthy subjects were recruited. All participants underwent T2 -mapping scan at 3T and patients completed American Orthopaedic Foot and Ankle Society (AOFAS) scoring. The total talar cartilage (TTC) was segmented into six compartments: medial anterior (MA), medial center (MC), medial posterior (MP), lateral anterior (LA), lateral center (LC), and lateral posterior (LP). The T2 value of each compartment was measured from T2 -mapping images. Data were analyzed with one-way analysis of variance (ANOVA), Student's t-test, and Pearson's correlation coefficient. The T2 values of MA, MC, MP, TTC in the ATFL group and MA, MC, MP, LC, LP, TTC in the ATFL+CFL group were higher than those in the control group (P < 0.05). Moreover, the T2 values of MC, MP, LC, and TTC in the ATFL+CFL group were higher than those in the ATFL group (P < 0.05). The T2 values of MA in both patient groups were negatively correlated with AOFAS scores (r = -0.596, r = -0.690, P < 0.05). Chronic LAI with ATFL tear had a trend of increasing cartilage T2 values in talar trochlea, mainly involving medial cartilage compartments. Chronic LAI with ATFL+CFL tear might result in higher T2 values in a much larger cartilage region than with ATFL tear. MA could be the main cartilage compartment that may affect the patient's clinical symptoms. 1 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:69-77.

Weber B Fracture of the Lateral Malleolus with Concomitant Anterior Talofibular Ligament Injury following an Ankle Supination Injury.

The Lauge-Hansen (LH) classification attempts to predict patterns of ankle injuries based upon the preceding mechanism of injury. Although it is widely used in clinical practice, it has been criticized mainly due to numerous reports of cases conflicting the prediction system. Here, we report a case of a 32-year-old male who sustained a Weber B fracture of the lateral malleolus following a supination ankle injury, which was treated conservatively, following which the patient presented with ankle instability and was found to have concurrent anterior talofibular ligament tear. Critical review of the LH classification along with its shortcomings is discussed.

Value of ultrasonography in assessment of recent injury of anterior talofibular ligament in children.

IntroductionSprained ankle is a very common injury in children. Proper treatment of ligament injuries enables full recovery. X-ray and US examinations are commonly available diagnostic methods.Material and methodsTwo hundred and six children (113 girls and 93 boys, mean age 10.6) with recent ankle joint sprain (up to 7 days of injury) were subject to a retrospective analysis. All patients underwent an X-ray and US examination of the ankle joint within 7 days of injury. In 19 patients, anterior talofibular ligament reconstruction was conducted.ResultsX-ray failed to visualize a pathology in 129 children (63%); in 24 patients (12%), avulsion fracture of the lateral malleolus was found, and in 36 cases (17%), effusion in the talocrural joint was detected. Ultrasonography failed to visualize a pathology in 19 children (9%); in 60 patients (29%), it showed avulsion fracture of the lateral malleolus involving the attachment of the anterior talofibular ligament (ATFL); in 34 cases (17%), complete ATFL tear was detected, and in 51 patients (25%), partial ATFL injury was found. Other injuries constituted 19%. The surgeries conducted to repair the anterior talofibular ligament (19) confirmed the US/X-ray diagnoses in 100% of cases. Avulsion ATFL injury, i.e. the one that involves the ligament attachment site, is usually found in younger children (median: 8 years of age). Complete ATFL tears (not involving the attachment site) concern older children (median: 14 years of age).ConclusionsSince X-ray is of limited value in diagnosing ankle joint pathologies in recent sprain injuries in children, soft tissue imaging, i.e. ultrasonography, is the basic examination to assess the ligament complex. Avulsion fractures, which involve the ATFL attachment site and are usually found in younger children, are a consequence of the incomplete ossification and require urgent diagnosis and orthopedic consultation.

Medial joint line bone bruising at MRI complicating acute ankle inversion injury: What is its clinical significance?

To assess the incidence and clinical significance of medial joint line bone bruising following acute ankle inversion injury. Forty-five patients who underwent ankle magnetic resonance imaging (MRI) within 2 weeks of acute ankle inversion injury were included in this prospective study. Integrity of the lateral collateral ligament complex, presence of medial joint line bone bruising, tibio-talar joint effusion, and soft-tissue swelling were documented. Clinical follow-up at 6 months was carried out to determine the impact of injury on length of time out of work, delay in return to normal walking, delay in return to sports activity, and persistence of medial joint line pain. Thirty-seven patients had tears of the anterior talofibular ligament (ATFL). Twenty-six patients had medial joint line bone bruising with altered marrow signal at the medial aspect of the talus and congruent surface of the medial malleolus. A complete ATFL tear was seen in 92% of the patients with medial joint line bone bruising (p = 0.05). Patients with an ATFL tear and medial joint line bone bruising had a longer delay in return to normal walking (p = 0.0002), longer delay in return to sports activity (p = 0.0001), and persistent medial joint line pain (p = 0.0003). There was no statistically significant difference in outcome for the eight patients without ATFL tears. Medial joint line bone bruising following an acute ankle inversion injury was significantly associated with a complete ATFL tear, longer delay in the return to normal walking and sports activity, as well as persistent medial joint line pain. Its presence should prompt detailed assessment of the lateral collateral ligament complex, particularly the ATFL.

The “All Inside” Arthroscopic Broström Procedure: A Prospective Study of 40 Consecutive Patients

Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended initially, including functional rehabilitation. Surgery might be an option for those patients in whom nonoperative attempts fail. Various surgical approaches have been described in published studies for treating chronic lateral ankle instability. The procedures are typically grouped into 2 main categories: anatomic and nonanatomic repair of the lateral ligament complex. The open modified Broström-Gould anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. In the present study, we used an arthroscopic approach to treat chronic anterior talofibular ligament tears without the extensive open incisions common in the traditional modified Broström-Gould procedure. Our hypothesis was that the use of an all-inside arthroscopic Broström procedure would provide a minimally invasive technique with acceptable patient outcomes. We also wished to explore the complication rates and interval to return to weightbearing activity. A total of 40 ankles in 40 consecutive patients were included in the cohort.

Pseudoband formation: Missed ATFL tears on MR imaging

Background: The anterior talofibular ligament (ATFL) is the ligament most commonly injured during ankle sprains. Objective: The purpose of this investigation was to assess the sensitivity of Magnetic Resonance (MR) imaging for ATFL with open surgery, Brostrom-Gould surgical interventional considered the gold standard. Methods: A retrospective chart review using Operating Room (OR) and MR reports from April 2008-November 2009 led to a review of 137 charts, with 15 cases meeting the inclusion criteria. Results: The sensitivity for ATFL tears irrespective of extent of the tear was 93%. For full thickness ATFL tears, 10 were found to be positive on MR but 13 on OR with a sensitivity of 77%. Of the three missed cases, 2 were described as sprain injuries and the other normal using MRI. Conclusion: The recommendations for MR assessment of ankle injury include use of dedicated sequences and understanding the “pseudoband” concept. The two full thickness and two partial thickness tears on OR described as sprain injuries on MRI had a band of inflammatory granulation tissue. This tissue accounted for the appearance of the thick continuous band at MRI, the pseudoband. This study reaffirms the usefulness of MR in determining ATFL tears, aiding surgical decision making.