Chronic Functional Instability Research Articles

Primary revision with replasty of the anterior cruciate ligament

Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft. Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening. Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage. Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and aperoneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall.In non-anatomical tunnels, anew femoral tunnel is drilled over adeep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL.Using drills and dilators, atunnel is prepared.At the tibia, the anterior horn of the lateral meniscus serves as alandmark in the absence of an ACL stump.The cortical tibial tunnel aperture is probed with aguide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with aspoon or synovial resector to remove graft residues and implants from the tunnel.The femoral fixation can either be done with aflip button, an interference screw or in the case of abone block graft implant-free. At the tibial side, the graft is fixed with aresorbable interference screw and fixation button. The rehabilitation program comprises 4-5phases. Inflammatory phase (weeks1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase3 (from week6): strength and coordination exercises. Phase4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10. Included were 51patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.

Surgical reconstruction with the remnant ligament improves joint position sense as well as functional ankle instability: a 1-year follow-up study.

Introduction. Chronic functional instability—characterized by repeated ankle inversion sprains and a subjective sensation of instability—is one of the most common residual disabilities after an inversion sprain. However, whether surgical reconstruction improves sensorimotor control has not been reported to date. The purpose of this study was to assess functional improvement of chronic ankle instability after surgical reconstruction using the remnant ligament. Materials and Methods. We performed 10 cases in the intervention group and 20 healthy individuals as the control group. Before and after surgical reconstruction, we evaluated joint position sense and functional ankle instability by means of a questionnaire. Results and Discussion. There was a statistically significant difference between the control and intervention groups before surgical reconstruction. Three months after surgery in the intervention group, the joint position sense was significantly different from those found preoperatively. Before surgery, the mean score of functional ankle instability in the intervention group was almost twice as low. Three months after surgery, however, the score significantly increased. The results showed that surgical reconstruction using the remnant ligament was effective not only for improving mechanical retensioning but also for ameliorating joint position sense and functional ankle instability.

Die anatomische Ersatzplastik des vorderen Kreuzbands in Einzelbündeltechnik

Restore the knee stability by ACL reconstruction of the anterior cruciate ligament. Acute and chronic functional instability with rupture of the anterior cruciate ligament giving way phenomena, acute rupture of the anterior cruciate ligament with concomitant meniscus repair. Local infection in the knee joint, local soft tissue damage, lack of cooperation of the patient. The operation begins with the examination under anesthesia. It follows an arthroscopic examination of the knee and the arthroscopic treatment of accompanying intra-articular lesions (meniscus and cartilage damage). The semitendinosus tendon is harvested via a 3 cm skin incision medial to the tibial tuberosity. A four stranded tendon graft is prepared with a minimum length of 6.5 cm. Alternative grafts for this technique are the patellar tendon, quadriceps tendon, and allografts. The femoral tunnel for the ACL graft is drilled via a deep anteromedial portal under arthroscopic control. For precise placement of the guide wire a specific offset aimer is used. For drilling the knee must be flexed more than 110°. Landmarks are the intercondylar line and the cartilage-bone interface. The position of the guide wire is always controlled by the medial portal (medial portal view). The guide wire is overdrilled with a cannulated drill (4.5 mm when a flip tack is used). The drill diameter for the 30 mm long blind tunnel is chosen according to the graft diameter. A gentle tunnel preparation may be achieved with the use of dilators. At the tibia, the anterior horn of the lateral meniscus is used as a landmark in the absence of ACL stump. The guide wire is first overdrilled with a 6 mm drill. Slight adjustments to the tibial tunnel location can be archieved when the guide wire is overdrilled eccentrically with a larger drill. At the femur an extracortical fixation technique with a flip button is preferred. At the tibia, a hybrid fixation with absorbable interference screw and button is used. The rehabilitation program is divided into three phases. During the inflammatory phase (1st-2nd week) control of pain and swelling is recommended. The patient is immobilized with 20 kg partial weight bearing. During the proliferative phase (3 nd-6th week), load and mobility are slowly increased. Goal of this phase is it full extension. Exercises should be performed in a closed chain. During the remodeling phase strength and coordination exercises can be started. Athletes should not return to competitive sports before the 6th to 8th month. In a prospective study, we have examined 21 patients treated with an anatomic anterior cruciate ligament reconstruction in single-bundle technique, after two years. As graft the semitendinosus was used. The postoperative MRI diagnosis showed that all tunnels were positioned anatomically. KT 1000 measurement showed that the difference of anterior translation decreased from an average of 6.4-1.7 mm. A sliding pivot shift phenomenon was detected in only one patient. The postoperative Lysholmscore was 94.2 points.

Subtalar instability: a biomechanical cadaver study

Subtalar instability is thought to be one of the possible causes for chronic functional instability of the foot and ankle. The purpose of this study was to determine the extent of ligament injury that is followed by subtalar instability and to depict consecutive pathologic joint motion. Twelve fresh human cadaver lower legs were investigated with respect to pathologic motion and mobility of the subtalar joint in a modified spinal column simulator after arthrodesis of the talocrural articulation and selective sectioning of the lateral ligaments of the subtalar joint. In order to simulate several injury mechanisms, ligaments were dissected starting anteriorly in group one (n = 6) and posteriorly in group two (n = 6). Dissection of the bifurcate ligament in group one resulted in a significant increase in plantar- and dorsiflexion, dissection of the inferior extensor retinaculum resulted in a significant increase in eversion and inversion. Additional dissection of the lateral talocalcaneal ligament resulted in a significant increase in internal and external rotation. Dissection of the calcaneofibular ligament in group two was followed by significant kinematic changes regarding all degrees of motion in the subtalar joint. The calcaneofibular ligament plays a key role in lateral stabilisation of the subtalar joint. Therefore, ligaments of the subtalar joint should be included in surgical repair.

Ankle sprains: from diagnosis to management. the physiatric view

Ankle injuries are the most frequently encountered injuries in clinical practice. They are often managed by general practicians, and not only by orthopaedic or physiatric physicians. This injury is usually non-complicated, but some care should be taken to assure an adequate management and to exclude severe lesions. The stability of the ankle is necessary for functional activity of lower extremity, allowing walking and participation in other high demanding activities like running or jumping. There is a constant concern in adopting the best diagnostic and treatment procedures to enhance the recovery and to prevent the chronic joint instability. According to this, there should be proposed comprehensive strategies focusing the rehabilitation view. The ankle is a complex articular structure with contributions from the talocrural, subtalar, and inferior tibiofibular joints. The full understanding of the functional anatomy and biomechanics is the first step for the evaluation of the etiologic factors. The recognition of the mechanism of injury, and the risk factors, should be carefully addressed to make an accurate diagnosis, proper management and to implement prophylactic measures, knowing that the lateral ligamentous complex is the most commonly injured. As always, diagnosis can be made taking an adequate history, performing a thorough physical examination, and when necessary, requesting complementary studies. The priority in initial assessment it's to clear out some severe complications, like fractures, that can mimic or that can be associated with ankle sprains. Although the conventional radiology is suitable for most cases, that has been greatly improved through the institution of the Ottawa Rules, in selected patients the severity of the damage is best evaluated with other imaging resources. Treatment of acute ankle sprains depends on the severity of the injury. Most acute lateral ligament injuries are best treated nonsurgically and will regain satisfactory ankle stability after functional treatment. The conservative approach has been found to be equally effective in treating grade I and II ankle sprains. Some controversy still exists regarding the appropriate treatment of grade III injuries. General belief is that the majority of these patients may also be treated well with conservative management. Surgical reconstruction may be necessary, in cases that develop chronic functional instability, and especially in athletes with high demands on ankle joint stability. The purpose of this article is to review the biomechanics, clinical examination, diagnosis, management and secondary prevention of ankle sprains. We discuss the use and benefit of different modalities and outline a three-phase intervention program of rehabilitation based on recent guidelines.

Anatomical variations in the anatomy of the posterolateral corner of the knee

This cadaveric study of 22 knees described the anatomy of the deeper structures of the posterolateral corner, the popliteus-tendon complex, arcuate ligament complex, the popliteofibular ligament, and the coronary ligament. Most variations occurred in the popliteofibular ligament; the variations and the different nomenclatures used in the literature for these structures make it difficult to diagnose and repair injuries to them. Untreated injuries may result in chronic functional instability to the posterolateral corner of the knee.

The Effects of Exercise on Non-Accident Related Chronic Ankle Instablitiy in Participants With Collagen Disorders

Chronic functional instability is the inability of an individual to perform routine daily activities, such as standing, walking, or rising from a chair, due to the instability of joint structures. Several genetic and neuromuscular disorders exist that result in severe ankle instability (hypermobility) without a prior history of traumatic injuries (Ehlers-Danlos Syndrome, Marfan's Syndrome, Osteogenesis Imperfecta, and Benign Hypermobility Syndrome). Individuals with hypermobility are susceptible to recurring injury and have been previously treated with extensive rest, a treatment that has been shown to increase chronic instability. PURPOSE: To determine the effects of exercise and movement on non-accident-related chronic ankle instability, particularly in participants who have Ehlers-Danlos Syndrome or Benign Hypermobility Syndrome. METHODS: Five female participants (32±12 yrs) were recruited for this study and all completed the full study; three of the participants had Benign Hypermobility Syndrome and two had Ehlers-Danlos Syndrome. Participants took part in an eight-week exercise regimen, with ankle stability measurements taken at the pre-, 4-weeks, and post-study. The exercise regimen included four sections: resistance training, reactive neuromuscular training, proprioception exercises, and active stabilization exercises. Participants underwent two days of resistance training with reactive neuromuscular training and proprioception exercises, and a third day of resistance training with active stabilization exercises each week. Range of motion (using a goniometer) of the ankle was tested, and functional strength assessment included single-weight-bearing tests for dorsiflexion, plantar flexion, inversion, and eversion. Stability tests included anterior draw, posterior draw, talar tilt, wedge, and Thompson, and Kleiger's tests. RESULTS: Functional strength was increased for the five subjects, and pain levels were reduced in every subject, for each of the tests. Not only were pain levels reduced, but also joint popping was reduced and participants reported feeling higher levels of stability and balance. Subjects showed a generally reduced range of motion, from 25% to 65%, in all areas of the ankle joint. This overall decrease in the range of movement indicates a tightening of the joint capsule and an increase in joint stability. CONCLUSION: Strength exercises lead to decreased range of motion, strengthening of the ankle, increased balance, decreased pain, and an overall increase in daily function.

Prevention and treatment of ankle sprain in athletes.

The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.

Peroneal reaction time: study of a normal sample

Chronic functional instability is a residual problem after acute ankle sprain. Reasons may be weak ligaments and/or a deficit in the proprioceptive system. Studies have shown that peroneal reaction time (PRT) can be used to quantify proprioceptive performance. To test the influence of anthropometric data on PRT, an experimental study with 120 healthy volunteers was performed. Surface electrodes recorded the activity of the peroneal muscles after a sudden inversion on a tilting platform. It was found that PRT is not influenced by extrinsic or anthropometric data. Furthermore, the results prove a significant slackening in PRT with increasing age. Therefore, the patient's age must to be considered in judging the PRT.

The unstable and painful ankle joint: what is new?

The treatment of grade III ligament injuries should be early mobilization followed by early weightbearing. The mechanism of injury is complex. The results after nonsurgical treatment are satisfactory in most cases, and if problems due to chronic instability persist, several different surgical reconstructions are available and produce good results in many patients. A major concern after tenodesis is the increased risk of development of osteoarthrosis, as well as reduced range of ankle motion. Several studies have shown superior results after anatomic reconstruction of the ligaments compared with tenodeses. The incidence of subtalar injuries is unknown, but these injuries should be evaluated if surgical intervention is necessary in case of chronic functional instability, which may be caused by prolonged peroneal reaction time. Balance training may be an effective means of improving joint proprioception and single-leg stance in unstable ankles. Abbreviation:AOFAS American Orthopaedic Foot and Ankle Society Lateral ligament injuries are one of the most common injuries and may, in the active population, lead to chronic instability and, in some cases, pain. The instability pattern may even progress to chronic problems that interfere with activities of daily living. Lynch and Renström [1•] stated that sequelae of lateral ligament injuries are common. After nonsurgical treatment, 10% to 30% of patients develop chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness, and giving-way. These authors stated that secondary surgical repair, even several years after the index injury, produces satisfactory results in most patients, but subtalar instability should be evaluated when surgery is indicated. Milner and Soames [2•] investigated the anatomy of the collateral ligaments of the ankle joint. They found that the anterior talofibular ligament was 13.0 ± 3.9 mm in length and 11.0 ± 3.3 mm in width and the calcaneofibular ligament was 19.5 ± 3.9 mm in length and 5.5 ± 1.6 mm in width. These results were in line with those of previous investigators and are potentially valuable in cases in which surgical reconstruction is indicated. Wilson et al.[3••] studied the motor activity and perceived athletic ability and found that the athletes' self-reported responses to motor activities were as useful as objective measures to assess treatment response after acute ankle sprains in the athlete.

Biomechanics of the unstable ankle joint and clinical implications.

The aim of this paper is to provide fundamental information about the biomechanics of the unstable ankle joint and to establish a rational for the daily clinic when dealing with patients in both, the acute and chronic unstable condition of the ankle joint complex. The problem of the unstable ankle joint is worked up by analyses of the basic anatomy and biomechanics followed by an overview of its clinical manifestation including a differential diagnosis. The ankle joint and its surrounding ligaments represent a complex mechanical structure whose mechanical properties highly depend on ligament integrity. Recent in vitro studies have supported the hypothesis that, besides maintaining lateral ankle stability, the lateral ankle ligaments play a significant role in maintaining rotational ankle stability and in transferring movement between leg and foot. Instability of the ankle results from acute ligament injuries and may become chronic when complete ligament healing does not occur. Chronic instability syndrome may manifest with recurrent injuries with chronic lateral pain, tenderness, swelling, or induration with great difficulties in sports and daily activities. Symptomatic instability can be caused by mechanical instability with demonstrable instability, but it can be also present with no demonstrable instability. Impairment of ankle proprioception has been shown to be a major cause of symptomatic ankle instability. Other conditions may mimic ankle instability. The cause of chronic functional instability is often not mechanical instability but impairment of ankle proprioception. A history of insecurity, instability, and giving way is far more important in diagnosis than the physical and radiographic examination. If surgical treatment is advised, anatomical reconstruction of the ankle ligaments is mandatory for fear of altering the biomechanics.

Peroneal reaction time in treated functional instability of the ankle

Summary Peroneal reaction time was measured in two groups of patients with either acute or chronic unilateral instability of the ankle, both before and after treatment. Group A consisted of patients with chronic functional instability who were treated with surgical stabilization while Group B contained patients with acute functional instability who were treated with proprioceptive exercises. Statistical analysis of the electromyographic recordings taken from peroneus longus muscles of these patients showed longer mean peroneal reaction time before conservative or surgical treatment in both groups ( P P

Subtalar ankle instability. A review.

The aetiology of chronic functional lateral ankle instability is fairly well understood. Pathophysiological factors such as mechanical instability, proprioceptive deficit and peroneal muscle weakness have been demonstrated. Subtalar instability has been in focus during the last years as one of the possible factors behind chronic functional instability of the foot. The exact aetiology and the true incidence of subtalar ligament injuries remain unknown. Most subtalar ligamentous injuries probably occur in combination with injuries of the talo-tibial articulation. Subtalar instability can have the characteristics of chronic lateral instability or recurrent ankle sprains. Patients with chronic subtalar instability typically complain of 'giving way' symptoms and a history of recurrent sprains. Clinical examination including increased inwards rotation and forward displacement of the calcaneus may not be sufficient for the differentiation between ankle and subtalar instability. Radiographic imaging using stress radiographs may be necessary to assess subtalar instability. Subtalar instability can be defined as chronic functional instability with increased values of talar tilt and talo-calcaneal displacement as measured with standardised stress radiographs. Few authors have addressed the treatment of subtalar instability and the condition has not been clearly defined. Subtalar instability can be treated either with a tendon transfer or tenodesis procedure, such as the Chrisman-Snook or triligamentous tenodeses, or with an anatomic ligament reconstruction using the calcaneo-fibular, lateral talo-calcaneal and cervical ligaments combined with a reinforcement of the inferior extensor retinaculum. There have been no studies comparing anatomical and non-anatomical reconstructions and the long term results after ligamentous stabilisation are unknown. The focus of this article is on subtalar instability causing chronic functional ankle instability.

Measurement of plantar pressure distribution during gait for diagnosis of functional lateral ankle instability

INTRODUCTION:: Chronic functional instability of the lateral ankle may be difficult to distinguish from mechanical instability when radiological stress tests reveal only small ligamentous defects. For decision making whether to surgically reconstruct the ligaments or not, it can be helpful to use additional information on joint and foot function. Therefore, the aim of a prospective study of patients with longstanding chronic ankle instability was to demonstrate that the dynamic measurement of plantar pressure distribution can identify patients with functional ankle instability. [Table: see text] MATERIALS AND METHODS:: Sixty five patients (mean age 24 (4.6 years)) were included. After clinical examination and radiological stress views, plantar pressure patterns were measured during gait using a capacitive platform, the EMED-SF 2-system. Five trials of each foot were documented and the maximum impulses in eight points of the foot (central heel, lateral and medial heel, midfoot, 1st, 2nd, 5th metatarsal head and hallux) were calculated intraindividually and compared with a group of 100 healthy subjects. The medio-lateral loading factor (MLF) as the quotient of the medial and lateral relative impulses indicated the tendency to walk on the lateral edge of the foot. RESULTS:: Based on clinical criteria alone, two comparable groups of patients were separated, 35 with functional instability and 30 with mechanical instability. After collective analyses of the results, the patients with functional instability showed a significantly increased lateral loading of the unstable foot (p=0 0 1), whereas the mechanically unstable group tended to walk more on the medial side of the unstable foot (Table 1). DISCUSSION:: Dynamic measurement of plantar pressure can identify a group of patients walking on the lateral side of the unstable foot when compared with the stable foot. This finding is explained by a deficit of peroneal strength during stance phase based on a proprioceptive defect after trauma. The new application of the EMED-system provides additional information which helps to make decisions about the individual patient with chronic instability.

Dynamic pedography for assessing functional ankle joint instability

Chronic functional instability of the lateral ankle may be difficult to distinguish from mechanical instability when radiological stress test reveal only small ligamentous defects. When a decision for or against surgical reconstruction of the ligaments has to be made it can be helpful to use additional information on joint function. Therefore, a prospective study of 65 patients (mean age 24.1 +/- 4.6 years) with long-standing chronic ankle instability was conducted to demonstrate that the dynamic measurement of plantar pressure distribution can identify patients with functional ankle instability. Plantar pressure patterns were measured during gait by means of a capacitive platform, the EMED-SF system. The impulses at eight points of the foot were calculated intraindividually and compared with those in a group of 100 healthy subjects. On the basis of clinical criteria alone, the two groups of patients were distinguished, 35 with functional instability and 30 with mechanical instability. The patients with functional instability showed significantly increased lateral loading of the unstable foot (P = 0.01), whereas the group with mechanical instability tended to walk more on the medial side of the unstable foot. This finding is explained by a deficit or peroneal strength during the stance phase, based on a proprioceptive deficit after trauma. The new technique provides additional information, which is relevant and sufficiently important to help in making decisions about the individual patient with chronic instability.

Lateral Instability of the Ankle Joint

Acute lateral ankle ligament ruptures are successfully treated nonoperatively with physiotherapy, peroneal strengthening, and coordination training. About 10-20% of patients may develop functional instability despite adequate nonoperative treatment. Chronic functional instability is not always a severe disability, but reconstruction of the lateral ankle ligaments may be necessary for patients with high demands on ankle stability. More than 50 different surgical procedures for the treatment of chronic lateral ankle joint instability have been described. Most of these are tenodeses where one of the peroneus tendons is used, such as Evans, Watson-Jones, and Chrisman-Snook reconstructions. Good short-term results have been reported, but the long-term results after the Evans and Watson-Jones reconstructions are worse than anticipated. Anatomic ligament reconstruction with shortening, reinsertion, and imbrication of the elongated ligaments, a simple procedure with good long-term results, might be a better alternative than other more complex ligament reconstructions.

Knee ligament injuries in adolescents. Eight year follow-up of conservative management.

We have reviewed 32 patients who sustained a substantial knee ligament injury during adolescence when their knee epiphyses were open. They were all treated non-operatively and re-examined and evaluated in detail after an average of eight years. There were 25 Grade II partial tears and seven Grade III complete tears. After Grade II injuries the functional results were excellent or good, though static instability had not improved from the initial post-traumatic examination. The long-term results of Grade III injuries were poor, because of chronic functional instability, with continuous symptoms and some post-traumatic osteoarthritis. The results of non-operative treatment for Grade III ligament injuries were not acceptable.