Chronic Lateral Ankle Instability Research Articles

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

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

[Evaluation of arthroscopic ATFL and CFL repair separately for chronic lateral ankle instability in conjunction with subtalar instability].

Objective: To investigate the clinical efficacy of simultaneous arthroscopic repair of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) for treating chronic lateral ankle instability (CLAI) in conjunction with subtalar instability (STI). Methods: This study is a retrospective case series study. The clinical data of 15 patients with ankle arthroscopic in the Department of Hand and Foot Surgery, the Second Affiliated Hospital of Soochow University from January 2019 to December 2022 were analyzed retrospectively. There were 11 male cases and 4 female cases, aged (28.6±1.5) years (range: 19 to 39 years). All the patients were evaluated by manual inversion stress X-ray and MRI before operation. Arthroscopically observing and then repairing the ATFL and CFL separately after further diagnostic confirmation. One year after operation, MRI was performed, and visual analogue (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle hindfoot scale (AOFAS-AH) and Karlsson ankle functional scale(KAFS) were evaluated. Data were compared using paired sample t test. Results: The follow-up period was (22.6±2.3) months (range: 12 to 30 months). At last follow-up,the VAS decreased from 6.1±1.4 preoperatively to 1.4±1.2(t=9.482, P<0.01). The AOFAS-AH improved from 50.5±11.7 preoperatively to 94.2±6.1(t=-13.132, P<0.01), and the KAFS improved from preoperatively 44.3±10.8 to 90.8±6.4 (t=-12.510, P<0.01). There were no complications such as recurred instability or joint stiffness. Conclusions: Arthroscopically repairing the ATFL and CFL separately can effectively restore the stability of the ankle and subtalar joint with small trauma. Patients can recover quickly after surgery. It provides a new idea for the clinical treatment of CLAI combined with STI.

Platelet-Rich Plasma Injections in Chronic Lateral Ankle Instability: A Case Series

The platelet-rich plasma (PRP) approach may be an effective treatment for joint and cartilage pathologies. However, the rationale for its effectiveness on joint instability is limited. This study aimed to assess the safety and effectiveness of PRP injections in patients with chronic lateral ankle instability (CLAI). This retrospective study was performed at a single-center outpatient clinic between January 2015 and February 2023 and included pre-intervention assessment and short-term follow-up. Patients were excluded if they had received previous surgical treatment or had constitutional hyperlaxity, systemic diseases, or grade II or III osteoarthritis. The clinical and functional evaluation consisted of the Karlsson score, the Cumberland Ankle Instability Tool (CAIT), Good’s grading system, the patient’s subjective satisfaction level, and the time required to return to exercise. The entire PRP therapy regime consisted of three PRP administrations at 7-day intervals and follow-up appointments. PRP was administered both intraarticularly and into talofibular ligaments. A total of 47 consecutive patients with CLAI were included, 11 were female (23.4%), with a mean age at intervention of 31.19 ± 9.74 years. A statistically significant improvement was found in the CAIT and Karlsson scores at 3 months (27.74 ± 1.68 and 96.45 ± 4.28, respectively) relative to the pre-intervention status (10.26 ± 4.33 and 42.26 ± 14.9, respectively, p &lt; 0.000). The mean follow-up of patients with CLAI was 17.94 ± 3.25 weeks. This study represents successful short-term functional and clinical outcomes in patients with CLAI after PRP treatment, with no adverse effects. It demonstrates the feasibility of a randomized controlled trial to further assess this therapy.

Anatomic Variations of the Calcaneofibular Ligament.

The lateral ankle joint comprises the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The purpose of this study was to propose a classification of CFL morphology. The material comprised 120 paired lower limbs from human cadavers (30 male, 30 female), mean age 62.3 years. The morphology was carefully assessed, and morphometric measurements were performed. A 4-part method for anatomic classification can be suggested based on our study. Type 1 (48.3%), the most common type, was characterized by a bandlike morphology. Type 2 (9.2%) was characterized by a Y-shaped band, and type 3 (21.7%) by a V-shaped band. Type 4 (20.8%) was characterized by the presence of 2 or 3 bands. Type 2 and 4 were divided into further subtypes based on origin footprint. The aim of our study was to describe variations of calcaneofibular ligament. Our proposed 4-part classification may be of value in clinical practice in future recognition of CFL injuries and in its repair or reconstruction. The anatomy of the CFL plays an important role in stability of the ankle. Greater recognition of anatomical variation may help improve reconstructive options for patients with chronic lateral ankle instability.

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability.

Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique. All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scalepain score, American Orthopaedic Foot and Ankle Societyankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared. A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference. Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients. Level III.

Functional outcomes and rates of return to sport activities in a non-athlete population after the open Brostrom-Gould repair: a seven-year follow-up.

After an ankle sprain, up to 20% of patients may develop chronic lateral ankle instability (CLAI) requiring surgical treatment. The objective of this study was to investigate the functional outcomes and rates of return to sport activities in a cohort of non-athlete patients with chronic lateral ankle instability (CLAI) who underwent the opened Brostrom-Gould technique (BGT). Seventy-nine patients (seventy-nine feet) from three different centers undergoing BGT were reviewed. For clinical and functional analysis, the AOFAS ankle-hindfoot scale was applied and rates of return to sport activities were assessed. Correlation of Δ-AOFAS and rates of return to sport activities with all variables analyzed was performed. Mean AOFAS score improved from 64.6 to 97.2 (p < 0.001). Sixty-one (77.2%) returned to preinjury activities and 18 (22.8%) changed to a lower-level modality. Symptoms of instability were related to Δ-AOFAS (p = 0.020). Change in the sport activity was related to pain and symptoms of instability (p = 0.41 and p < 0.001). Recreational athlete patients who underwent the BGT demonstrated excellent functional outcomes after a mean follow-up of 7years. Residual pain and symptoms of instability after surgery were the main complaints associated with limitations in physical activities.

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

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

A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure.

Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability. Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years. Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001). A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure. Level IV, retrospective cohort study.

Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients.

In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients. Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated. Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively. We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport. Level III, retrospective case control study.

Evaluation of Open Versus Arthroscopic Anterior Talofibular Ligament Reconstruction for Chronic Lateral Ankle Instability With Talar and Subtalar Cartilage MRI T2 Mapping: A 3-Year Prospective Study.

Previous studies have examined patients with chronic lateral ankle instability (CLAI) undergoing open and arthroscopic anterior talofibular ligament (ATFL) reconstruction, reporting equivalent clinical results between the 2 procedures. However, data on the magnetic resonance imaging (MRI) outcomes on cartilage health after the 2 procedures are limited. To compare the cartilage MRI T2 values of the talar and subtalar joints between patients with CLAI undergoing open and arthroscopic ATFL reconstruction. Cohort study; Level of evidence, 3. A prospective study was conducted on patients who underwent open or arthroscopic ATFL reconstruction between January 2018 and December 2019, with a mean follow-up duration of 3 years. MRI scans and American Orthopaedic Foot & Ankle Society (AOFAS) and Tegner score estimations were completed by patients ≤1 week before surgery, as a baseline measurement, and at a 3-year follow-up. A total of 21 healthy volunteers were included who underwent MRI at baseline. Cartilage health was evaluated using MRI T2 mapping. The talar and subtalar cartilage regions were segmented into 14 subregions. At baseline, patients with CLAI had substantially higher T2 values in the medial anterior, medial center, medial posterior, and lateral center regions on the talus compared with the healthy controls (P = .009, .003, .001, and .025, respectively). Remarkable increases in T2 values in the lateral posterior region on the talus were observed from baseline to follow-up in the open group (P = .007). Furthermore, T2 values were considerably higher in the medial center, medial posterior, lateral posterior, and lateral posterior calcaneal facets of the posterior subtalar joint at follow-up in the arthroscopic group compared with the baseline values (P = .025, .002, .006, and .044, respectively). No obvious differences in ΔT2 values were noted between the 2 groups at follow-up. The AOFAS and Tegner scores remarkably improved from baseline to follow-up for the 2 groups (open: 3.25 ± 0.58 vs 5.13 ± 0.81, P < .001; arthroscopic: 3.11 ± 0.90 vs 5.11 ± 1.08, P < .001), with no considerable difference between them. The elevated T2 values of cartilage could not be fully recovered after open or arthroscopic ATFL reconstruction. Both arthroscopic and open ATFL reconstruction displayed similar effects on cartilage health concerning ΔT2, but the arthroscopic group demonstrated more degenerative cartilage subregions than the open group.

Perioperative duloxetine improves postoperative outcomes after anterior talofibular ligament repair for chronic lateral ankle instability for patients with depression: A prospective randomized clinical trial

Background: Recent studies have indicated that depression is associated with persistent postoperative pain and decreased satisfaction following foot and ankle surgery. This study aimed to evaluate the effect of perioperative duloxetine on postoperative outcomes of anterior talofibular ligament (ATFL) surgical repair for chronic ankle instability (CAI) in patients with depression. We further sought to evaluate patients’ satisfaction and side effects related to duloxetine.Material and methods: Patients undergoing ATFL repair were screened for depression preoperatively with the Patient Health Questionnaire (PHQ-9). Among 249 patients who underwent arthroscopic or open surgical Brostrom repair of the ATFL, 120 patients were identified as being "possibly depressed" and were included in the study. Sixty patients were randomly assigned to the duloxetine group (one day preoperatively and for 6 weeks postoperatively), and the other sixty were randomized to the placebo group. Painkillers and opioid consumption, pain scores, and patient satisfaction were recorded at 12, 24, 48, and 72 hours postoperatively and at follow-up visits 1, 3, and 6 months after surgery. Patient-reported outcome measures (PROMs) were assessed preoperatively and at 3, 6, 12 and 24 months postoperatively. Duloxetine-related side effects such as nausea/vomiting and fatigue were also recorded.Results: The patients in the duloxetine group reported a significantly longer time to rescue analgesic and reduced opioid requirements (including celecoxib, pregabalin, acetaminophen, and tramadol). The patients experienced decreased pain intensity and greater satisfaction with their pain management at 24, 48, 72 h and 1 and 3 months after surgery (P < 0.05). The duloxetine group also had significantly better clinical and functional outcomes at 3 and 6 month follow-up compared to the placebo group (P < 0.05). The occurrence and rate of symptoms of duloxetine side effects was not significant.Discussion: Depression is an important factor to consider and address because its presence before surgery can predict poor postoperative outcomes, including more severe postoperative pain, persistent postoperative pain, and increased consumption of painkillers and opioids.Conclusion: Perioperative administration of duloxetine following ATFL repair for CAI in patients with depression increased the time to first postoperative rescue analgesic request and reduced both opioid consumption and postoperative pain. This approach also led to a high level of patient satisfaction. In addition, duloxetine improved the quality of recovery without leading to significant side effects.Level of Evidence: I; prospective randomized controlled trial.

A Review of Chronic Lateral Ankle Instability and Emerging Alternative Outcome Monitoring Tools in Patients following Ankle Ligament Reconstruction Surgery.

Ankle sprains are exceedingly common injuries in both athletes and the general population. They account for 10 to 30% of all sports injuries. Although the vast majority of lateral ankle ligament injuries respond successfully to conservative management, the absolute number of those that progress to chronic lateral ankle instability (CLAI) remains considerably important. This condition is characterized by persistent symptoms and may be associated with short-term and long-term complications and functional deficits. There is still a lack of ideal postoperative management of CLAI patients. Furthermore, an evidence-based rehabilitation phasing does not exist and most of the published studies regarding this subject suggest some protocols based on a wide variety of functional assessment scores and other modalities that are not accurate enough. Moreover, the literature that assesses the ability to return to work (RTW) and return to sport (RTS) in the general population and athletes operated for CLAI most commonly shows aggregated results with global rates of RTW or RTS without describing a detailed timeline based on the readiness of patients to return to each level of activity. Although stress radiographs and MRI have been assessed as potential tools to improve postoperative management of CLAI patients, the first modality is limited by its low sensitivity to detect laxity and the second one by its static character and its inability to predict neither the healing process phase nor the mechanical properties of the repaired/reconstructed ligaments. Bioelectrical impedance, mechanical impedance and near-infrared spectroscopy are non-invasive methods of measurement that could be potential assessment tools to help surgeons improve the postoperative management of patients after CLAI surgery.

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.

Patient-Reported Outcomes Following Open Broström-Gould Procedure: Minimum 5-Year Follow-Up.

Ankle sprains are a common musculoskeletal injury among the general population and often involve the lateral ligament complex. Although the majority of ankle sprains are treated successfully with nonsurgical conservative measures, an estimated 5% to 20% of ankle injuries ultimately develop chronic lateral ankle instability (CAI). Multiple surgical treatment modalities for the lateral ankle complex exist, such as anatomical and nonanatomical reconstruction. The current gold standard for primary surgical repair is the Broström-Gould procedure. This is the first article to provide PROMIS scores following BG and the largest study with 5-year outcomes for an open BG. This was a descriptive study of a retrospective cohort of patients undergoing a BG with a minimum follow-up of 5 years. Patient-reported outcome instruments collected postoperatively were PROMIS Pain, Physical Function, Depression, and FAAM. Further preoperative clinic characteristics were analyzed to correlate with the final outcome. The electronic medical record was queried for Current Procedural Terminology (CPT) code 27698 (Broström-Gould) from January 2010 to June 2017. Surveys were conducted in the clinic and through phone interviews. Patient charts were reviewed to obtain basic patient demographic information including sex, age, race, and body mass index (BMI). The following preoperative variables were recorded: history of prior CAI procedures, history of major trauma, duration of symptoms, number of diagnosed ankle sprains, other collagen pathologies, generalized ligament laxity, participation in sports/activity level, peroneal subluxation, clinically diagnosed peroneus longus or brevis tendinopathy, deltoid ligament injury, anterior ankle impingement, and posterior ankle impingement. The PROMIS and Foot and Ankle Ability Measure (FAAM) scores were obtained with a combination of clinic and phone interviews. Data were aggregated in Microsoft Excel and entered in R (version 4.2.0) for statistical analysis. Our results show that the minimum 5-year patient-reported PROMIS scores for patients following a Broström-Gould procedure are as follows: PROMIS physical function, 50.5; PROMIS pain interference, 48.2; and PROMIS depression, 38.2. This indicates, at a minimum, that patients 5 years removed from the procedure are within 1 SD of the general population in regard to PROMIS physical function and pain. Our patient-reported FAAM, activities of daily living, and FAAM sports scores were 59.6 and 13.0 respectively. Preoperative magnetic resonance imaging (MRI) findings were recorded. Arthroscopic examination was performed before lateral ligaments reconstruction for patients with intra-articular pathologies confirmed on MRI. The findings from our study offer evidence supporting the effectiveness of the Broström-Gould procedure to be associated with normal physical function, even 5 years after surgery. Furthermore, our research identified specific factors such as tobacco use, diabetes, and sports participation that independently correlated with reported outcome measures. These insights enable physicians to better manage patient expectations and tailor treatment strategies accordingly. Our study establishes a foundation for future prospective research endeavors that aim to leverage the PROMIS system for comprehensive outcome assessments. Level III, retrospective cohort study.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

Diagnostic value of measuring the talofibular space using stress sonography in chronic lateral ankle instability

ObjectivesTo investigate the diagnostic value of measuring the talofibular space using stress sonography for chronic lateral ankle instability (CLAI). Materials & methodsWe recruited patients who were clinically diagnosed with CLAI between October 2018 and December 2019 (CLAI group). A control group of healthy volunteers was also included for this study. Both groups underwent a preliminary stress sonographic examination. First, the ultrasonic characteristics of the anterior talofibular ligament (ATFL), including length, thickness, relaxation, calcification, and rupture, were observed using conventional sonography. Second, the talofibular space at the passive neutral position (D1) and maximum varus position (D2) was measured (by stress sonographic images), and the difference (ΔD = D1-D2) between them was determined. Third, the parameters of the two groups were statistically compared. Finally, receiver operating characteristic (ROC) curves and area under the curve (AUC) analyses were performed for parameters with significant differences. ResultsThe CLAI group comprised 60 patients, yielding data on 60 ankles, whereas the control group comprised 35 participants, yielding data for 70 ankles. Differences in D1, D2, and ΔD of the talofibular space between the two groups were significant, with ΔD proving to be the best diagnostic indicator (P < 0.001). Its AUC, optimal cutoff value, sensitivity, and specificity were 0.922, 0.11 cm, 73 %, and 94 %, respectively, followed by D2 (0.850, 0.47 cm, 67 %, and 94 %, respectively; P < 0.001) and D1 (0.635, 0.47 cm, 67 %, and 94 %, respectively; P = 0.006). ConclusionMeasurement of talofibular space in stress sonography is a valuable diagnostic indicator for CLAI, especially the ΔD between the neutral and stress position.

Single Incision Broström-Gould Surgery With Peroneal Debridement and Calcaneal Osteotomy

Objective: Chronic lateral ankle instability (CLAI) with hindfoot varus is a common condition that can be treated with various surgical approaches. The Broström-Gould procedure is the gold-standard surgery for CLAI, and a sliding lateralizing calcaneal osteotomy (SLCO) is a common procedure for CLAI with hindfoot varus. The purpose of this paper is to describe a single-incision approach for the Broström-Gould repair with concomitant peroneal tendon debridement and an SLCO. Patients and Methods: The study retrospectively reviewed 189 cases of lateral ankle ligamentous repair with peroneal tendon debridement and an SLCO between 2011 and 2020. Of these, 53 patients had a single-incision approach, meeting the major inclusion criteria. The remaining patients had 2 incisions. Inclusion criteria for this study required patients to be at least 18 years of age, have a preoperative diagnosis of CLAI with hindfoot varus, and receive an isolated one-incision approach for a Broström-Gould procedure with concomitant peroneal tendon debridement and an SLCO. Results: The single-incision technique has shown to be equally effective with potential for decreased wound and neurovascular complications in comparison to a traditional multi-incisional approach. Conclusions: The single-incision technique for the Broström-Gould repair with concomitant peroneal tendon debridement and an SLCO is a safe and effective approach for treating CLAI with hindfoot varus. This technique offers adequate visualization of the lateral ankle ligaments, peroneal tendons, and lateral calcaneus while still achieving excellent postoperative cosmesis.

Results of Anatomical Arthroscopic Repair of Anterior Talofibular Ligament in Chronic Lateral Ankle Instability Patients.

To assess the clinical and functional outcomes of all-inside arthroscopic anatomical repair of anterior talofibular ligament (ATFL) for management of chronic lateral ankle instability (CLAI) in a considerable number of patients during medium-term follow-up. A retrospective analytic study was performed on 100 patients with CLAI who presented between August 2015 and July 2020 (average age: 32.9 years; range: 16-54 years). All-inside arthroscopic ATFL direct repair was performed in all patients through 2 portals only with fixation using 2 knotless anchors. Associated intraarticular lesions were treated in the same procedure. Outcomes were assessed with pre- and postoperative visual analog scale (VAS), the ankle-hindfoot score of the American Orthopaedic Foot & Ankle Society (AOFAS), and the Karlsson Ankle Functional Score (KAFS). All patients were followed for 24-48 months. At the final follow-up, ankle pain had improved significantly. Both the ankle anterior drawer test and the ankle varus stress tests were negative. There was no loss of ankle range of motion compared with preoperative measures, and all patients returned to normal gait. The mean VAS score decreased to 0.39 ± 0.63, the AOFAS score increased to 95.17 ± 4.7, and the KAFS score increased to 95 ± 4.07. All the follow-up indexes significantly improved compared to those before surgery. At minimum 24-month follow-up, the all-inside arthroscopic ATFL repair used to treat CLAI was found to restore ankle stability and yield good clinical outcomes with a relatively low complication rate. Level III, retrospective cohort study.

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability.

Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI. Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed. The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain. Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

Clinical outcomes of arthroscopic lateral ligament repair using a knotless anchor for chronic lateral ankle instability

Background/objectiveArthroscopic lateral ligament repair (ALLR) for chronic lateral ankle instability (CLAI) has been improving with technical innovations. However, there is a lack of information regarding mid- and/or long-term clinical outcomes after the introduction of ALLR. This study aimed to report mid-term clinical outcomes of ALLR with a knotless anchor. MethodsThirty-two patients (11 men and 21 women; mean age, 28 ± 14 years) who underwent ALLR with a knotless anchor from December 2015 to October 2020 were included. The mean follow-up period was 31 ± 11 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were used for clinical evaluation preoperatively and at the 2-year follow-up. Surgical complications, particularly knot irritation, were also examined. ResultsThe JSSF scale scores were significantly improved, from 71.3 ± 13.1 preoperatively to 96.6 ± 5.1 postoperatively (P < 0.05), and the SAFE-Q showed similar improvement in all subscales (P < 0.05). One case had a complication of persistent pain around the lateral portal (3.1%). ConclusionALLR using a knotless anchor provided satisfactory clinical outcomes over 2 years, and no major complications, such as knot irritation, were observed. Case seriesLevel of Evidence, 4.