Chronic Lateral Instability Research Articles

Comparison of Clinical Outcomes after Arthroscopic Anterior Talofibular Ligament Repair with or without Inferior Extensor Retinaculum Augmentation

Category:Sports; ArthroscopyIntroduction/Purpose:Though several arthroscopic surgical techniques for the treatment of lateral instability of the ankle have been introduced recently; the effect for the inferior extensor retinaculum augmentation is remained unclear. The purpose of this study was to compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair with or without additional retinaculum augmentation.Methods:We performed a retrospective review between 2017 and 2018 of 61 consecutive patients who underwent arthroscopic ATFL repair surgery for chronic ankle lateral instability. The exclusion criteria were previous surgery on affected ankle and combined medial ligament instability. Demographic data were evaluated including age, gender, smoking, Body mass index, generalized hyperlaxity and concomitant lesions. Patients were divided into two groups according to whether retinaculum repair or not. Clinical results were analysed to compare groups A and R preoperatively and at minimum follow-up of 1 years by using the Visual Analogue Scale, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome score (FAOS), and Karlsson Ankle Functional Score. Radiologic outcome evaluations were performed preoperatively and at 2 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle.Results:A total of 62 patients were included in this study. Patients were divided into two groups: group A consisted of 29 patients who underwent only arthroscopic ATFL repair and group R consisted of 32 patients who underwent arthroscopic ATFL repair and additional retinaculum augmentation. There was no difference statistically between two group in demographics (Table 1). All clinical scores were improved after surgery in both groups. (P<0.001) There were no differences were found in VAS, AOFAS score, total FAOS and Karlsson score between two groups. However, sports activity unit in FAOS, there were significant differences between group A (71.4 +- 8.1) and group R (83.4 +- 8.6) (Table 2). (p=0.032) Radiographic data also showed no differences (Table 3).Conclusion:Arthroscopic ATFL repair achieved improved outcomes postoperatively with or without retinaculum augmentation. However, among physically active patients with chronic ankle lateral instability, arthroscopic ATFL repair with retinaculum augmentation results in better sports activity unit in FAOS as compare with arthroscopic ATFL repair alone.

Lateral Ligament Instability: Review of Pathology and Diagnosis.

Ankle sprains are a common injury that can lead to chronic lateral ankle instability resulting in pain, poor function, and decreased quality of life. The purpose of this review is to present information regarding injury mechanisms to the lateral ligaments of the ankle and the necessary steps to appropriately diagnose lateral ligament instability. The literature demonstrates that history and physical examination is often a reliable method for diagnosis of lateral ankle instability. In addition, imaging modalities are often used as adjuncts for diagnosis, especially when physical exam findings are equivocal. In summary, chronic lateral ligament instability of the ankle occurs secondary to failure of the lateral ligamentous complex. A focused physical examination to evaluate the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament is necessary for diagnosis. Imaging modalities including plain radiographs, stress radiographs, and MRI are helpful for definitive diagnosis and to rule out other pathology.

Arthroscopic Anatomical Repair of Anterior Talofibular Ligament for Chronic Lateral Instability of the Ankle: Medium- and Long-Term Functional Follow-Up.

ObjectiveTo evaluate the functional outcomes of arthroscopic anatomical repair of anterior talofibular ligament (ATFL) in the treatment of chronic lateral ankle instability (CLAI) during medium‐ and long‐term follow‐up.MethodsFrom September 2014 to August 2017, the data of 37 patients (23 males, 14 females; 12 left ankles, 25 right ankles) aged between 21 and 56 years, with an average age of 32.17 ± 6.35 years, presenting with CLAI, was retrospectively analyzed. Among them, 32 injuries were caused by sprain and five injuries were caused by car accidents. The course of the disease lasted for 12 to 60 months, with an average of 26.07 ± 13.29 months. All patients had intact skin around the ankle and no skin lesions. All patients underwent arthroscopic anatomical repair of ATFL, with the fixation of one to two anchors. Pre‐ and post‐operative visual analogue scales (VAS), the American Orthopaedic Foot and Ankle Society Ankle‐Hindfoot Score (AOFAS), and the Karlsson Ankle Functional Score (KAFS) were compared to evaluate the curative effect of the operation.ResultsThe operation was successful in all 37 cases. The operation time ranged from 40 to 75 min, with an average of 51.25 ± 11.49 min. After surgery, all incisions healed in stage I and there were no complications such as nerve, blood vessel and tendon injury, implant rejection, or suture rejection. Hospital stays of postoperative patients were 3 to 5 days, with an average of 3.77 ± 1.36 days. All patients were followed for 24 to 45 months, averaging 33.16 ± 10.58 months. For three patients with CLAI combined with mild limitation of subjective ankle movement, joint activity was normal after rehabilitation function exercise and proprioceptive function training for 2 months. At the final follow‐up, ankle pain had disappeared completely. The ankle varus stress test and ankle anterior drawer test were both negative. Range of joint motion was good. There was no lateral instability of the ankle and all patients returned to normal gait. The mean VAS score decreased to 1.12 ± 0.13, the AOFAS score increased to 92.53 ± 4.87, and the KAFS score increased to 93.36 ± 6.15. All the follow‐up indexes were significantly different from those before surgery.ConclusionArthroscopic anatomical repair of ATFL for CLAI is precise, with less surgical trauma and reliable medium‐ and long‐term effect.

Evaluation of Patellar Contact Pressure Changes after Static versus Dynamic Medial Patellofemoral Ligament Reconstructions Using a Finite Element Model

Objectives: To evaluate the effect of various medial patellofemoral ligament (MPFL) fixation techniques on patellar pressure compared with the native knee. Methods: A finite element model of the patellofemoral joint consisting of approximately 30,700 nodes and 22,200 elements was created from computed tomography scans of 24 knees with chronic lateral patellar instability. Patellar contact pressures and maximum MPFL graft stress at five positions of flexion (0°, 30°, 60°, 90°, and 120°) were analyzed in three types of MPFL reconstruction (MPFLr): (1) static/anatomic, (2) dynamic, using the adductor magnus tendon (AMT) as the femoral fixation, and (3) dynamic, using the quadriceps tendon as the attachment (medial quadriceps tendon-femoral ligament (MQTFL) reconstruction). Results: In the static/anatomic technique, the patellar contact pressures at 0° and 30° were greater than in the native knee. As in a native knee, the contact pressures at 60°, 90°, and 120° were very low. The maximum MPFL graft stress at 0° and 30° was greater than in a native knee. However, the MPFL graft was loose at 60°, 90°, and 120°, meaning it had no tension. In the dynamic MPFLr using the AMT as a pulley, the patellar contact pressures were like those of a native knee throughout the entire range of motion. However, the maximum stress of the MPFL graft at 0° was less than that of a native ligament. Yet, the maximum MPFL graft stress was greater at 30° than in a native ligament. After 30° of flexion, the MPFL graft loosened, similarly to a native knee. In the dynamic MQTFL reconstruction, the maximum patellar contact pressure was slightly greater than in a normal knee. The maximum stress of the MPFL graft was much greater at 0° and 30° than that of a native MPFL. After 30° of flexion, the MQPFL graft loosened just as in the native knee. Conclusions: The patellar contact pressures after the dynamic MPFLr were like those of the native knee, whereas a static reconstruction resulted in greater pressures, potentially increasing the risk of patellofemoral osteoarthritis in the long term. Therefore, the dynamic MPFLr might be a safer option than a static reconstruction from a biomechanical perspective.

Medial Patellofemoral Ligament Reconstruction

Medial patellofemoral ligament reconstruction (MPFLr) is the most frequent surgical procedure performed in patients with chronic lateral patellar instability (CLPI). Depending on the fixation technique used, there are 2 types of MPFLr: the static and the dynamic. The current trend is to perform a static MPFLr with an anatomic femoral bone attachment and a patellar bone attachment. However, dynamic MPFLr using the adductor magnus tendon as a pulley could be a good option in children in order to avoid the risk of an injury to the distal femur growth plate with the subsequent risk of developing a deformity of the knee. MPFLr has proven to be a safe, reliable and reproducible technique for the treatment of CLPI. The paramount requirement for a successful MPFLr is the proper patient selection as well as correct presurgical planning and a meticulous surgical technique.

Dorsiflexion is more feasible than plantar flexion in ultrasound evaluation of the calcaneofibular ligament: a combination study of ultrasound and cadaver

Ultrasound (US) is a valuable tool for the evaluation of chronic lateral instability of the ankle; however, the feasibility of US for calcaneofibular ligament (CFL) assessment remains unknown. This study aimed to depict and compare CFL on US in various ankle positions to determine the optimal method for evaluating CFL with US and to interpret US findings using cadaveric specimens. The US study included 43 ankles of 25 healthy individuals. The CFL was scanned with US in 20° plantar flexion, neutral position, 20° dorsiflexion and maximum dorsiflexion. The distances between fibula and CFL were compared. The cadaveric study included macroscopic qualitative observation of the dynamic change of CFL in 7 ankles and quantitative observation of the directions of CFL and footprints in 17 ankles. In the US study, the mean distance (mm) between fibula and CFL was 7.3 ± 1.3 in 20° plantar flexion, 6.7 ± 1.6 in neutral position, 4.3 ± 2.5 in 20° dorsiflexion and 3.1 ± 2.1 in maximum dorsiflexion. The more dorsiflexed the ankle was, the shorter the distance between fibula and CFL was (Jonckheere's trend test p < 0.001). In the cadaveric study, the CFL fibres were aligned parallel between the mid-substance and the fibular attachment in maximum dorsiflexion, whilst CFL was reflected and rotated in plantar flexion. The whole length of the CFL, including its fibular attachment, is more likely to be visualized with US in dorsiflexion than in plantar flexion due to the direction of the CFL at the fibular attachment, which is parallel with the mid-substance in maximum dorsiflexion. IV.

Implantless patellar fixation in medial patellofemoral ligament reconstruction

PurposeThe medial patellofemoral ligament (MPFL) acts as primary restraint to lateral patellar dislocation and its rupture has been reported in almost all cases of acute patellar dislocation. Various surgical techniques have been described for MPFL reconstruction, using many femoral and patellar fixation techniques and different grafts. This article details our technique for MPFL reconstruction using semitendinosus graft which avoids the use of implant at patellar end. MethodsTwenty patients (8 males and 12 females) with complaints regarding acute and chronic lateral patellar instability were evaluated and treated by MPFL reconstruction procedure. The mean age of patients was 21 years (range 17–34 years). MPFL reconstruction was performed using semitendinosus graft passing through two parallel, obliquely directed tunnels created in patella. Fixation of graft was done with an interference screw only at the femoral end. Mean follow-up period after intervention was 26.4 months (range 23–30 months). Results were evaluated using Kujala score. ResultsAll patients gained adequate patellar stability and full arc of motion. No incidence of patella fracture was noted. There were no postoperative complications related to the procedure. There was no recurrence of instability in patella at final follow-up. ConclusionPassing the graft through the tunnels in patella without use of any implant has given excellent functional outcome and moreover has the advantages of less implant-related complications and cost-effectiveness.

Parametric finite element model of medial patellofemoral ligament reconstruction model development and clinical validation

BackgroundCurrently, there is uncertainty regarding the long-term outcome of medial patellofemoral ligament reconstructions (MPFLr). Our objectives were: (1) to develop a parametric model of the patellofemoral joint (PFJ) enabling us to simulate different surgical techniques for MPFLr; (2) to determine the negative effects on the PFJ associated with each technique, which could be related to long-term deterioration of the PFJ.MethodsA finite element model of the PFJ was created based on CT data from 24 knees with chronic lateral patellar instability. Patella contact pressure and maximum MPFL-graft stress at five angles of knee flexion (0, 30, 60, 90 and 120°) were analysed in three types of MPFLr: anatomic, non-anatomic with physiometric behaviour, and non-anatomic with non-physiometric behaviour.ResultsAn increase in patella contact pressure was observed at 0 and 30° of knee flexion after both anatomic and non-anatomic MPFLr with physiometric behaviour. In both reconstructions, the ligament was tense between 0 and 30° of knee flexion, but at 60, 90 and 120°, it had no tension. In the third reconstruction, the behaviour was completely the opposite.ConclusionA parametric model of the PFJ enables us to evaluate different types of MPFLr throughout the full range of motion of the knee, regarding the effect on the patellofemoral contact pressure, as well as the kinematic behaviour of the MPFL-graft and the maximum MPFL-graft stress.

Repairing anterior talofibular ligament with non-binding anchor technique under full scope in the treatment of chronic lateral ankle instability

Objective To evaluate the clinical efficacy of total arthroscopic anterior talofibular ligament repair for chron-ic lateral instability of ankle joint. Methods Data of 70 patients with chronic lateral mechanical instability of ankle joint treated by anterior talofibular ligament repair under full scope from September 2016 to October 2017 were retrospectively analyzed. There were 48 males and 22 females, aging from 18 to 49 years old (average, 32.3±3.4 years). Arthroscopic exploration, synovial mem-brane cleaning, extraction of lateral malleolus free body or microfracture were used in the operation, and the anterior talofibular lig-ament was repaired with knottless anchors to restore ankle stability. After the operation, plaster support was used for fixation, and relevant rehabilitation plans were conducted. X-ray films of the front drawer stress position of the ankle joint was taken preopera-tively and during follow-up, and the talus advancing distance was measured preoperatively and during follow-up. Ankle function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot function score, and pain was evaluat-ed by visual analogue scale (VAS). Results Seventy patients were followed up for 8-18 months, with an average of 11.5 months. The incisions of all patients were healed in one stage without internal plant rejection reaction. The plaster was fixed for 2 weeks af-ter operation, followed by rehabilitation training 2 weeks later, non-confrontational physical exercise 3 months later and confronta-tional physical exercise 6 months later. Within one year after operation, 58 patients could meet the needs of daily life and exercise. Seven basketball and football fans complained of ankle joint soreness and discomfort after strenuous exercise, and the symptoms were relieved after treatment. The symptoms of foot and ankle instability were not significantly improved in 5 patients. Stress X-ray showed that the talus advancing distance was improved from 11.70±1.05 mm before operation to 3.25±1.09 mm at the latest follow-up, and the difference was statistically significant (t=32.15, P< 0.0001). VAS decreased from 5.70±2.90 before operation to 2.05±0.52 at the latest follow-up (t=11.75, P< 0.0001). AOFAS increased from 54.50±7.40 before operation to 87.80±5.60 at the latest follow-up (t=34.04, P< 0.0001). There was excellent in 53 cases, good in 8 cases, fair in 5 cases, poor in 4 cases, thus the excellent and good rate was 87.14% (61/70). One of the patients suffered from joint pain in ankle metatarsal flexion half a year later, and MRI reexamination found that the anchor had entered the joint cavity, whose symptom was relieved after the anchor was cleared by arthroscopy at the later stage. Conclusion The treatment of lateral chronic instability of ankle joint with arthroscopic non-knot anchor nail repair of anterior talofibular ligament can effectively restore the stability of ankle joint and the movement ability of pa-tients. The operation has advantages of definite curative effect, minimally invasive, fast recovery and easy acceptance by patients. Key words: Ankle joint; Joint instability; Ligament; Wounds and injuries; Arthroscopy

Long-Term Results for Treatment of Chronic Ankle Instability With Fibular Periosteum Ligamentoplasty and Extensor Retinaculum Flap

Long-term results of anatomic reconstruction for chronic ankle instability are good, but no study has shown the results of fibular periosteum ligamentoplasty associated with extensor retinaculum flap at long-term follow-up. To demonstrate the efficacy of fibular periosteum ligamentoplasty and extensor retinaculum flap in chronic lateral instability, 40 patients underwent surgery for ankle instability. Thirty-three (82.5%) patients were reviewed, with a median follow-up duration of 8.2 (range 4 to 13) years. Functional results were assessed using the Karlsson score. Static and dynamic x-ray images were realized to measure varus tilt and anterior drawer, and osteoarthritis was evaluated with the van Dijk classification. The median Karlsson score was 95 (range 80 to 100). The mean decrease in varus laxity was 11° (range 0 to 18) and in anterior drawer was 1 (range -8 to 4) mm. At the last follow-up visit, 3 (7.5%) patients showed an evidence of osteoarthritis according to the preoperative criteria of the van Dijk classification (grade 2) and 6 (15%) patients had radiologic changes, without narrowing of the joint space (grade 1). Studies that have a follow-up time >5 years are rare. This study shows that despite the excellent control of ankle laxity, severe radiographic changes (grade 2) continue to evolve in the long term. This study indicates a good long-term outcome but suggests the need to monitor the occurrence of osteoarthritis over the long term.

Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: A 5-Year Randomized Controlled Trial

Background: “Ankle sprain” is a common injury, and >20% of patients may develop chronic instability for which surgery is indicated. The modified Broström-Gould (MBG) procedure remains the gold standard; however, there are a number of relative contraindications to this procedure, and the longer-term outcomes after the MBG have been questioned. An alternative procedure is augmentation of a primary repair with a ligament augmentation reconstruction system (LARS). Purpose: To conduct a randomized controlled trial testing the null-hypothesis that there is no difference in patient scored outcomes and activity levels, between patients undergoing a MBG procedure compared with those undergoing a primary repair with LARS augmentation, for lateral ligament instability of the ankle. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients who satisfied the inclusion criteria were invited to take part in the study. Patients were randomly allocated to undergo the LARS or MBG procedure. Both groups followed similar postoperative rehabilitation. Patients completed the Foot and Ankle Outcome Score (FAOS) before surgery and then at 1, 2, and 5 years after surgery. Tegner activity scores were recorded at 5years. The scores in the 2 groups were compared via statistical analysis (P < .05). Results: Of the 50 patients satisfying the inclusion criteria, 47 agreed to take part in the study. Twenty-two were randomized to the LARS group and 25 to the MBG group. At 5 years, follow-up data were complete for 20 patients in the LARS group and 21 in the MBG. There were 2 failures in the MBG group and 0 in the LARS group. The LARS group had significantly better improvement in total FAOS at 1 year (mean ± SD, 92.4 ± 2.5 vs 78.2 ± 3.4, P = .005), 2 years (94.0 ± 3.0 vs 78.0 ± 5.2, P = .003), and 5 years (93.7 ± 6.0 vs 75.1 ± 5.5, P = .002) after surgery. The 5-year Tegner activity scores were higher in the LARS group (8.25 ± 1.1 vs 7.2 ± 0.9, P = .03). Conclusion: Among physically active patients with chronic lateral ligament instability, primary repair combined with LARS results in better total FAOS at 5-year follow-up and higher Tegner activity scores as compared with the MBG procedure. Registration: ACTRN12618000906257 (Australia New Zealand Clinical Trial Registry).

Anatomic Reconstruction of the Posterolateral Corner: An All-Arthroscopic Technique

Injuries of the posterolateral corner (PLC) of the knee lead to chronic lateral and external rotational instability. Successful treatment of PLC injuries requires an understanding of the complex anatomy and biomechanics of the PLC. Several open PLC reconstruction techniques have been published. It is understood that anatomic reconstruction is superior to extra-anatomic techniques, leading to better clinical results. An open, anatomic, fibula-based technique for reconstruction to address lateral and rotational instability has been described. However, when an open technique is used, surgeon and patient are faced with disadvantages, such as soft tissue damage or exposure of vulnerable structures. Few arthroscopic techniques for tibia- or fibula-based reconstruction of rotational posterolateral instability have been described. A complete arthroscopic stabilization of the combined lateral and posterolateral rotational instability of the knee has not yet been described. We therefore present the first all-arthroscopic technique for complete PLC reconstruction, based on an open technique described previously. All relevant landmarks of the PLC can be arthroscopically visualized in detail, allowing safe and effective treatment of PLC injuries.

Rotational and Varus Instability in Chronic Lateral Ankle Instability: In Vivo 3D Biomechanical Analysis.

We retrospectively evaluated the altered biomechanics of the talus in 15 adult patients (7 males, 8 females) with chronic lateral ankle instability when the ankle joint moved actively from full dorsiflexion to full plantarflexion under a non-weight bearing condition. CT images were taken for the unstable ankle and the contralateral normal (control) ankle. Three-dimensional surface models of both ankle joints were reconstructed from the CT data, and we used a computer simulation program to compare both ankle motions of inversion/eversion in the coronal plane, plantarflexion/dorsiflexion in the sagittal plane, and internal rotation/external rotation in the axial plane. This evaluation method provides in vivo, dynamic, and 3D results of ankle motion. In the ankles with chronic lateral instability and the controls, the average talar rotational movement of inversion (+)/eversion (-) was 19.0° and 15.5° and the internal rotation (+)/external rotation (-) was 30.4° and 20.7°, respectively. Paired t-tests revealed significant differences in the amount of inversion (+)/eversion (-) (p=0.012) and internal rotation (+)/external rotation (-) (p<0.001) between unstable and normal ankle joints. The difference of mean rotational movement in internal rotation (9.7°) was greater than that of inversion (3.5°). Rotational instability should be considered when evaluating chronic lateral ankle instability.

Revisiting the Prevalence of Associated Copathologies in Chronic Lateral Ankle Instability: Are There Any Predictors of Outcome?

Multiple ankle pathologies have been found to coexist with chronic lateral ankle ligament instability, but their prevalence varies widely in the literature. The purpose of this study is to reexamine the prevalence of these associated pathologies and to determine their impact on reoperation rate. We retrospectively reviewed 382 cases of lateral ankle ligament repair/reconstruction between June 2006 and November 2016. Patient charts and radiograph reports were examined for the presence of any associated foot and ankle pathologies as well as clinical course. The effect of copathologies on reoperation rate was examined using binary logistic regression and the χ2 test. We included a total of 99 cases. Copathologies included peroneal pathology (75/99, 75.8%), ankle impingement (40/99, 40.4%), and osteochondral lesion of the talus (17/99, 17.2%); 36.4% (36/99) had a low-lying muscle belly of peroneus brevis. The total reoperation rate was 12/92 (13.1%). It was lower in cases with peroneal pathology (8.7% vs 27.5%, P = .032). Peroneal pathology, ankle impingement, and osteochondral lesions were the most common associated copathologies in surgical patients with chronic lateral ankle ligament instability. The presence of peroneal pathology may lead to fewer reoperations, possibly as a result of a more comprehensive first-time surgical approach. Level of Evidence: Level III: Retrospective cohort.

Lateral ankle anatomical variants predisposing to peroneal tendon impingement

PurposeTo delineate the significant association between the peroneal tendons injury and the lateral ankle joint anatomical variants. SubjectsRetrospective revision of the last 600 ankle MRI examinations, with dividing such candidates into: Group A: Inclusion group including patients with pure Peroneal tendon injury & lateral ankle anatomical variants. Group B: Control group including patients with Peroneal Tendonsinjury & no anatomical variants. Group C: Exclusion group including patients with other different types of ankle injuries. TechniqueStandard MRI ankle joint protocols. ResultsGroup A: 73 patients (40.3%) had PTT including: straight/convex RMG in 48 (26.5%) patients; 19 of them (39.6%) had PTT, PT hypertrophy in 39 (21.6%) patients; 14 (35.9%) of them had PTT. RCE hypertrophy in 33 (18.3%) patients; 12 of them (36.4%) had PTT. PQ muscle was seen in 15 (8.3%) patients; 7 (46.7%) of them had PTT. Low PB muscle belly was found in 29 (16%) patients; 13 (44.9%) of them had PTT. OP was found in 17 (9.3%) patients; 8 (47%) of them had PTT. Group B: 26 of them (18%) had PTT. Fisher exact test 0 P value. ConclusionThe lateral ankle joint anatomical variants facilitate peroneal tendons injury, ending in chronic lateral joint instability.

Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction.

Background:A frequently used method to determine the anatomic femoral fixation point in the operating room during medial patellofemoral ligament (MPFL) reconstruction is the radiographic method. However, the ability of this radiological method to establish an anatomic femoral attachment point might not be as accurate as expected.Purpose:(1) To evaluate the accuracy of the radiological method to locate the anatomic femoral fixation point in MPFL reconstruction surgery and (2) to determine the factors influencing the predictability of this method to obtain this objective.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 100 consecutive 3-dimensional computed tomography (3D CT) knee examinations were performed at 0° of extension in 87 patients treated for chronic lateral patellar instability. For each knee, 2 virtual 7 mm–diameter femoral tunnels were created: 1 using the adductor tubercle as a landmark (anatomic tunnel) and the other according to the radiological method described by Schöttle et al (radiographic tunnel). We measured the percentage of overlap between both tunnels. Moreover, of the 100 included knees, 10 were randomly selected for a variability study.Results:Considering an overlap area greater than 50% as reasonable, the radiographic method achieved this in only 38 of the 100 knees. Intrarater and interrater reliability were excellent. There was a trend for female patients with severe trochlear dysplasia to have less overlap. This model accounted for 64.2% of the initial variability in the data.Conclusion:An exact anatomic femoral tunnel placement could not be achieved with the radiographic method. Radiography provided only an approximation and should not be the sole basis for the femoral attachment location. Moreover, in female patients with severe trochlear dysplasia, the radiographic method was less accurate in determining the anatomic femoral fixation point, although differences were not statistically significant.

Lateral talocalcaneal ligament substitution for calcaneofibular ligament difficient chronic ankle lateral instability

Category: Ankle, Hindfoot, Sports, Trauma Introduction/Purpose: Introduction: Treatment of chronic ankle lateral instability associated with defective calcaneofibular ligament via tendon reconstruction or artificial grafts has several disadvantages. The method of substitution with lateral talocalcaneal ligament has never been reported. Purpose: To investigate the role of lateral talocalcaneal ligament substitution for the treatment of chronic ankle lateral instability associated with defective calcaneofibular ligament. Methods: Repair of ankle lateral ligament was performed on 32 patients with chronic ankle instability. The mean age was 26.4±8.7 years. The calcaneofibular ligament was absent in all the patients and was confirmed surgically. The calcaneofibular ligament was repaired via transfer of talar insertion of the lateral talocalcaneal ligament. Patients were followed up for an average of 22.3±4.0 months. AOFAS, Mazur and Tegner scores, objective examinations (anterior drawer test and varus stress test) and re-injury were assessed before and after the operation. The anterior translation distance of the talus and the talar tilt angle were also measured. Results: In all the patients, postoperative AOFAS, Mazur and Tegner scores were significantly improved. Postoperative evaluation (drawer test and lateral stress test) yielded negative results. The anterior translation distance was reduced from 4.9±1.0 mm to 2.0±0.8 mm. The talar tilt angle was reduced from 12.7º±2.5º to 5.0º±1.4º. The average satisfaction score was 7.4. No subjective instability or re-injury, subtalar joint (tarsal sinus) pain or/and instability occurred. Conclusion: Lateral talocalcaneal ligament substitution was effective against chronic ankle lateral instability associated with the absence of calcaneofibular ligament, without any significant effect on subtalar joint clinically.

Immediate Unrestricted Weight Bearing with Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization

Category: Ankle Introduction/Purpose: Anatomic lateral ankle ligament reconstruction has been shown to reliably restore the functional stability of the joint. Current orthopedic literature supports accelerated rehabilitation and protected weight bearing advancement as a safe and effective means to timely patient recovery. To our knowledge, there have not been clinical outcome reports of a protocol utilizing immediate unrestricted weight bearing in a stirrup brace following single anchor lateral ligament stabilization. The purpose of this study is to report on a series of patients treated with a more progressive protocol resulting in durable ankle stability and favorable clinical outcomes. Methods: A total of 28 patients with chronic lateral ankle ligament instability who failed conservative management underwent arthroscopy and modified Brostrom-Gould lateral ligament reconstruction between 2014 and 2015 were identified. The anterior talofibular and calcaneofibular ligaments were released from the fibula and advanced using one double-loaded metallic 3.5 mm suture anchor. Immediate unrestricted full weightbearing in a stirrup brace was allowed from the first postoperative day and accelerated physical therapy was initiated at 2 weeks postoperatively. Patients were assessed preoperatively, and at a minimum 1- year follow-up, using the AOFAS Hindfoot scale and VAS pain score. Additional postoperative outcome measures included the FAOS and a custom clinical questionnaire. Range of motion, ligamentous stability and single-blinded examination with Star Excursion Balance Test (SEBT) functional testing were performed postoperatively. Complication and recurrent instability rates were also recorded. Results: Twelve patients participated in the study (8F, 4 M). Mean age at final follow-up was 49 years (21-70). Average follow-up was 21 months (16 to 26). Average satisfaction score was 94%, and all patients reported they would have the procedure again. AOFAS Hindfoot score and VAS improved significantly from preoperative to postoperative, respectively (55.6 to 89.8, 5.4 to 1.6). Average postoperative FAOS score was 80.3 (51.8-100) . No measurable difference was observed on examination of range of motion, ligamentous stability, or SEBT testing in the anterior, posterolateral or posteromedial planes of the contralateral side, respectively (61.5 to 62.2 cm, 62.4 to 64.1 cm, 56.4 to 57.6 cm). No patients reported recurrent instability. Conclusion: This study demonstrates that anterior talofibular ligament and calcaneofibular ligament advancement utilizing a single 3.5 mm anchor construct followed by immediate unrestricted weight bearing is a safe and effective protocol for the treatment of chronic lateral ankle instability. Ligamentous stability was achieved and maintained in all patients across a wide variety of patient ages and desired activity levels. Patient satisfaction was excellent. This surgical technique and postoperative protocol may help reduce surgical time and implant cost, and may facilitate a more timely return to preinjury functional level.

Anatomic versus non-anatomic reconstruction for chronic lateral ankle ligament instability

Anatomic versus non-anatomic reconstruction for chronic lateral ankle ligament instability

Allograft tendon reconstruction of the anterior talofibular ligament and calcaneofibular Ligament in the treatment of chronic ankle instability

BackgroundThe purpose was retrospectively to investigate functional and clinical outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) reconstruction using a single allograft.MethodsPatients with severe chronic lateral instability of the ankle underwent surgery after conservative treatment failed. Ultrasounds of the ankle were performed, and if the AFTL and CFL were completely torn without enough soft tissue for repair, the ligaments were reconstructed using allograft tendon. Outcomes were assessed by clinical examination, stress radiography, ultrasound, the American Orthopaedic Foot and Ankle Society score (AOFAS), and Karlsson Ankle Functional score (KAFS) before surgery and at final follow-up.ResultsNineteen patients, ten men and nine women with mean age of 27.9 years (range, 19–41 years), underwent reconstruction. Mean follow-up was 30 months (range, 24–40 months). At final follow-up, all patients had returned to activity without instability, pain, or limited range of motion. On stress radiography, mean talar tilt angle decreased from 17.32° ± 3.58° before surgery to 4.16° ± 1.12° at follow-up (p < 0.001). Mean anterior drawer test (ADT) distance decreased from 9.79 ± 1.01 mm before surgery to 3.97 ± 0.99 mm at follow-up (p < 0.05). Mean AOFAS improved from 64.00 ± 18.43 to 90.32 ± 5.17 points (p < 0.001), and mean KAFS improved from 50.84 ± 16.73 to 90.89 ± 5.08 points (p < 0.001). Ultrasound showed the reconstructed ligaments maintained good continuity and excellent tension. No case of infection and immunological rejection was reported.ConclusionThis novel reconstruction technique takes into account the anatomical specialty of AFTL and CFL. This case series showed increased stability of the ankle in clinical and functional outcomes.Trial registrationThe trial registration number (TRN) and date of registration: ChiCTR-ORC-17010796, Mar 6th 2017. Retrospectively registered.