Lateral Ankle Ligament Instability Research Articles

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.

Techniques for Cavovarus Foot Reconstruction with Concomitant Ankle Instability

Patients who present with lateral ankle ligament instability always need to be evaluated for cavovarus foot deformity. Cavovarus reconstruction may need to be performed in order to ensure the ankle instability procedure is successful. Which procedures are required will depend on the specific deformity present, and may need to be determined intraoperatively depending on the initial deformity correction achieved through the first procedures performed. A general though not strict algorithm for sequence of procedures involves soft tissue releases first, followed by hindfoot correction, then forefoot correction, and securing ligament reconstruction or tendon transfers as the final step. Tendon transfers can be an effective tool to aid in the deformity correction and several are described. For hindfoot and forefoot deformity correction, traditional calcaneus and metatarsal osteotomies work well, but fusion should be considered for joints with degenerative change or in cases where the deformity is severe or can't be corrected through osteotomy alone.

Immediate Unrestricted Weightbearing With Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization.

To report on a series of patients treated with immediate unrestricted weightbearing with limited protection following single anchor lateral ligament stabilization. Patients with chronic lateral ankle ligament instability who underwent modified Broström-Gould lateral ligament reconstruction with a single double-loaded anchor were identified. Immediate unrestricted full weightbearing in a stirrup brace was allowed the first postoperative day and accelerated physical therapy was initiated from 2 weeks. Subsequent assessment was performed at a minimum of 1-year follow-up. Thirteen patients with a mean age at final follow-up of 49 years (range 21-70 years). Average follow-up was 21 months (16 to 26). American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and visual analogue scale (VAS) score improved significantly (P < .05) from preoperative to postoperative, respectively (57 to 91, 5.7 to 1.5). Average postoperative Foot and Ankle Outcome Score (FAOS) was 82 (range 52-100). Short Form-12 (SF-12) scores averaged 55 and 49 on mental component and physical components, respectively, consistent with US age-matched averages. No measurable differences in range of motion, ligamentous stability, or Star Excursion Balance Test in the anterior, posterolateral, or posteromedial planes compared to the contralateral side (P > .05) were observed. No recurrence was reported. Immediate unrestricted weightbearing in a stirrup brace following single anchor lateral ligament reconstruction is a successful protocol for the treatment of chronic lateral ankle instability. Therapeutic, Level IV: Case series.

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.

Magnetic Resonance Imaging Findings of the Lateral Ankle Instability after Anatomical Ligament Reconstruction Using a Semitendinosus Allograft Tendon with Biotenodesis Screws

Category: Ankle Introduction/Purpose: Surgery for lateral ankle instability is indicated in patients who have repetitive inversion ankle sprains despite conservative therapy. There have been many reconstruction procedures performed for the lateral ankle ligament instability. However, there has not been any report of postoperative MRI findings of lateral ankle instability after ligament reconstruction using a free tendon and biotenodesis screws. Therefore, this study was to analysis the MRI finding of the postoperative lateral ankle reconstruction using semitendinosus allograft tendon and the correlation with clinical outcome. Methods: The study is based on 34 ankles (33 patients) of chronic lateral ankle instability which underwent anatomical lateral ankle ligament reconstruction using a semitendinosus allograft tendon with bio-tendosis screws from July 2009 to April 2017 with at least 6 month postoperative ankle MRI checked (mean follow-up 16.5mo). In addition, clinical outcomes were evaluated using VAS pain score, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Karlsson-Peterson score, ankle stress views and subjective patient satisfaction. Results: Six ankles (17.6%) showed normal signal intensity(SI) while 28 ankles (82.4%) showed high SI on reconstructed allograft tendon area. High signal was shown around the biotenodesis screws. Eleven ankles showed synovitis (39.3%), partial tear of reconstructed allograft tendon 6 ankles (21.4), 5 osteolysis of the bone tunnel (17.9%), 4 screw pulled-outs (14.3%), 2 tendon complete tear (7.1%), 2 mucoid changes (7.1%), 2 cystic changes (7.1%). One ankle showed post-op MRI findings of reconstructed tendon infection (3.6%). The mean VAS pain score significantly decreased from 5.7 to 1.5. The mean AOFAS score improved from 72.0 to 89.1, while the Karlsson-Peterson score significantly improved from 54.7 to 85.7 (p&lt;0.01) with 88% patient satisfaction. Stress talar tilt angle improved from 15.7o to 5.4 o. Conclusion: In the current study, various postoperative MRI findings were found after lateral ankle ligament reconstruction using allograft tendon and biotenodesis screws including high signal change of tendon, synovitis, tunnel osteolysis, screw pull-outs, tendon tears and etc. However, these MRI findings did not present as clinical complications and did not correlate with poor clinical outcomes.

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

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

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.

The Addition of an “Internal Brace” to Augment the Broström Technique for Lateral Ankle Ligament Instability

This article describes the augmentation of a Brostrom anatomic repair for ankle lateral ligament instability by the use of the internal brace. The paper describes the role of the internal brace in allowing the natural tissues to progressively strengthen while encouraging early rehabilitation. The su

The results of surgical treatment of chronic lateral ankle instability with the Evans technique

Purpose The aim of this study was to review the outcome of the Evans technique in patients with chronic lateral ankle–ligament instability. Patients and methods Between August 2009 and June 2012 a prospective study was conducted on 14 patients between 15 and 50 years of age (mean: 26.6 years) with chronic lateral instability who underwent the Evans technique and followed up for 2 years. Patients were assessed postoperatively using the Kaikkonen ankle scoring scale. Stress radiographs were also obtained to evaluate talar tilt and anterior drawer. Results The results were good to excellent in 79% of the 14 patients, fair in 14%, and poor in 7% of patients. Clinical examination showed an anterior drawer test results were equal to or less than that on the unaffected side in 75% of patients. Stress radiographs showed a mean anterior drawer of 7.0±1.8 mm and a mean talar tilt of 4.8 ± 3.8°. Conclusion The Evans reconstruction procedure is a valuable option in treating recurrent and complex chronic lateral ankle instability and provides good ankle instability, particularly when the original, frayed ligaments cannot be easily identified.

Ultrasonography in the Assessment of Lateral Ankle Ligament Injury, Instability, and Anterior Ankle Impingement: A Diagnostic Case Report

ObjectiveThe purpose of this case report is to describe the diagnostic value of ultrasonography (US) in a patient with injury to the lateral ligaments of the ankle with concomitant ankle joint osteoarthritis and anterior impingement. Clinical FeaturesA 28-year-old male had a history of an inversion injury of the left ankle. Diagnostic US of the left ankle using an 8- to 15-MHz linear array transducer demonstrated a full thickness tear of the anterior talofibular ligament, partial thickness tearing of the calcaneofibular ligament, and laxity of the ankle with varus stress testing. In addition, US was able to demonstrate degeneration of the ankle and talonavicular joints and anterior impingement with dorsiflexion. Osteoarthritic changes were confirmed with radiography. Other US findings included remote deltoid ligamentous complex injury, multiple sites of tenosynovitis, and a large ankle joint effusion with synovial hypertrophy and synovitis. Intervention and OutcomeUsing US, an accurate diagnosis was established with respect to the pathology and functional impairments of the patient’s ankle. ConclusionThis case report exemplifies the value and utility of US in diagnosing derangement in ligamentous, tendinous, articular, and osseous injuries of the ankle.

Effect of Ankle Arthritis on Clinical Outcome of Lateral Ankle Ligament Reconstruction in Cavovarus Feet

Patients with idiopathic cavovarus deformity and lateral ankle ligament instability often present with varying degrees of ankle arthritis. The purpose of this study was to determine whether the severity of degenerative change would impact the clinical outcome in patients treated operatively for both cavovarus deformity and lateral ankle ligament instability. Twenty-two patients were treated with lateral ankle ligament reconstruction and realignment foot osteotomy. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Karlsson and Peterson (KP) scoring scale, Visual Analog Scale (VAS) for pain, and level of satisfaction were obtained. Preoperative and postoperative ankle radiographs were reviewed and graded using the van Dijk score. Patients with Grade 0 and I arthritis preoperatively were grouped together as ``no to minimal arthritis'' (Group 1) and those with Grade II and III arthritis preoperatively as ``moderate to severe arthritis'' (Group 2). There were 14 ankles in Group 1 and eight ankles in Group 2. Mean followup was 60.4 months. Mean AOFAS and KP scores were significantly improved in Group 1 compared to Group 2 at latest followup, while VAS pain scale trended lower in Group 1. There were 12 excellent/good results, one fair result, and one poor result in Group 1. Patients in Group 2 had three excellent/good results, two fair results, and three poor results. One of 14 patients in Group 1 had progression of arthritis, while five of eight patients in Group 2 either had progression of arthritis or required an ankle fusion. Patients treated with lateral ankle ligament reconstruction and cavovarus realignment osteotomy with no to minimal preoperative tibiotalar arthritis have higher clinical scores and increased satisfaction compared to patients with more advanced preoperative tibiotalar arthritis. A cautious and realistic approach should be followed when recommending surgical treatment for this patient population.

Modified Brostrom-Evans-Gould Technique for Recurrent Lateral Ankle Ligament Instability

To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability. Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6-20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale. Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85-100) and 4 (19%) attained good scores (70-84). The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian population with a higher prevalence of generalised joint hyperlaxity.

Dorsal calcaneocuboid ligament versus lateral ankle ligament repair: a case-control study

Objective: Anatomic reconstruction is the treatment of choice for lateral ankle ligament instability. A similar technique has recently been described for stabilisation of a chronic unstable calcaneocuboid joint as an...

Arthroscopic repair of lateral ankle instability by using the thermal-assisted capsular shift procedure: a review of 4 cases

The purpose of this study is to determine the preliminary effectiveness of the thermal-assisted capsular shift procedure for treatment of chronic lateral ankle instability. A retrospective preoperative evaluation using a modified American Orthopedic Foot and Ankle Society’s ankle scoring system was performed on 4 patients treated with the procedure. Patients were then contacted for a 6-month follow-up evaluation using the same scale. The mean preoperative score was 26 of 60 and the mean postoperative score was 51 of 60, a mean 25-point improvement. All 4 rated their satisfaction with the surgery as good or excellent and 3 of 4 stated they would have the surgery again if necessary. The thermal-assisted capsular shift procedure showed good to excellent early results in this small study group and offers the foot and ankle surgeon a minimally invasive surgical alternative for treatment of lateral ankle ligament instability.

An instrumented, dynamic test for anterior laxity of the ankle joint complex

Evaluation of anterior laxity of the ankle joint complex is a difficult clinical problem. Currently, the prime determinant for anterolateral ligament function is the subjective manual examination of anterior laxity of the ankle joint complex. An instrumented dynamic test was developed for objective measurement of anterior laxity of the ankle joint complex. The principle of the test was to apply a force-impulse to the calcaneus, within the muscle reflex time, and to measure anterior–posterior and mediolateral rotation. The test was performed on a cadaver specimen and on 15 volunteers of which five subjects suffered from chronic one-sided lateral ankle ligament instability. In the cadaver test, anterior translation values increased from 5 to 11 mm, after cutting the anterior talofibular ligament and subsequently cutting the calcaneofibular ligament. In the 10 normal subjects, the mean anterior translation value was 6.7 mm (±1.9 mm). The relative variation of the test result within a measurement session was 2.5% (±1.6%). Between the sessions the relative laxity variation was 2.6% (±2.6%). In the ten normal subjects the mean right–left difference was not significantly different from zero. In four out of the five patients it was more than 2 mm. As in the cadaver test in all measurements, the mediolateral rotations were small (<2.5°). The volunteers complained about same pain at the heel after multiple test sessions. In conclusion the dynamic, functional test appears to be capable of objectively measuring a value for anterior laxity of the ankle joint complex reflecting the functional status of the anterolateral ankle ligaments.

Chronic Lateral Ankle Instability

Chronic lateral ankle instability may be present in as many as 10% to 30% of people suffering from acute lateral ankle ligament injuries. Ankle instability has been referred to as either functional instability or mechanical instability. Management options consist of either nonoperative or operative treatment, with the majority of the literature emphasizing operative management for chronic instability. Long-term studies assessing the different types of available operative repairs have now been published. This review article discusses chronic lateral ankle ligament instability from a functional, anatomical point of view. The indications for treatment, nonoperative and operative treatment, as well as the biomechanical information available regarding these methods of treatment are considered. The major emphasis of this review is discussion and analysis of the many different surgical treatment options. Following this review, we presently recommend anatomical repair to the bone of both the anterior talofibular ligament and the calcaneofibular ligament, together with imbrication of the ligaments. In patients with hypermobility, long-standing instability, or arthritis, reconstruction using the Chrisman-Snook technique is recommended.