Lateral Ligament Complex Injury Research Articles

Comparative analyses of arthroscopic and open repairs of lateral ligament complex injuries of the ankle: a systematic review and meta-analysis of the medium-term outcomes.

Little is known regarding the comparative analyses of the medium-term outcomes (with a mean minimum follow-up period of 24months), between arthroscopic and open repairs of lateral ligament complex (LLC) injuries of the ankle. Thus, in this study, we aimed to explore the comparative analyses regarding the medium-term follow-up outcomes of these repairs, by conducting a systematic review and meta-analysis. The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; data were extracted from the PubMed and Google Scholar databases. From an initial search, a total of 1182 abstracts (280 and 902 abstracts, from PubMed and Google Scholar, respectively) were found and screened in accordance with the eligibility criteria. Subsequently, six articles were found to be eligible for further review. A total of 419 patients underwent surgical repairs; 205 and 214 patients underwent arthroscopic and open repairs, respectively. The mean minimum follow-up period was 29.2months. The medium-term follow-up for arthroscopic LLC repairs was found to be superior to that of open LLC repairs, with more favorable outcomes; as evidenced by better clinical scores, lower pooled complication rates, earlier return times to pre-injury sport, and higher early sport ratios. The findings of this systematic review and meta-analysis support near-future developments validating arthroscopic repair as the new gold standard for LLC repairs, similarly to arthroscopic ligament and tendon repairs, as well as arthroscopic reconstruction surgeries, of the knee and shoulder.

Effect of Ankle Exercises in Preventing Ankle Sprain in Amateur Football Players: A Follow-up Study

Purpose: A lateral ligament complex injury to the ankle joint affects around 1 out of every 10,000 persons every day, accounting for a quarter of all sports injuries. As a result, injury prevention initiatives aimed at adolescents may have a greater influence on player health in the future. Materials and Methods: 74 people were screened, and 60 were chosen based on inclusion criteria to participate in the study. A total of 60 football players were separated into two groups, each with 30 players. Players between the ages of 10 and 15 years who had been practicing for at least 6 months were included, while players with previous ankle sprain injuries, as well as previous neurological and musculoskeletal problems, were excluded. The range of motion of the ankle joint was measured and demographic data were gathered. The Star Excursion Balance Test (SEBT) was utilized as an end measure before the exercise program, after 4 weeks, and after 6 months of follow-up. Conventional exercises along with a conventional ankle exercise program were given to the two groups. Results: The severity of injuries in the experimental group was mild to moderate, whereas it was moderate to severe in the control group. The experimental group’s SEBT reach distance improved considerably after 4 weeks and 6 months of follow-up (p0.00001), but the control group’s improvement was not significant after 4 weeks. The control group showed considerable improvement after 6 months of follow-up except for anteromedial and posterolateral directions. Conclusion: The difference in SEBT reach distance between the two groups was significant in all directions; however, there was no significant difference in medial reach when the difference between the two groups was compared at post 4 weeks and 6 months.

Ability to return to sports after early lateral ligament repair of the ankle in 147 elite athletes.

The literature on elite athletes' ability to return to sports (RTS) after early lateral ligament repair of the ankle remains inadequate. The time needed to RTS after modified Broström repair for acute grade III lateral ligament injuries in a large cohort of elite athletes was evaluated while assessing the impact of other associated injuries. Prospective data from 147 elite athletes who underwent a primary lateral ligament repair for acute grade III injuries with clinical ankle instability from 2015 to 2019 with a minimum of 2-year follow-up were reviewed. Pertinent details such as characteristics of injury, time taken to RTS, impact of associated injuries on RTS and complications were recorded and analysed. The average age was 24.4years (S.D = 4.9) with 89.1% males. Approximately two-thirds of the elite athletes were football players (66.0%) and 21.1% were rugby players. Isolated lateral ligament complex injuries were sustained by 122 (83%) patients, while 25 (17%) had associated injuries (osteochondral lesions of the talus/deltoid injury/syndesmosis injury). All 147 athletes returned to their preinjury level of sports with a median time of 69days (range 58-132days). There was no significant difference found in time to RTS between gender, age, and types of sports. However, there was a statistically significant difference noted in the time taken to RTS earlier in patients with isolated lateral ligament injuries when compared to those with associated injuries (68.6 vs. 82.8days; p = 0.004). Multiple conditional linear regression yielded three independent predictors of longer time taken to RTS which were associated deltoid injury (7.5days longer; 95% CI 2.9-12.3; p = 0.002), associated syndesmosis injury (6.7days longer; 95% CI 0.5-12.8; p = 0.034) and associated OLT (30.3days longer; 95% CI 25.1-35.5; p = 0.000). Early surgical repair for acute grade III lateral ligament injuries in elite athletes yielded excellent rate of RTS at 9-10weeks and a re-injury rate of 2%. Concomitant injuries will delay RTS after surgical intervention. These findings serve as important guide to managing elite athletes following acute rupture of the lateral ligament complex. Level III.

Isometry of the lateral, posterolateral and anterolateral knee complex: a cadaveric study

Objectives:There is no consensus on the insertion points for reconstruction of lateral ligament complex injuries. The aim of this study is to evaluate the relative isometry between easily identifiable bony ridges in order to recommend adequate reconstruction of the external structures: the lateral collateral ligament, the popliteus complex and the anterolateral ligament.Methods:After dissection of the cutaneous and subcutaneous planes of six lower limbs from 3 anatomical subjects, metal markers were fixed on 7 anatomical edges of interest: no. 1: posteroproximal to the lateral epicondyle, within a bony depression - no. 2: at the tip of the lateral epicondyle - no. 3: 18 mm distal and 0.84 mm anterior to the LCL insertion - no. 4: at Gerdy’s tubercle - no. 5: at the anterior part of the fibular head - no. 6: at the posterior part of the fibular head - no. 7: at the popliteal fossa of the tibia, 10 mm medial to the proximal tibiofibular joint, and 10 mm inferior to the joint space. The distance between these points was measured with a caliper at 0, 30, 60 and 90 degrees of flexion in neutral rotation.Results:We noted a decrease in the distance between anatomic femoral and fibular LCL (pair) insertions 1-5 during flexion (63 mm ± 2.6 to 50 mm ± 4.8). The most isometric positions were identified for the following point pairs: 2-5 (57 mm ± 3.4 to 55 mm ± 3), 3-6 (60 mm ± 3.5 to 59 mm ± 3.2), 2-4 (52 mm ± 4.6 to 55 mm ± 2.7) and 3-7 (53 mm ± 6.4 to 52 mm ± 4.6). We noted no difference between knees.Conclusion:These results show that the anatomical structures are not isometric. However, some easily identifiable point pairs of the lateral aspect of the knee show an isometric feature. Therefore, we recommend using pairs 2-5 for the LCL, 2-4 for the ALL and 3-7 for the PC.

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

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

Lateral dislocation of the elbow: a report of two cases and literature review

Elbow dislocation is the most common dislocation, but most elbow dislocations are posterolateral or posterior. Pure lateral elbow dislocation is rare and often under recognized. It is necessary to assess the radiographic status and clinical features for diagnosis and appropriate management of pure lateral elbow dislocation. The position of the affected extremity at the time of injury and the characteristics and impact of forces over the injured part determine the pattern and direction of subluxation/dislocation of the elbow. We reported two adult cases of lateral elbow dislocation who received closed reduction, splinting and supervised physiotherapy. Lateral ligament complex injury was also managed conservatively. Good functional outcomes with evident limitation of movement were obtained during the follow-up period. No residual instability or re-dislocation was noted.

Cochrane in CORR ®: surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (review).

Importance of the Topic More than 650,000 ankle sprains present to emergency departments in the United States for treatment every year [14]. The vast majority of these sprains are injuries to the lateral ligament complex resulting from a forceful inversion of the ankle joint during physical activity [7]. The impact of a lateral ligament complex sprain is experienced through acute pain and swelling, several weeks of acute disability resulting in time lost from work or other activities, and in as many as 20% of patients, chronic instability of the ankle joint [1, 7]. Anatomically, lateral ligament sprains are almost always localized to the anterior talofibular ligament. The calcaneofibular ligament is also involved in 50% to 75% of sprains [2]. The third ligament of the lateral ligament complex - the posterior talofibular ligament - is rarely involved. In cases of chronic instability, anatomic reconstructive procedures (as originally described by Brostrom [4] and subsequently modified) frequently are used to correct a deficient lateral ligament complex and restore stability of the ankle joint [4]. It is plausible that primary repair of acute lateral ligament complex tears may facilitate ligament healing, shorten time off work and/or athletic activities, and reduce the incidence of chronic instability. However, surgical intervention also has inherent disadvantages, such as wound infection, iatrogenic nerve injury, and other postsurgical complications. The primary objective of this Cochrane Review is to determine whether surgical management is superior to conservative management of acute lateral ligament complex injuries [6]. Upon Closer Inspection The lack of a standardized patient-oriented outcome instrument provided unique challenges to this meta-analysis, and led to the need to independently evaluate 11 outcomes (four primary outcomes and seven secondary outcomes). A maximum of 12 of 20 trials reported data on a common outcome to allow for a meta-analysis. A validated, reliable, and universally accepted ankle outcome instrument would have facilitated a rigorous and informative meta-analysis of outcome data from all trials [5], but such an outcome instrument does not presently exist [3, 9]. A single trial published by Prins [10] in 1978 demonstrated several benefits of surgical management - results that differed substantially from other published trials, including several more-recent and better-designed efforts [8, 11-13] - and greatly influenced the pooled estimate for many outcomes. The pronounced and, occasionally differing, direction of Prins’ results may be attributable to the trial being only quasi-randomized, resulting in no concealment of treatment allocation or blinding. In order to test the robustness of the results, the authors of this review performed several sensitivity analyses both with and without Prins’ trial data. Excluding this trial reduced the variability of results between trials, and eliminated all significant benefits in applicable primary outcomes for surgical intervention. When interpreting the results, it is also important to explicitly recognize characteristics of patients enrolled in the included trials. Both adults with chronic ankle instability and children were deliberately excluded. The majority of patients in these trials were young active adult males suffering from ankle injuries that were painful and/or swollen enough for them to present to an acute care setting. In other words, these are patients who had relatively severe injuries, and theoretically are most likely to have benefited from surgical intervention. In general, one would expect a patient presenting to an ambulatory or primary care clinic to have an even more diminished benefit from surgical intervention. This is an important consideration when determining the clinical relevance of the results. Take-Home Messages Overall, this Cochrane Review (which is current to January 2006) failed to demonstrate a benefit of surgery compared with conservative management for acute lateral ligament complex injuries. Since this review was conducted, at least two more randomized controlled trials have been published comparing conservative and surgical management for acute lateral ligament complex injuries [8, 11]. Both of these trials failed to demonstrate significant differences between surgery and conservative management in their primary outcomes, further corroborating the findings of this Cochrane review. Because studies have failed to consistently demonstrate evidence of benefit for surgical repair, along with the additional complications inherent with an invasive surgical procedure, surgery for acute lateral ligament complex injuries is not recommended, regardless of severity. The optimal method of conservative management (rigid immobilization versus early mobilization) remains a topic of ongoing investigation. The development of a standardized outcome instrument that is validated, reliable, and universally accepted will facilitate analysis of future trials in foot and ankle surgery.

The Anatomic Pattern of Injuries in Acute Inversion Ankle Sprains: A Magnetic Resonance Imaging Study.

Background:There are little data on the incidence and patterns of injuries seen on magnetic resonance imaging (MRI) in acute inversion ankle sprains. This study may help in the understanding of the pathomechanics, natural history, and outcomes of this common injury.Study Design:Case series; Level of evidence, 4.Methods:From June 2011 to June 2013, a total of 64 consecutive patients had MRI of the ankle performed for acute inversion injury to the ankle. All injuries/pathologies reported were recorded.Results:Only 22% of patients had isolated lateral ligament complex injuries. Twenty-two percent of patients had other pathologies but no lateral ligament injury, and 53% had lateral ligament injuries in combination with other pathologies or injuries. The most common associated finding with lateral ligament injuries was bone bruising (76%) followed by deltoid ligament injury (50%). The overall incidence of bone bruising was 50%. Thirty percent of ankles had tendon pathology, 27% had deltoid ligament injury, and 22% had occult fractures.Conclusion:Isolated lateral ligament ankle injury is not as common as is believed. The pattern of injury seems complex, and most patients appear to have more injuries than expected. MRI reveals additional information that may have significance in terms of diagnosis, treatment, and prognosis in this common injury.

Assessment of the Lateral Ligaments of the Ankle After Healed Fractures

Lateral ligament complex injuries are difficult to diagnose immediately after ankle fracture, and treatment is focused on the fracture. This study examines the prevalence of ligamentous injuries after severe ankle fractures. Lateral ligament instability can be revealed by inversion and anterior stress views after fracture healing. The results of 54 inversion and anterior stress examinations of the ankle after fracture healing, using a Telos stress device at 15 kPa force, were compared with uninjured ankles. No patient had 5 degrees or more of talar tilt or 6 mm or more of anterior displacement of the talus in uninjured ankles; however, in ankles with fractures, we found abnormal talar tilt angle in 12 and excessive anterior displacement in five. An abnormal inversion stress test was found to be considerably more common in the fractured ankles. Our study revealed that lateral ligament injuries may occur simultaneously with ankle fractures, with the most frequently injured being the calcaneofibular ligament.

Ankle ligament injuries

Acute ankle ligament sprains are common injuries. The majority of these occur during athletic participation in the 15 to 35 year age range. Despite the frequency of the injury, diagnostic and treatment protocols have varied greatly. Lateral ligament complex injuries are by far the most common of the ankle sprains. Lateral ligament injuries typically occur during plantar flexion and inversion, which is the position of maximum stress on the anterotalofibular liagment (ATFL). For this reason, the ATFL is the most commonly torn ligament during an inversion injury. In more severe inversion injuries the calcaneofibular (CFL), posterotalofibular (PTFL) and subtalar ligament can also be injured. Most acute lateral ankle ligament injuries recover quickly with nonoperative management. The treatment program, called "functional treatment," includes application of the RICE principle (rest, ice, compression, and elevation) immediately after the injury, a short period of immobilization and protection with an elastic or inelastic tape or bandage, and early motion exercises followed by early weight bearing and neuromuscular ankle training. Proprioceptive training with a tilt board is commenced as soon as possible, usually after 3 to 4 weeks. The purpose is to improve the balance and neuromuscular control of the ankle. Sequelae after ankle ligament injuries are very common. As much as 10% to 30% of patients with a lateral ligament injury may have chronic symptoms. Symptoms usually include persistent synovitis or tendinitis, ankle stiffness, swelling, and pain, muscle weakness, and frequent giving-way. A well designed physical therapy program with peroneal strengthening and proprioceptive training, along with bracing and/or taping can alleviate instability problems in most patients. For cases of chronic instability that are refractory to bracing and external support, surgical treatment can be explored. If the chronic instability is associated with subtalar instability that is refractory to conservative measures and bracing as outlined above, surgical treatment must address the subtalar joint as well. Subtalar ligament injury and instability are probably more common than appreciated. Definition and diagnosis of this entity are difficult, however. Fortunately, it appears that in the majority of the acute injuries healing occurs with the same functional rehabilitation program as that for lateral ankle ligament sprains. For chronic subtalar instability an intial attempt at functional rehabilitation with ankle proprioceptive training and bracing should be attempted. If this program fails primary repair or reconstruction can be beneficial. Reconstructive procedures must address the subtalar joint. Subtalar instability often occurs in conjunction with talocrural instability, so careful diagnosis is critical in anyone with chronic ankle instability. If either is not addressed, the patient will continue to have problems. Deltoid ligament injuries most often occur in association with ankle fractures. They are rare as isolated injuries. If no fracture is evident on radiographs, particular attention must be paid to the syndesmosis to ensure there is not an associated syndesmosis disruption. True isolated deltoid injuries seem to do well with non-operative functional treatment as for lateral ankle ligament injuries. Deltoid ruptures associated with ankle fractures appear to heal well by addressing the other injuries and allowing the deltoid to heal on its own. It is vital to correct any syndesmosis injury and to obtain correct bony alignment. Syndesmosis injuries can be debilitating if not treated properly. Careful physical exam and interpretation of radiographs is necessary to obtain a correct diagnosis. Partial injuries appear to do well with functional rehabilitation. However, complete tears, if widening is not corrected, can lead to chronic ankle pain and early degenerative changes. Widening of the syndesmosis with a tear of the inferior tibiofibular ligaments is an indication for surgery to place a syndesmosis screw for reduction of the mortise. Protected weight bearing is required for about 6 weeks after surgery, at which time the screw should be removed. A functional rehabilitation program can then begin.