Lateral Ligament Injuries Research Articles

Early clinical efficacy study on the efficacy of a three-stage conservative Chinese medicine external treatment for acute lateral ankle ligament injuries

To evaluate the clinical effect of a new three-phase Chinese medicine (CM) external treatment for acute lateral ankle ligament injuries. From July to December 2023, 64 patients with acute lateral ankle ligament injuries were randomly assigned to receive either the new three-phase CM external treatment combined with the POLICE(protect, optimal loading, ice, compression, elevation) treatment (observation group) or the POLICE treatment (control group), with 32 cases in each group. The observation group consisted of 17 males and 15 females, with an average age of(30.59±3.10) years old ranging from 25 to 36 years old, while the control group included 14 males and 18 females, with an average age of(30.03±3.19) years old ranging from 24 to 37 years old. Visual analogue scale (VAS) evaluation and Figure of 8 measurement were used to evaluate the degree of ankle joint pain and swelling of the subjects at the initial enrollment and after 1 week and sixth weeks of treatment. At the same time, the American Orthopaedic Foot and Ankle Society (AOFAS) and Karlsson Ankle Function Score System were used to evaluate the improvement of ankle joint function in patients at all stages. MRI imaging was employed to observe the degree of biological healing of the anterior talofibular ligament, with the signal to noise ratio(SNR) indicating the level of healing. A lower SNR suggests better ligament healing, as it represents lower water content in the ligament. All patients completed a 6-week follow-up. There was no significant difference in VAS, AOFAS score and Karlsson score between the two groups before treatment (P>0.05). After 1 week and 6 weeks of treatment, the VAS, AOFAS score and Karlsson score of the two groups were significantly improved (P<0.05). After 1 week of treatment, the VAS score of the observation group (3.21±0.87) was lower than that of the control group (4.21±1.50), and the difference was statistically significant (P<0.05). After 1 weeks of treatment, the AOFAS and Karlsson scores [(50.84±4.70) points, (49.97±4.00) points] of the observation group were higher than those [(46.91±5.56) points, (46.66±5.36) points]of the control group (P<0.05). MRI images showed that after 6 weeks of treatment, the SNR value of the observation group was significantly lower than that of the control group, and the difference was statistically significant(SNR of the observation group was 75.25±16.59, the contral gruop was 85.81±15.55), (P<0.05). Compared with the control group, the new three-phase CM external treatment is significantly effective in reducing pain and swelling, enhancing ligament repair quality, and promoting functional recovery of the ankle joint in patients with acute lateral malleolar ligament injuries.

Cross-Cultural Adaptation, Feasibility, Reliability, and Validity Tests of the Chinese Version of Ankle Ligament Reconstruction-Return to Sport After Injury Scale.

The Ankle Ligament Reconstruction-Return to Sport After Injury (ALR-RSI) scale can be utilized for assessing patients who have previously sustained lateral ankle ligament injury before returning to sport. Given its original development for use in different languages, it is essential to translate and validate this scale for application to the Chinese population. To translate and culturally adapt the ALR-RSI scale into a Chinese version and assess its reliability and validity. Cohort study (Diagnosis); Level of evidence, 2. The procedure of translation and cross-cultural adaptation was performed following the recommended guidelines and the Chinese version of ALR-RSI (ALR-RSI-CHN) was conducted in patients with lateral ankle ligament surgery. Feasibility was assessed by floor/ceiling effects. Reliability was assessed by using Cronbach α as a measure to analyze internal consistency, while the intraclass correlation coefficient was utilized to examine test-retest reliability. Validity was assessed by using Spearman coefficients to analyze the correlations between ALR-RSI-CHN, the Karlsson scale, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale. A total of 66 participants were included. The ALR-RSI-CHN scale showed good feasibility with no floor/ceiling effects. The internal consistency of the scale was adequate with a Cronbach α of 0.93, and test-retest reliability was excellent with an interclass correlation coefficient of 0.97 (95% CI, 0.92-0.99). The ALR-RSI-CHN scale demonstrated moderate correlation with the Karlsson scale (r = 0.48 [range, 0.26-0.65]) and strong correlation with the AOFAS scale (r = 0.55 [range, 0.35-0.71]). A significant difference in ALR-RSI-CHN scores was observed between patients who returned to sports and those who did not, with respective scores of 53.60 (range, 44.50-62.69) and 42.25 (range, 35.51-49) (P = .04). The study demonstrated that the ALR-RSI-CHN scale had satisfactory psychometric properties, rendering it a feasible, reliable, and valid instrument for evaluating patients who have lateral ligament surgery in China.

Lateral ligament reconstruction and additive medial ligament reconstruction in chronic ankle instability: a retrospective study.

Ligamentous lesions of the ankle joint are common. Isolated medial ligament injuries are rare but are often associated with lateral ligament injuries, isolated medial ligament lesions are often overlooked. The present study aimed to evaluate the clinical and functional differences in the outcomes of isolated lateral and combined medial and lateral ligament reconstruction. The study is based on patient-reported outcome measurements and motion sensor technology to assess these outcomes. The purpose of this study was to compare the clinical and functional outcomes of isolated lateral and combined lateral and medial ankle ligament reconstruction. From December 2014 to August 2018, 111 patients underwent either isolated lateral ligament (LG) or medial and lateral ligament (MLG) reconstruction. Of the 104 patients meeting the inclusion criteria, 49 had LG and 55 had MLG reconstruction. Outcome measures included the Short Form-36 Health Survey SF-36, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAMG), Tegner Activity Scale, the European Foot and Ankle Society (EFAS), American Orthopaedic Foot and Ancle Society (AOFAS) hindfoot score, and the Karlsson Peterson Score. Mobility and stability were assessed using the Ortheligent™ motion sensor for both healthy and treated ankles. While there were no significant differences in outcome scores between the groups, overall scores improved after treatment (p >0.00). Notably LG showed improved movement, with better dorsal extension measured by the Sensor (p ÷ 0.02). The sensor's results correlated significantly with FAOS subscales for pain (p ÷0.05), stiffness (p ÷ 0.01), ADL (p ÷0.02), and sports (p >0.00). Postoperative results, regardless of LG or MLG, showed significant subjective well-being improvement. LG's advantages were highlighted by a significant improvement in dorsal extension, supported by correlated results from a portable motion sensor assessing ankle stability.

Diagnostic accuracy of ultrasonography in acute lateral ankle ligament injury: A systematic review and meta-analysis

BackgroundThe gold standard diagnostic method for acute lateral ankle ligament sprain is magnetic resonance imaging (MRI). However, it is hardly accessible and is time-consuming. Therefore, additional diagnostic methods are warranted. Point-of-care ultrasound, on the other hand, is inexpensive, widely available, time-efficient testing method. PurposeTherefore, the aim of this meta-analysis is to determine the diagnostic accuracy of ultrasound for acute ankle ligament injuries compared to MRI. MethodsIn our systematic review and meta-analysis, we followed the recommendations of the Cochrane Handbook. We searched the following databases from inception to March 31, 2022: Medline (PubMed), EMBASE, and Cochrane Library. Eligible studies investigated the diagnostic accuracy of US compared to MRI for diagnosing acute lateral ankle ligament injuries. Finally, we calculated pooled sensitivity and specificity with a 95 % confidence interval (CI). ResultsEight studies met our eligibility criteria, involving 434 patients. For anterior tibiofibular ligament (ATFL) injury, the summary sensitivity and specificity were Se = 0.97 (CI: 0.89–0.99) and Sp = 0.93 (CI: 0.84–0.97). For calcaneofibular ligament (CFL) injury, the summary sensitivity and specificity were Se.: Se = 0.81 (CI: 0.58–0.93) and Sp = 0.92 [0,81;0,97]. In addition, subgroup analysis based on US performed by different types of investigators was comparable between each other (radiologist group Se = 0.98, CI: 0.24–1, and Sp = 0.91, CI: 0.74–0.97, and the orthopedic/ emergency department group Se = 0.96, CI: 0–1, and Sp = 0.97, CI: 0–1). ConclusionUltrasound showed high diagnostic accuracy for acute lateral ankle ligament injury, irrespective of the investigator. Therefore, based on the current available data, it could be used in primary diagnostics of acute lateral ankle ligament injury.

Lateral Ankle Instability

Ankle sprains are frequent injuries among athletes and the general population, making them one of the most prevalent sports-relatedinjuries. While most lateral ankle ligament injuries typically respond well to conservative treatment, a significant portion evolves intochronic lateral ankle instability, which may require surgical intervention. Recently, new anatomical insights regarding the lateral ankleligaments have emerged, enhancing the advancement of innovative diagnostic and treatment approaches. The objective of this articlewas to discuss the latest trends in lateral ankle instability. Level of evidence V; Expert opinion.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using a Flexible Reaming System

The combination of anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction represents a therapeutic modality that exhibits superior clinical efficacy for certain risk groups when compared with isolated ACL reconstruction. This approach is progressively gaining broader applicability owing to its inherent prospective advantages. Despite the absence of a universally acknowledged gold-standard surgical technique, several methods have been delineated for its implementation. Typically, conventional practice involves the creation of distinct individual tunnels in the femur, followed by graft fixation using interference screws. However, the conventional steps in the technique are not without potential drawbacks. These include tunnel convergence, screw migration, screw irritation, and the risk of lateral collateral ligament injury. The manifestation of such unfavorable outcomes can necessitate a subsequent surgical intervention for effective management. Consequently, adopting a single socket-shaped tunnel strategy for concurrent reconstruction of the ACL and ALL, coupled with femoral fixation using an adjustable-loop button facilitated by a flexible reaming system, presents potential advantages. This alternative approach can mitigate the aforementioned risks by minimizing morbidity and preserving bone stock. The technique is feasible and reproducible, offering a pragmatic avenue for optimizing clinical outcomes in combined ACL and ALL reconstruction.

A Study Evaluating the Functional Outcomes of Mason Type III and IV Radial Head Fractures Treated With a Radial Head Prosthesis.

Objective This research aimed to assess the functional result of type III and IV radial head fractures that were treated using a radial head prosthesis. Methods A retrospective investigation was conducted on 70 patients with type III and IV radial head and neck fractures, as classified by Mason. The patients were hospitalized and received treatment at the Orthopaedics Department, where they had radial head prosthesis surgery for three years. Results Among the total of 70 cases, 42 (60%) cases were below the age of 40, while 28 (47%) cases were over 40 years. The average age was 36.4 years. The maximum age recorded was 54 years, while the lowest age recorded was 30 years. The female population outnumbered the male population. The majority of instances (42, 60%) were attributed to falls, while the remaining cases were caused by road traffic accidents (RTAs). Out of the total 70 instances, 52 cases (74.28%) exhibited right-side dominance, whereas 18 cases (25.72%) exhibited left-side dominance. Within our case study group, 56 (80%) cases fell under modified Mason's classification type Ill, totaling 56 instances. The remaining 20% of the cases, amounting to 11 cases, were classified as modified Mason's classification type IV. Among the 70 patients, 55 cases (78.58%) did not have any ligamentous damage, whereas seven (10%) cases had lateral ulnar collateral ligament (LUCL) injury and eight (11%) cases had medial collateral ligament (MCL)injury. The P value for flexion, extension, pronation, and supination was shown to be very significant. Out of the total, 47 (67%) instances had an MEPI score (Mayo Elbow Performance Index) of more than 90, indicating exceptional performance. In addition, 16 cases (22.85%) had an MEPI score ranging from 75 to 89, which is considered a good result. Lastly, seven cases (10%) had an MEPI score ranging from 60 to 74, indicating a fair result. Conclusion The use of a radial head prosthesis is considered a viable option for managing severe and irreparable fractures of the radial head. Effective outcomes hinge on meticulous preoperative planning, skilled intraoperative techniques, and intensive postoperative rehabilitation. These elements collectively contribute to achieving consistent and favorable results in patients undergoing this surgical intervention.

Radiological characteristics and injury mechanism of Logsplitter injury: a descriptive and retrospective study

BackgroundLogsplitter Injury is a type of high-energy ankle fracture dislocation. The mechanism of injury has not been described in detail. A detailed understanding of the radiological features and pathological changes can further guide treatment.MethodsBetween April 2009 and December 2018, a retrospective analysis was conducted on 62 patients with Logsplitter injury. The study analysed the characteristics of fibular injury, tibial injury, syndesmosis injury, medial injury and lateral ligament injury on preoperative X-ray and CT scans. The incidence of the different injury types was summarised. The correlation between Logsplitter injuries and the mechanisms causing them were analysed using the Lauge-Hansen classification of ankle fractures.ResultsThe study provides data on the types of fractures observed. Of the total fractures, 98.4% were open fractures. The fibula injuries were classified as no fracture (1.6%), transverse or short oblique fractures (61.3%), butterfly fragments (25.8%), and comminuted fractures (11.3%). The tibial injuries included compression of lateral articular surfaces (38.7%) and posterior compressions (6.5%). Medial injuries, including medial malleolar fractures, accounted for 87.1%, and deltoid ligament rupture accounted for 12.9%. The study found that injuries to the syndesmosis consisted of simple ligament ruptures (11.3%), Tillaux fractures (8.1%), Volkmann fractures (43.5%), and Tillaux and Volkmann fractures (37.1%). In 12.9% of cases, there was a complete rupture of the lateral collateral ligament. Based on the Lauge-Hansen classification, 87.1% of injuries were pronation-abduction injuries, while 8.1% were pronation and external rotation injuries, and 1.6% were supination external rotation injuries. Furthermore, 3.2% of cases could not be classified.ConclusionThe pathoanatomic characteristics of Logsplitter injury are diverse, with some cases accompanied by collateral ligament injury. It is important to note that these evaluations are objective and based on current results. The most common injury mechanism is vertical violence combined with abduction, although in some cases, it may be a vertical combined external-rotation injury.Level of evidence(4) case series.Trial registrationThis study has been approved by the ethical research committee of the Honghui Hospital of Xi’an Jiaotong University, under the code: 202,003,002.

Analysis of stress response distribution in patients with lateral ankle ligament injuries: a study of neural control strategies utilizing predictive computing models.

Ankle sprains are prevalent in sports, often causing complex injuries to the lateral ligaments. Among these, anterior talofibular ligament (ATFL) injuries constitute 85%, and calcaneofibular ligament (CFL) injuries comprise 35%. Despite conservative treatment, some ankle sprain patients develop chronic lateral ankle instability (CLAI). Thus, this study aimed to investigate stress response and neural control alterations during landing in lateral ankle ligament injury patients. This study recruited twenty individuals from a Healthy group and twenty CLAI patients performed a landing task using relevant instruments to collect biomechanical data. The study constructed a finite element (FE) foot model to examine stress responses in the presence of laxity of the lateral ankle ligaments. The lateral ankle ligament was modeled as a hyperelastic composite structure with a refined representation of collagen bundles and ligament laxity was simulated by adjusting material parameters. Finally, the validity of the finite element model is verified by a high-speed dual fluoroscopic imaging system (DFIS). CLAI patients exhibited earlier Vastus medialis (p < 0.001) and tibialis anterior (p < 0.001) muscle activation during landing. The FE analysis revealed that with laxity in the ATFL, the peak von Mises stress in the fifth metatarsal was 20.74MPa, while with laxity in the CFL, it was 17.52MPa. However, when both ligaments were relaxed simultaneously, the peak von Mises stress surged to 21.93MPa. When the ATFL exhibits laxity, the CFL is subjected to a higher stress of 3.84MPa. Conversely, when the CFL displays laxity, the ATFL experiences a peak von Mises stress of 2.34MPa. This study found that changes in the laxity of the ATFL and the CFL are linked to shifts in metatarsal stress levels, potentially affecting ankle joint stability. These alterations may contribute to the progression towards CLAI in individuals with posterolateral ankle ligament injuries. Additionally, significant muscle activation pattern changes were observed in CLAI patients, suggesting altered neural control strategies post-ankle ligament injury.

Tibial plateau fractures are associated with ligamentous and meniscal injuries. Preoperative evaluation of magnetic resonance imaging influences surgical treatment.

Tibial plateau fractures (TPFs) are usually associated with ligamentous or meniscal injuries that could remain misdiagnosed. An appropriate and early recognition may change the surgical management of these soft tissue injuries (STIs) that could be addressed concomitantly with TPF treatment. Magnetic resonance imaging (MRI) is an efficient diagnostic test to identify all associated STIs in TPFs. This study aims to analyze the MRI impact in identifying and guiding the STIs treatment in TPFs. This retrospective study included a consecutive series of 57 patients with TPFs treated between January 1st, 2022, and December 31st, 2022. All fracture patterns were classified according to the AO/OTA and Schatzker classification. The prevalence of STIs, including medial meniscus (MM), lateral meniscus (LM), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) injuries, was assessed through the MRI evaluation. A statistical significance was found regarding the MRI detection of LM, ACL, PCL and MCL injuries that led to additional surgical procedures at the same time as the TPFs treatment (p < 0.05). In contrast, the amount of additional MM and LCL injuries identified by MRI, which resulted in other surgical procedures, was not statistically significant (p > 0.05). Preoperative MRI has been demonstrated to be an effective procedure for diagnosing STIs in TPFs, significantly influencing and changing the surgical treatment. IV.

IS INTERNAL BRACE AUGMENTATION (IBA) BETTER THAN ISOLATED MODIFIED BROSTROM GOULD (MBG) REPAIR FOR CHRONIC LATERAL LIGAMENT INJURY? A RETROSPECTIVE ANALYSIS

IntroductionAcute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation.MethodsA single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation.ResultsA total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair.ConclusionInternal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair.

Transformer-Based Multilabel Deep Learning Model Is Efficient for Detecting Ankle Lateral and Medial Ligament Injuries on Magnetic Resonance Imaging and Improving Clinicians’ Diagnostic Accuracy for Rotational Chronic Ankle Instability

To develop a deep learning (DL) model that can simultaneously detect lateral and medial collateral ligament injuries of the ankle, aiding in the diagnosis of chronic ankle instability (CAI), and assess its impact on clinicians' diagnostic performance. DL models were developed and external validated on retrospectively collected ankle MRIs between April 2016 and March 2022 respectively at three centers. Included patients were confirmed diagnoses of CAI through arthroscopy, as well as individuals who had undergone MRI and physical examinations that ruled out ligament injuries. DL models were constructed based on a multi-label paradigm. A transformer-based multi-label DL model (AnkleNet) was developed and compared with four convolution neural network (CNN) models. Subsequently, a reader study was conducted to evaluate the impact of model assistance on clinicians when diagnosing challenging cases: identifying rotational CAI (RCAI). Diagnostic performance was assessed using area under the receiver operating characteristic curve (AUC). Our transformer-based model achieved AUC of 0.910 and 0.892 for detecting lateral and medial collateral ligament injury, respectively, both of which was significantly higher than that of CNN-based models (all P < 0.001). In terms of further CAI diagnosis, it exhibited a macro-average AUC of 0.870 and a balanced accuracy of 0.805. The reader study indicated that incorporation with our model significantly enhanced the diagnostic accuracy of clinicians (P = 0.042), particularly junior clinicians, and led to a reduction in diagnostic variability. The code of the model can be accessed at https://github.com/ChiariRay/AnkleNet. Our transformer-based model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models, demonstrating a promising performance in diagnosing CAI, especially RCAI patients.

The presence of a deep lateral femoral notch sign in ACL-injured patients is associated with a 2.7° steeper posterior tibial slope and a 19% higher frequency of lateral meniscal injuries.

The purpose of this study was to study the relationship between the presence of a deep lateral femoral notch sign (DLFNS) in anterior cruciate ligament (ACL)-injured patients and a higher posterior lateral tibial slope (LPTS), a reduced meniscal bone angle (MBA), a higher LPTS/MBA ratio and a higher incidence of concomitant injuries in primary ACL tears. A retrospective case-control study was performed in patients submitted to primary ACL reconstruction with an available preoperative magnetic resonance imaging (MRI) scan. Patients with ACL tears and a femoral impactation with a depth ≥2 mm were assorted to the DLFNS groupand patients with ACL tear and without a DLFNS to the control group. LPTS and MBA were measured in MRI. The presence of concomitant injuries (meniscal, posterior cruciate ligament, medial collateral ligament, lateral collateral ligament and bone injuries) was assessed in MRI. Quantitative data are presented in the median ± interquartile range (IQR). There were 206 patients included in the study, with 46 patients assorted to the DLFNS group and 160 patients to the control group. In the DLFNS group, the median LPTS was 6.7° (IQR: 4.0-8.2) versus 4.0° in the control group (IQR: 2.2-6.5) (p = 0.003). The LPTS/MBA ratio was significantly higher in the DLFNS group, with a median of 0.32 (IQR: 0.19-0.44), in comparison to the control group, with a median of 0.19 (IQR: 0.11-0.31) (p < 0.001). The multivariable logistic regression analysis showed that the LPTS is an independent risk factor to having a DLFNS (odds ratio [OR] = 1.161; 95% confidence interval [CI]: 1.042-1.293, p = 0.007). There was a higher incidence of concomitant lateral meniscal injuries in the DLFNS group (67% vs. 48%, p = 0.017). In patients with ACL tears, the presence of a DLFNS is associated with a steeper lateral posterior tibial slope, as well as a higher incidence of concomitant lateral meniscal injuries. Level III.

The Relationship Between Calcaneofibular Ligament Injury and Ankle Osteoarthritis Progression: A Comprehensive Analysis of Stress Distribution and Osteophyte Formation in the Subtalar Joint.

Ankle osteoarthritis (OA) mainly arises from trauma, particularly lateral ligament injuries. Among lateral ligament injuries, ankles with calcaneofibular ligament (CFL) injuries exhibit increased instability and can be a risk factor ankle OA progression. However, the relationship between CFL injury and OA progression remains unclear. Therefore, this study aims to assess the relationship between CFL injuries and ankle OA by investigating stress changes and osteophyte formation in subtalar joint. We retrospectively reviewed the magnetic resonance imaging (MRI) and plain radiographic evaluations of 100 ankles of 91 patients presenting with chronic ankle instability (CAI), ankle OA, or other ankle conditions. The association between CFL injuries on the oblique view of MRI and the severity of ankle OA (based on Takakura-Tanaka classification) was statistically evaluated. Additionally, 71 ankles were further subjected to CT evaluation to determine the association between the CFL injuries and the Hounsfield unit (HU) ratios of the subtalar joint and medial gutter, and the correlation between the subtalar HU ratios and osteophyte severity were statistically evaluated. CFL injury was observed in 35.9% (14/39) of patients with stage 0, 42.9% (9/21) with stage 1, 50.0% (10/20) with stage 2, 100% (9/9) with stage 3a, and 90.9% (10/11) with stage 3b. CFL-injured ankles exhibited higher HU ratios in the medial gutter and lower ratios in the medial posterior subtalar joint compared to uninjured ankles. A negative correlation was observed between medial osteophyte severity and the medial subtalar joint HU ratio. Our findings suggest that CFL injuries are common in severe ankle OA impairing the compensatory function of the subtalar joint through abnormal stress distribution and osteophyte formation.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes

BackgroundPosterior ankle impingement syndrome (PAIS) is sometimes complicated by bilateral cases and lateral ankle ligament injuries. Reports on bilateral surgery for PAIS and simultaneous surgery for lateral ankle ligament injury are scarce in the literature. MethodsWe present a 2-year follow-up of 76 athletic patients who underwent endoscopic hindfoot surgery for PAIS. Patients were divided into those who underwent unilateral or simultaneous bilateral surgery and PAIS surgery alone or simultaneous bilateral PAIS surgery without arthroscopic ankle lateral ligament repair. ResultsAll patients returned to full athletic activities postoperatively. There was no difference in all subscales of the SAFE-Q score between groups except for mean days after surgery for full return to athletic activities. ConclusionSimultaneous bilateral surgery and simultaneous arthroscopic lateral ankle ligament repair had no negative effect on subjective clinical evaluation 2 years after surgery in hindfoot endoscopic surgery for PAIS. Level of EvidenceIII, retrospective case-control study.

Arthroscopic treatment of ankle multiligamentous injuries provides similar clinical outcomes to the treatment of isolated lateral ligament injury at the 2-yearfollow-up.

Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up. Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). Thesame postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded. In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups. Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment. Level II, prospective comparative.

Combined ACL and Anterolateral Ligament Reconstruction Using an Adjustable-Loop Fixation Device: Surgical Technique

Background: There are several techniques for the combined reconstruction of the anterior cruciate ligament (ACL) and the anterolateral ligament (ALL), but none have shown superiority. This study aims to present a surgical technique that theoretically reduces some of the risks reported in these procedures. Indications: The main indications for the ALL reconstruction include chronic ACL injuries, revision ACL reconstruction, acute ACL injuries in patients with high-grade pivot-shift (grades 2 or 3), patients involved in pivoting sports, and generalized ligament hyperlaxity or knee hyperextension. Technique Description: Hamstring tendon autografts are used for the ACL and ALL reconstruction; a common femoral ACL and ALL tunnel is made outside-in, making a short socket. A continuous looped hamstring tendon autograft attached to one button is used. The ACL is fixed with an adjustable-loop button. Through small incisions, the tibial fixation of both grafts is performed with bioabsorbable screws. Results: We present a 19-year-old professional soccer player with an acute ACL tear, with no associated meniscal or chondral lesions. Owing to his young age and high-risk sports practice, a combined ACL and ALL reconstruction was performed. The combined ACL and ALL reconstruction with a single femoral tunnel using the hamstrings tendons graft is a well-established procedure for ACL augmentation, reducing failure rates for certain risk groups, with excellent outcomes reported. The use of an adjustable-loop button on the femur is a viable option for this kind of reconstruction with postoperative stability comparable to the interference screw, classically used for this kind of reconstruction. Discussion/Conclusion: This technique has some advantages, such as the use of a short outside-in femoral socket, thus theoretically improving healing. In addition, this lowers the risk of lateral collateral ligament injury, and since the ileotibial band graft is not used, the risk of injuring the lateral inferior genicular vessels and the peroneal nerve is theoretically reduced. Besides, using an adjustable-loop cortical button in the femur can theoretically reduce potential complications such as screw migration, soft-tissue impingement, femoral-site pain, and implant removal. Finally, the reconstruction is done with small incisions, improving the aesthetic result and postoperative pain. Considering all the aforementioned factors, this technique theoretically offers some benefits. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. Forty-seven patients (with 48 MRIs) met inclusion criteria over a tenyear period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. Level III.