Lateral Ankle Ligament Repair Research Articles

Clinical outcomes over 2 years following arthroscopic ankle lateral ligament repair with os subfibulare

There are reports indicating that between 10 and 38.5% of patients with chronic lateral ankle instability (CLAI) have an os subfibulare. In cases where CLAI accompanied by os subfibulare is resistant to conservative treatment, surgery may be necessary; however, there is no consensus on the most appropriate surgical method. We report outcomes of arthroscopic lateral ligament repair for chronic lateral ankle instability with os subfibulare at our hospital, followed for over 2 years post-operatively. We reviewed 33 patients (39 ankles) whom underwent arthroscopic lateral ankle ligament repair (ALLR) for CLAI and followed for at least 2 years post-operatively between November 2015 and May 2020. Patients were classified into two groups: a group with os subfibulare (ossicle group) and a group without os subfibulare (non-ossicle group), based on the presence of an os subfibulare on pre-operative plain radiographs. ALLR surgeries were performed without resection of the os subfibulare in ossicle group. Clinical outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) scale and the Self-administered Foot Evaluation Questionnaire (SAFE-Q). In addition, the bone-union rate was evaluated by using plain computer tomography in the ossicle group. There were significant improvements in the mean total JSSF scale scores from pre-operative to post-operative measurements in both the ossicle and non-ossicle groups. The mean scores for pain and related symptoms, foot function and activities of daily living, social functioning, shoe-related, and general health and well-being subscales of the SAFE-Q also showed significant improvements in both groups. There were no significant differences between the post-operative ossicle and non-ossicle groups regarding the JSSF scale scores or the SAFE-Q subscale scores. In the ossicle group, the bone-union rate was 14.3% (2 of 14 ankles), but no symptom recurrence was observed. The 2 years outcomes of arthroscopic lateral ligament repair for chronic lateral ankle instability with os subfibulare revealed good results and no symptom recurrence.

Ultrasound of Postoperative Ankle Instability: How to Manage with Arthroscopic Reparation or Anatomical Reconstruction of Lateral Ankle Ligaments.

Surgical repair or reconstruction of lateral ankle ligaments is indicated in patients with persistent ankle instability, with arthroscopic/endoscopic treatment becoming more frequent. Although presurgical imaging of the ankle is always standard procedure, more is needed to understand the evolution of the repaired ligament or the tendinous graft to help improve length of postoperative time and functional results. This review describes the normal ultrasound aspects and possible complications of repaired/reconstructed ankle ligaments after an all-inside endoscopic repair/reconstruction of the anterior talofibular ligament and the calcaneofibular ligament.

Functional Outcomes of Immediate Weightbearing After Arthroscopic Lateral Ankle Ligament Repair: A Prospective Randomized Single-Center Trial

Background: Previous studies have revealed that early postoperative rehabilitation of chronic lateral ankle instability is just as crucial as surgical intervention. Immediate weightbearing has yielded good clinical results; however, randomized controlled studies have been limited. Purpose: To compare the clinical outcomes of patients with immediate weightbearing after lateral ankle ligament repair with those with delayed weightbearing after 2 weeks in a prospective randomized controlled study. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: Patients who underwent arthroscopic anterior talofibular ligament repair between August 2021 and December 2022 were randomized into 2 groups—immediate weightbearing with a hard ankle brace and nonweightbearing casting for 2 weeks followed by cast removal and weightbearing. Primary outcomes were the ankle function scores as assessed using the visual analog scale at rest and during activities, the American Orthopaedic Foot & Ankle Society (AOFAS) score, and the Karlsson Ankle Functional Score (Karlsson score). Secondary outcomes were the time to return to unsupported walking, jogging, work, and exercise and change in the ankle range of motion (ROM) at 3-, 6-, and 12-month follow-ups. Results: A total of 88 participants were included, consisting of 58 men and 30 women, with a mean age of 30.26 years. Computerized randomization resulted in 44 patients per group. These 2 groups displayed no difference in the AOFAS score, Karlsson score, and ankle ROM at all follow-ups. Patients who underwent immediate weightbearing had a significantly shorter time of returning to unsupported walking (P < .001). No differences were observed in the time of returning to work, jogging, and sports exercise. Conclusion: For patients with chronic ankle instability after arthroscopic anterior talofibular ligament repair, immediate weightbearing allowed patients to return to unsupported walking more quickly and had no negative effects on the AOFAS score, Karlsson score, times of returning to normal life, jogging, sports exercise, and ankle ROM at 3-, 6-, and 12-month follow-ups compared with cast fixation. Registration: ChiCTR2100049612 (Chinese Clinical Trial Registry; https://www.chictr.org.cn/).

Ankle Ligament Reconstruction-Return to Sport After Injury (ALR-RSI) Scale and Return to Sports After Ankle Ligament Reconstruction or Repair – A Systematic Review

Category: Ankle; Sports Introduction/Purpose: While objective outcome measures assessing foot and ankle function are well established to determine return to sport (RTS) following ankle injuries, psychological factors have been recognized in recent years to be equally important. The Return to Sport after Injury (RSI) scale has become an emergingly useful tool used in assessing psychological readiness to return to sporting activity after various pathologies and their treatment. The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale is a novel questionnaire and scoring system for the evaluation of psychological readiness to return to sport following lateral ankle ligament reconstruction or repair. Purpose: To systematically review existing literature regarding the ALR-RSI scale and to assess its correlation with RTS and functional outcomes as well as feasibility, reliability, and consistency. Methods: A systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) was conducting using PubMed, Embase and Cochrane Library. Studies that evaluated psychological readiness after ankle ligament reconstruction or repair for the treatment of chronic lateral ankle instability using the ALR-RSI scale were included. The results from each study were pooled, and weighted means and overall rates were calculated. Results: In total, 157 patients (53.2% male, mean age: 34.2 years) from 3 articles were included. Overall, 85.0% of patients reported successful RTS, but only 48.9% of patients returned to the preoperative sporting level. All studies reported a significant difference in psychological scores between patients who returned to sport and those who didn’t. The pooled mean functional outcome measures, reported as the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS) Score and Karlsson-Peterson Score, were 82.7 (range, 29-100) and 81.7 (range, 25-100), respectively. The ALR-RSI scale demonstrated strong correlations with the AOFAS Score and Karlsson-Peterson Score. Conclusion: Patients who RTS after ankle ligament reconstruction or repair exhibited higher psychological readiness compared to those who didn’t return to sport. The ALR-RSI scale showed strong correlations with ankle function. Evaluation of psychological readiness using the ALR-RSI scale may provide an additional tool in the rehabilitation process of athletes that aim to assess RTS after ankle ligament reconstruction or repair.

Primary Lateral Ankle Ligament Repair is Associated with Increased Reoperation Rates Compared to Secondary Lateral Ankle Ligament Reconstruction: A Propensity-Matched Analysis

Category: Ankle; Sports Introduction/Purpose: Lateral ankle ligament stabilization is indicated for patients with chronic ankle instability that persists despite nonoperative management. The purpose of this investigation was to compare reoperation rates in patients who underwent a primary repair versus those who underwent a secondary reconstruction of the lateral ankle ligaments. Methods: A large, nationwide insurance database was retrospectively reviewed to identify all patients who underwent isolated primary repair and/or secondary reconstruction of the lateral ankle ligamentous complex from 2010 and 2019. Patients who underwent primary repair were matched using a propensity-scoring algorithm to patients who underwent secondary lateral ankle reconstruction. Reoperation rates including ankle arthroscopy and revision lateral ankle ligament repair/reconstruction were compared between groups at two years postoperatively. Complication rates within 90 days postoperatively were also evaluated and compared between groups. Results: 41,452 patients who underwent primary lateral ankle ligament repair were matched to 41,452 patients who underwent secondary reconstruction. Patients who underwent primary repair had an increased risk of undergoing a subsequent ankle arthroscopy (OR: 1.15; p &lt; 0.001) or revision stabilization procedure (OR: 1.30; p &lt; 0.001) within two years postoperatively. Moreover, the risks of sustaining complications such as wound dehiscence (OR 1.34; p &lt; 0.001) or surgical site infection (OR 1.43; p = 0.008) within 90 days were higher for the primary ligament repair group compared to the secondary reconstruction group. Conclusion: Patients who underwent primary lateral ankle ligament repair were more likely to require subsequent ankle arthroscopy or revision ankle stabilization within two years postoperatively, compared to those who underwent secondary reconstruction of the lateral ankle ligament complex. Although secondary reconstruction procedures (e.g. Watson-Jones, Colville) are conventionally utilized in the revision setting, surgeons may consider expanding the indications for reconstruction to the primary setting, particularly in surgical candidates who are identified preoperatively as high-risk for recurrent instability.

Arthroscopic ankle lateral ligament instabilities repair

Lateral ankle sprain is one of the most common sports injuries both in high level and recreational athletes. The frequency of injuries increases in recent years as more sports participations grow. Untreated ankle sprain can lead to deteriorated chronic lateral ankle instability (CLAI/LAI), thus understanding the management is of most important. Surgery for ankle instability can varied from a simple non augmented repair, augmented repair using autograft/allograft/or other choices of internal bracing, and revision cases of failed primary repair. The decision of what surgery is of the surgeon learning curves. However, with a proper diagnosis, a simple non augmented repair is acceptable with high success rate. In certain population and narrow indication, surgeon need other armamentarium such as augmented reconstruction using graft or other technique to avoid failure of primary case that leads to revision. Anterior arthroscopic for anterior talofibular ligament (ATFL) repair is widely performed for CLAI. Many studies have reported excellent outcomes, however recurrent instabilities still become a common concern for many. Selected individuals with good indication will prevent the surgeon from revision surgeries. Surgeon need to add the risk factors such as poor ATFL remnants, involvement of calcaneofibular ligament (CFL), and preoperative activity level to their decision making. At last, the success of lateral ankle instability surgery is also dependent on proper phases of rehabilitation period. Understanding all matter that involves in the recovery of lateral ankle ligament repair is of most important for the best outcome of the patients.

Clinical Results of All-Inside Lateral Ankle Ligament Complex Repair were Comparable to Open Brostrom Procedure in High-Demand Patients with Chronic Ankle Instability: Randomized Controlled Study

Category: Ankle; Arthroscopy Introduction/Purpose: The open modified Broström-Gould procedure is widely accepted as the reference standard for lateral ankle stabilization. However, there is a lack of research comparing the outcomes of arthroscopic repair and open repair procedures for chronic ankle instability (CAI), despite the increasing number of publications on arthroscopic repair of the anterior talofibular ligament (ATFL). This study aimed to compare the clinical and radiological outcomes of arthroscopic repair and open repair of the lateral ligament complex (LLC) in patients with CAI. Methods: We prospectively randomized 64 patients who underwent ligament repair surgery for CAI into two groups: arthroscopic LLC repair (group A, 33 patients) and open modified Broström-Gould procedure (group O, 31 patients). High-demand patients, as determined by a Tegner Activity level ≥ 6, with CAI were included. Subjective outcomes were measured using the pain visual analog scale, American Orthopaedic Foot &amp; Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score. Posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic evaluations were conducted preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI). A subgroup analysis was also performed according to arthroscopic ligament quality (excellent to fair vs. poor). Results: Both groups showed significant improvements in all clinical scores, objective posturography results, and stress radiographs at 2 years postoperatively (all p &lt; 0.05), with no significant differences between the groups in terms of preoperative and postoperative values (all p &gt; 0.05). Additionally, we identified 5 cases of retear (7.8%) based on postoperative MRI evaluation (9.1% [3/33] in group A and 6.5% [2/31] in group O). One patient in group O experienced postoperative soft tissue infection. However, there were no significant differences between the two groups (p &gt; 0.05). There was no difference in clinical results between each group in subgroup analysis according to ligament quality (p &gt; 0.05). Conclusion: Arthroscopic LLC repair produced similarly favorable outcomes when compared with open lateral ankle ligament repair. In addition, arthroscopic LLC repair, as a minimally invasive technique, provide comparable outcomes to open procedure, even when the ligament tissue was poor.

Lateral Ankle Ligament Repair Is Not Only for Young Patients: Trends in Incidence and Demographics.

The purpose of this study was to examine the changes in annual incidence and patient population undergoing lateral ankle ligament repair (LALR) for the surgical treatment of chronic ankle instability. The IBM Watson Health MarketScan Database was queried for patients who underwent LALR from January 2009 to December 2019 based on CPT code 27698. Volume and incidence per 100 000 population were determined for annual sums, gender, age, and geographical regions based on population estimates from the United States Census Bureau. Future annual volumes were statistically projected with linear regression modeling to the year 2032. Overall, 160 457 LALR procedures were identified in the database from 2009 to 2019. Annual incidence increased 76.6% from 3.46 to 6.11 cases per 100 000 population, while estimates of annual volumes are projected to increase 61.5% from 19 829 to 32 033 procedures to the year 2032. Interestingly, the greatest increase in incidence was observed among patients above 70 years old, which might suggest older patients are staying active longer and desiring elective procedures to maintain their activity levels. As the incidence of LALR increases in older patients, more research will be needed to understand the unique surgical considerations and risk factors impacting patient-reported outcomes.Level of Evidence: Level IV.

A ‘STRONG REGIME’ FOR SAFE ANKLES: A PROSPECTIVE STUDY TO VALIDATE AN EARLY MOBILIZATION PROGRAMME AFTER A LATERAL ANKLE LIGAMENT REPAIR WITH SUTURE TAPE AUGMENTATION

ObjectiveTo evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation.BackgroundThe ESSKA-AFAS ankle instability group presented in 2016 evidence-based guidelines for rehabilitation and return to activity after lateral ankle ligament repair. Early mobilization is considered an important element of postoperative rehabilitation. Patients have to be immobilized for approximately six weeks to protect the delicate repair. Lateral ankle ligament repair with suture tape augmentation results in greater strength compared with standard repairs and early mobilization proved to be successful in small sample size studies. Augmented surgery technique is getting increasingly popular. However, it is unknown which rehabilitation regimes are used. It is essential to establish a clear evidence-based guideline for rehabilitation after surgery.MethodsA systematic literature search was performed to obtain the best evidence research regarding this surgery. In cooperation between the orthopaedic- and physical therapy department a post-operative rehabilitation protocol with early mobilization was established. This STRONG protocol (figure 1) is based on milestones and three stages.ResultsIn February 2016 the first patients were selected for the early mobilization regime. In total 102 patients with a lateral ankle ligament repair were treated with the STRONG protocol. No re-ruptures were observed with a follow up of a year. In a subgroup of athletes hop tests showed a symmetry index of 100,5% for triple hop, 98,6 for side hop and 103,6 for figure of 8 hop. First return to sport was achieved between 9–12 weeks, with full return to competition after a mean of 4 months.ConclusionsAn early postoperative mobilization regime based on supervised exercises seems to be a safe intervention after a lateral ankle ligament reconstruction.Clinical implicationsAugmented ankle ligament surgery with early mobilization could be an important advancement in treating patients with chronic ankle injuries.For any figures or tables, please contact authors directly.

Broström ankle ligament repair augmented with suture tape : Results of magnetic resonance imaging evaluation.

The Broström procedure is an established procedure in cases of primary lateral ankle ligament repair (LALR). To improve postoperative stability an augmentation device, InternalBrace™ (Arthrex, Naples, FL) has been introduced. This study evaluates remodelling of the anterior talofibular ligament (ATFL) in patients undergoing atape augmented Broström technique as well as clinical outcomes. In this study 32patients with chronic lateral ankle instability (CLAI) receiving augmented LALR were included. Clinical outcomes were evaluated at aone-time postoperative visit between 12and 18months. A3 T magnetic resonance imaging (MRI) was done to evaluate the morphology of the ATFL. Statistical analysis was completed with the free software and environment Rversion3.6.3 (Bell Laboratories, Murray Hill, NJ, USA) and P-values < 0.05 were considered statistically significant. The mean follow-up time was 15.3 ± 1.8months with areturn to sport time of 4.0 ± 2.4months. The average AOFAS (American Orthopaedic Foot and Ankle Society Score) score was 94.4 ± 7.2, the FAOS (Foot and Ankle Outcome Score) demonstrated 87.3 ± 10.4 points and the FFI (Foot Function Index - 2scores (pain and function score)) was 22.9 ± 20.1 and 15.4 ± 10.4, respectively. The MRI findings demonstrated an average length of the ATFL of 18.6 ± 4.3 mm and the width was 3.6 ± 0.9 mm. Aclear differentiation between the ATFL and the augmentation device could be shown in 28cases. The Fisher's exact test could not depict asignificant correlation between the presence of abone marrow edema and the tension of the augmentation device with alevel of significance of α = 0.05. An anatomical healing tendency of the ligament repair and good integrity of the augmentation device could be shown based on MRI findings. The lateral ligament repair augmented with suture tape is an effective and safe procedure regarding surgical treatment in chronic lateral ankle instability producing good clinical outcome.

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.

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

Posterior 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. We 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. All 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. Simultaneous 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. III, retrospective case-control study.

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

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

Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability.

Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair. Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed. The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05). Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

High body mass index is not a contraindication for an arthroscopic ligament repair with biological augmentation in case of chronic ankle instability.

Obesity remains frequently mentioned as a contraindication for lateral ankle ligament repair. The aim of the study was to compare the clinical results of an arthroscopic lateral ligament repair with biological augmentation between patients with a body mass index (BMI) of more than 30 and less than 30. Sixty-nine patients with an isolated lateral ankle instability were treated with an arthroscopic anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER). Patients were divided into two groups according to their BMI: ≥ 30 (Group A; n = 26) and < 30 (Group B; n = 43). Patients were pre-and post-operatively evaluated, with a minimum of 2years follow-up, and using the Karlsson Score. Characteristics of the patients, complications, ankle instability symptoms recurrence, and satisfaction score were recorded. In group A, the median Karlsson Score increased from 43.5 (Range 22-72) to 85 (Range 37-100) at follow-up. Complications were observed in seven patients (27%). Nineteen patients (73%) reported that they were "very satisfied". One patient (4%) described persistent ankle instability symptoms. In group B, the median Karlsson Score increased from 65 (Range 42-80) to 95 (Range 50-100) at follow-up. Complications were observed in four patients (9%). Thirty-three patients (77%) reported that they were "very satisfied". Two patients (5%) described persistent ankle instability symptoms. Pre-operative and at last follow-up Karlsson Score, results were significantly different between the two groups. There was no significant statistical difference in favour of satisfaction score, complications and recurrence of ankle instability between the two groups. ATFL repair with biological augmentation using IER gives excellent results for patients with BMI ≥ 30. Compared to patients with BMI < 30, they present a slightly lower preoperative and postoperative Karlsson score, however, with a similar satisfaction rate, but are at higher risk of transient superficial peroneal nerve dysesthesia. Level III.

Hindfoot Alignment and Ankle Stability Following Arthroscopic Lateral Ankle Ligament Repair.

Hindfoot varus deformity is a known risk factor for chronic lateral ankle instability (CLAI). The impact of this deformity on clinical results following arthroscopic lateral ankle ligament repair (ALLR) for CLAI has not been studied. Sixty-three ankles from 62 patients who received ALLR for CLAI were retrospectively examined. Preoperative plain radiographs were used to measure tibial articular surface (TAS) angles, and long axial hindfoot alignment radiographs were used to measure tibiocalcaneal angles (TCAs) pre- and postoperatively. Results included ratings on the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and recurrent ankle instability (respraining of the operated ankle following surgery). Recurrent ankle instability, defined as incidence of any new ankle sprain after surgery reported in the follow-up period, occurred in 13 ankles. The TAS angles of these patients were significantly low, and their preoperative TCA was significantly high. Multivariate analysis showed that preoperative TCA was an independent risk factor for recurrent ankle instability. The threshold values for preoperative TCA for recurrent instability were determined via the receiver operating characteristic curve analysis to be 3.4 degrees. Patients were assigned to a low- or high-TCA group based on the reported average TCA (2.7 degrees) of healthy patients. In the high-TCA group, recurrent instability was significantly more frequent, and the scores on the pain subscale of the postoperative SAFE-Q were significantly lower. Hindfoot varus alignment was associated with pooreroutcomes after ALLR. Level III, retrospective comparative study.

Risk Factors for the Recurrence of Instability After Lateral Ankle Ligament Repair.

Arthroscopic anterior talofibular ligament (ATFL) repair is widely performed for chronic lateral ankle instability (CLAI). Although many studies have reported excellent outcomes with this procedure, the recurrence of instability remains a common concern. Therefore, this study aimed to analyze the risk factors for the recurrence of instability after arthroscopic repair for CLAI. Fifty-six ankles of 53 patients with a mean age of 31.8 ± 14.7 years were retrospectively reviewed. All patients underwent arthroscopic ATFL repair. If instability remained immediately after ATFL repair, calcaneofibular ligament (CFL) repair was performed. The Ankle Activity Score (AAS) was assessed preoperatively, and clinical outcomes including the Japanese Society for Surgery of the Foot scale, Karlsson-Peterson scores, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were evaluated preoperatively and at the final follow-up. Talar tilt angle (TTA) was assessed preoperatively and 1 year postoperatively. Ankles were divided into 2 groups-nonrecurrence (postoperative TTA, <6 degrees) and recurrence (postoperative TTA, ≥6 degrees)-and clinical outcomes were compared. Sixteen ankles showed recurrent instability, whereas 40 did not. AAS, TTA, and social functioning in the SAFE-Q were significantly higher in the recurrence group than those in the nonrecurrence group preoperatively. In addition, the rate of poor ATFL remnant quality and the number of CFLs not repaired despite the preoperative injury diagnosis were significantly higher in the recurrence group than in the nonrecurrence group. Arthroscopic repair for ATFL and CFL deficiencies with preoperative high activity, poor remnant quality, and neglected CFL injury can result in the recurrence of instability. Appropriate surgical procedures to prevent the recurrence of instability should be selected for these ankles. Level IV, retrospective case series.

In-Office Needle Arthroscopy for the Foot and Ankle

In-office needle arthroscopy (IONA) has been a readily available tool dating back to the 1990s, primarily for diagnostic purposes. This technique was not fully accepted and implemented because of significant limitations with the image quality and lack of instrumentation available to simultaneously treat the identified pathologies. However, recent advancements in IONA technology have made it possible to perform arthroscopic procedures under local anesthesia in the office setting, which once required a full operating suite. IONA has revolutionized how we treat foot and ankle pathologies in our practice. IONA allows the patient to be an active participant in the procedure and provides an interactive experience. IONA can be used to treat a range of foot and ankle pathologies, including anterior ankle impingement, posterior ankle impingement, osteochondral lesions of the ankle joint, hallux rigidus, lateral ankle ligament repair, and tendoscopic treatment of Achilles, peroneal, and posterior tibial tendon disorders. Excellent outcomes with regard to subjective clinical outcomes, return to play times, and complications have been reported following IONA for these pathologies.

Advancement of Periosteal and Capsular Complexes With or Without Augmentation Using a Free Graft From Lower Extensor Retinaculum: A Comparative Study With Propensity Score Matching.

This study compared the outcome of the L-shaped (L-AD) advancement of the periosteal and capsular complexes with or without augmentation using a free graft of the lower extensor retinaculum (AUG) in patients with chronic lateral ankle instability. A matched pair analysis was performed of retrospectively collected medical records of patients undergoing lateral ankle ligament repair who had completed at least 2 years of follow-up. Patients who underwent L-AD with AUG and patients undergoing L-AD alone were matched for age, sex, stress radiography findings, and body mass index. Patients with general joint laxity, osteoarthritic changes in the ankle, and subtalar symptoms and who underwent simultaneous surgical treatment for conditions other than that for lateral ankle ligament were excluded. A total of 46 patients were included in the study (23 patients in each group). Clinical outcome scores and postoperative mechanical instability were compared. The median American Orthopaedic Foot & Ankle Society (AOFAS) score improved significantly (P < .001) from 72 to 97 in the L-AD alone group and from 77 to 100 in the L-AD with AUG group. The mean (±SD) talar tilt angles improved significantly from 11.1 to 4.7 degrees postoperatively (P < .001) in the L-AD alone group vs 9.7 to 5.2 degrees (P < .001) in the L-AD with AUG group. The mean anterior drawer distances were improved significantly postoperatively from 6.4 to 4.7 mm (P < .001) in the L-AD alone group, and from 6.5 to 4.5 mm (P < .001) in the L-AD with AUG group. The L-AD technique significantly improved AOFAS scores and mechanical instability of ankles with chronic lateral instability with a very low complication rate. Additional augmentation using a free graft showed no advantages in the ankle with a talar tilt of <20 degrees. Level III, retrospective case-control series.

Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair.

The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair. A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores. Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy. Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. IV.