Rotational Ankle Instability Research Articles

Improvement in clinical outcomes following arthroscopic all-inside medial lateral ligament reconstruction for rotational ankle instability.

Rotational ankle instability can be diagnosed in up to 18% of cases of chronic lateral ankle instability. It is characterised by an abnormal increase of talar rotation within the tibiofibular mortise, due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligament. The aim of this prospective observational study was to investigate the clinical outcomes following arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability. A prospective observational study of consecutive patients undergoing arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with minimum 6-month follow-up. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire. Secondary outcomes included the EQ-5D, European Foot and Ankle Society score and complications. Between 2020 and 2023, 12 patients underwent primary arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with pre- and post-operative PROMs available for all 12 patients. The mean ± standard deviation age was 33.9 ± 7.2 years and the mean follow-up was 1.9 ± 1.2 (range: 0.5-3.8, interquartile range: 0.9-3.0) years. There was a significant improvement in all Manchester-Oxford Foot Questionnaire domain scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ-5D-5L Index, VAS and VAS Pain; however, these were not statistically significant. There was one complication-a superficial peroneal nerve injury which resolved with a corticosteroid injection. The arthroscopic all-inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9-year follow-up. Level IV.

Investigation into the effect of deltoid ligament injury on rotational ankle instability using a three-dimensional ankle finite element model.

Injury to the lateral collateral ligament of the ankle may cause ankle instability and, when combined with deltoid ligament (DL) injury, may lead to a more complex situation known as rotational ankle instability (RAI). It is unclear how DL rupture interferes with the mechanical function of an ankle joint with RAI. To study the influence of DL injury on the biomechanical function of the ankle joint. A comprehensive finite element model of an ankle joint, incorporating detailed ligaments, was developed from MRI scans of an adult female. A range of ligament injury scenarios were simulated in the ankle joint model, which was then subjected to a static standing load of 300N and a 1.5Nm internal and external rotation torque. The analysis focused on comparing the distribution and peak values of von Mises stress in the articular cartilages of both the tibia and talus and measuring the talus rotation angle and contact area of the talocrural joint. The dimensions and location of insertion points of ligaments in the finite element ankle model were adopted from previous anatomical research and dissection studies. The anterior drawer distance in the finite element model was within 6.5% of the anatomical range, and the talus tilt angle was within 3% of anatomical results. During static standing, a combined rupture of the anterior talofibular ligament (ATFL) and anterior tibiotalar ligament (ATTL) generates new stress concentrations on the talus cartilage, which markedly increases the joint contact area and stress on the cartilage. During static standing with external rotation, the anterior talofibular ligament and anterior tibiotalar ligament ruptured the ankle's rotational angle by 21.8% compared to an intact joint. In contrast, static standing with internal rotation led to a similar increase in stress and a nearly 2.5 times increase in the talus rotational angle. Injury to the DL altered the stress distribution in the tibiotalar joint and increased the talus rotation angle when subjected to a rotational torque, which may increase the risk of RAI. When treating RAI, it is essential to address not only multi-band DL injuries but also single-band deep DL injuries, especially those affecting the ATTL.

Comparison of the clinical efficacy of all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure for the treatment of chronic lateral rotational ankle instability

Objective: To compare the clinical efficacy of patients with chronic lateral rotational ankle instability(CLRAI) after all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure. Methods: This is a retrospective cohort study. The clinical and imaging data of 106 CLRAI patients were collected at the Xuzhou Central Hospital from January 2021 to December 2022. The patients included 55 males and 51 females with an age of (32.6±8.2) years (range: 16 to 50 years). All patients were treated under all-inside arthroscopic, and were divided into Broström-Gould surgery group (n=54) and Broström surgery group (n=52) according to different ligament repair methods. At 3, 6, and 12 months after surgery, ankle inversion stress tests and anterior drawer tests were used to examine the stability of the ankle joint and observe gait. The American Orthopedic Foot and Ankle Society ankle hindfoot scale (AOFAS-AH) and Karlsson ankle function score (KAFS) were used to assess ankle function; Tegner score was used to assess the patient's level of exercise; the foot and ankle outcome score(FAOS)(including score of symptoms,pain,function, daily living,function, sports and recreational activities (sport); quality of life (QOL)) was used to assess the patient's daily activity ability. Comparisons of data were made using independent sample t test, repeated measures analysis of variance, LSD multiple comparison method, χ2 test or Mann-Whitney U test. Results: All operations were successfully accomplished. All incisions healed by first intention, without evidence of postoperative complications of implant rejection, ligation reaction, and nerve and vessel injury. All patients were followed up at 3, 6, and 12 months after surgery. Ankle varus stress test and anterior drawer test were negative. No evidence supporting lateral ankle instability was obtained. All patients eventually regained normal gait. No patients underwent revision surgery. Repeated measurement analysis of variance showed that AOFAS-AH, Tegner, KAFS and FAOS scores in the Brostrom-Gould group and the Brostrom group were significantly higher than those before surgery (P<0.01). The change trends of Tegner score and FAOS-sport score were significantly different between the two groups (F=18.839, P<0.01; F=8.169, P=0.005). Multiple comparisons revealed that at 3-, 6-and 12-month follow-up, the Tegner scores ((3 months: 3.7±0.5 vs. 3.3±0.5, t=-3.980, P<0.01; 6 months: 4.4±0.6 vs. 3.8±0.7, t=-4.792,P<0.01;12 months: 5.8±0.9 vs. 5.1±1.0, t=-3.889,P<0.01)), sport scores ((3 months: 82.5±3.7 vs. 79.3±3.8, LSD-t=-4.316, P<0.01; 6 months: 88.5±4.9 vs. 85.7±3.8, LSD-t=-3.312,P=0.001;12 months: 90.1±4.3 vs. 88.2±5.1, LSD-t=-2.112,P=0.037)) in the Broström-Gould surgery group were higher than those in the Broström surgery group, with statistical significances. Conclusions: Both Broström-Gould and Broström procedures under all-inside arthroscopic can make ankle stability and improve ankle function in the treatment of CLRAI. However, the former maybe shorten the time to return to exercise and achieve higher motor function.

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.

Arthroscopic Deltoid Ligament Reconstruction in Rotational Ankle Instability

Chronic lateral ankle instability is a common orthopaedic problem. The continuous stress applied by the lateral instability may affect the superficial deltoid ligament. The combination of lateral ankle instability and injury to the most anterior fascicles of the deltoid ligament contributes to rotational ankle instability. The purpose of this Technical Note is to describe the details of arthroscopic deltoid ligament reconstruction in rotational ankle instability. This minimally invasive approach allows other associated lesions to be detected and managed arthroscopically.

Rotational ankle instability: A current concept review.

Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.

The delta-snook ankle ligament reconstruction for combined deltoid insufficiency and lateral ankle instability

BackgroundAnkle sprains are one of the most common injuries amongst the general population and affect all spectrums of activity levels. While the anterior talofibular and calcaneal fibular ligaments are most prevalently injured during sprains there are instances when chronic lateral ankle instability leads to rotational ankle instability and attenuate the deltoid ligament. The few literature that exists concerning lateral and medial ankle ligament reconstruction focus on an arthroscopic approach. AimThe goal of this current work is to describe a novel open surgical reconstruction of the lateral collateral ligaments and anterior deltoid through a coupled repair. Surgical TechniqueA singular semitendinosus allograft is utilized to reconstruct the anterior deltoid, anterior talofibular and calcaneofibular ligaments. Canals are reamed for anchoring of the allograft through the medial malleolus, anterior talar body, distal fibula, and midline calcaneus. The anterior talar body, distal fibula and midline calcaneus are reamed fully to allow for pull through technique of the allograft. The medial malleolus and talar neck are anchored first, followed by the anterior fibula, and lastly the lateral calcaneus. All anchoring is performed with the ankle in a neutral position. ConclusionThis work successfully describes a novel open surgical reconstruction of the lateral collateral ligaments and anterior deltoid through a coupled repair. This technique affords the surgeon greater control over the final product and allows for a repair in a neutral position. The semitendinosus allograft also allows for a more anatomic repair with less incidence of stiffening at the ankle joint. The authors’ have noted good results and return to full activity for the patients that have undergone this procedure.

Acute Deep Deltoid Ligament Reconstruction using a Novel, Arthroscopically-Assisted Technique: Case Report

Category: Arthroscopy; Ankle; Sports; Trauma Introduction/Purpose: The deltoid ligament complex is the main stabilizing structure of the ankle mortise and is often disrupted in rotational ankle injuries. Current treatment involves open techniques for the acute repair of the superficial deltoid layer, however, repair or reconstruction of the deep deltoid ligament (DDL) has proven to be challenging using open techniques. Our described arthroscopically-assisted technique allows for better intra-articular visualization and durable reconstruction of the ruptured DDL with suture and knotless bone anchors. The goal of this new, minimally invasive approach is to facilitate a faster and more reliable recovery and prevent long-term dysfunction and degeneration from medial and rotational ankle instability. We believe it has the potential to provide improved immediate ankle stability and decrease overall surgical morbidity compared to open treatments. Methods: Case of a 48-year-old male with ligamentous-equivalent Massioneuve fracture with medial clear space (MCS) measuring 11 millimeters. Arthroscopy revealed unstable syndesmosis and rupture of the DDL. After syndesmotic fixation, there was persistent MCS widening on stress exam. Arthroscopically-assisted DDL reconstruction was performed using an accessory anteromedial (AAM) portal between the tibialis anterior tendon and posterior tibial tendon. Needle localization identified the sagittal midpoint of the medial wall of the talus, inferior to articular cartilage. Anchor sites at both the medial talar wall and midportion of the distal medial malleolus (insertion and origin of the DDL, respectively) were then drilled via the AAM portal under arthroscopic and fluoroscopic guidance respectively at the isometric point. A suture anchor was placed into the talus and tails were loaded and secured to the medial malleolus with a bioabsorbable anchor. Ankle mortise was stable to stress exam and there were no restraints to physiologic motion. Results: The patient was kept non-weight bearing on his right lower extremity for a total of 6 weeks postoperatively and was seen in the clinic for routine follow-up visits at 2 weeks, 6 weeks, and 3 months post-procedure. Sutures were removed at 2 weeks, without any wound complications, and he was transitioned from splint to a short leg cast. He required only three days of oral narcotic analgesia. Weight-bearing in a controlled ankle motion (CAM) boot and physical therapy were both initiated at 6 weeks post-op. Radiographs at each follow-up visit were without abnormalities. At 3 months post-op, he was graduated from the CAM boot into a lace-up ankle brace, without any complaints of ankle pain or instability. The patient progressed well with full weight-bearing and physical therapy and was seen for a final visit at 5 months post-op with stable MCS. No complications were encountered. Conclusion: Acute DDL rupture is a common occurrence in ankle fractures and can be diagnosed radiographically and by arthroscopy. Known sequelae of untreated DDL disruption include medial instability and late valgus collapse. This case report demonstrates a novel, minimally invasive technique to successfully reconstruct the DDL, which may minimize the surgical morbidity compared to open dissection methods and allow for decreased recovery time postoperatively. This approach may also be utilized for cases of chronic instability. Future work includes larger case series with long-term follow-up and refinement of the technique as instrumentation advances.

Deltoid ligament (DL) repair produced better results than DL nonrepair for the treatment for rotational ankle instability.

To compare the clinical and magnetic resonance imaging (MRI) results after arthroscopic deltoid ligament (DL) repair versus DL nonrepair in patients with rotational ankle instability. All patients with rotational ankle instability were enrolled in this retrospective cohort study. Clinical evaluation was performed by the American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score preoperatively and at a minimum follow-up of 2years. MRI at follow-up was performed to evaluate the DL morphology. A total of 50 patients were enrolled in this study. Among them, 24 patients received DL repair (the repair group), whereas 26 patients did not (the nonrepair group). No significant difference was found in the AOFAS score (98 ± 4 vs. 97 ± 4; n.s.), KAFS (94 ± 7 vs. 93 ± 9; n.s.), or Tegner activity score (5 ± 2 vs. 5 ± 1; n.s.) between the repair group and the nonrepair group at the final follow-up. However, the repair group had a significantly shorter return-to-sport time than the nonrepair group (4.6 ± 1.6 mo vs. 6.0 ± 2.5 mo; p = 0.03). Comparison of the postoperative deltoid ligament showed that the repair group had a lower signal intensity than the nonrepair group. Arthroscopic treatment of rotational ankle instability revealed good to excellent clinical results. However, patients who underwent DL repair had a significantly earlier return to sports as well as a lower signal intensity of DL than those who did not undergo DL repair. Level III.

Quantitative Analysis of Deltoid Ligament Degradation in Patients With Chronic Ankle Instability Using Computed Tomographic Images.

Rotational ankle instability (RAI) is associated with the faster onset of severe ankle osteoarthritis via dysfunction of the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. No specific clinical examination is available for RAI, and diagnostic imaging has limitations in evaluating ligament degradation. This study investigated the deltoid ligament degeneration using Hounsfield unit (HU) values on computed tomography (CT) images. Patients were enrolled in this retrospective analysis if they had undergone magnetic resonance imaging (MRI) and CT scans of the ankle. The chronic ankle instability (CAI) group comprised 20 ankles with CAI (9 men, 11 women; mean age, 28.7 years) and the control group comprised 28 ankles (16 men, 12 women, mean age, 41.3 years). The average HU values of the deep posterior tibiotalar ligament (dPTL) that constitutes the deltoid ligament were measured on coronal CT images, and MRI results were used as a reference. All patients were subdivided based on the MRI findings of dPTL injury such as fascicular disruption, irregularity, and the loss of striation. A strong negative correlation was identified between age and HU values for all patients (Spearman ρ = -0.63; P < .001). The mean HU values of the dPTL for participants aged <60 years were 81.0 HU for the control group (21 ankles) and 69.5 HU for the CAI group (P = .0075). No significant differences in the HU values were observed for the dPTL among the MRI subgroups. In addition to the conventional imaging examination such as stress radiographs and MRI, HU measurements of CT images could be useful for quantitatively and noninvasively evaluating degenerative changes in the deltoid ligament for CAI patients to assist the diagnosis of RAI. Level III. case-control study.

Chronic lateral ankle instability: a current concepts review

ABSTRACT Injuries to the lateral ankle ligaments are quite common, with a reported incidence of up to 22% of all sports injuries, and 85% of all ankle sprains. Most of these are effectively managed using nonoperative measures in the acute setting. Approximately 20% of patients will, however, develop chronic lateral ankle instability (CLAI). Although the anatomy and biomechanics are well documented, more recently, the concepts of the lateral talofibular calcaneal ligament (LTFCL) and microinstability have been described. For those who develop CLAI, a full assessment is mandatory to not only search for correctable risk factors (malalignment), but also to differentiate between functional and mechanical instability. Associated injuries need to be excluded, such as osteochondral lesions of the talus. Rotational ankle instability is a new concept that needs to be considered. Patients who present with CLAI are initially managed conservatively in the form of functional rehabilitation. This management is especially effective in patients with functional instability. Surgery is generally indicated after failed conservative management in patients with objective mechanical instability. The elite athlete is a relative indication to performing surgery early. The choice of surgical procedure is made on an individualised basis, although open anatomical procedures remain the gold standard. Non-anatomical procedures are no longer recommended. Newer minimally invasive and endoscopic techniques show promise in experienced hands but there is only limited evidence to support its use at present. The use of a suture tape as an augment is reserved for specific indications and should not be used routinely. Level of evidence: Level 5 Keywords: chronic lateral ankle instability, ATFL, CFL, functional rehabilitation, Broström, surgical procedures for lateral ankle ligaments

Contact patterns in the ankle joint after lateral ligamentous injury during internal rotation: A computational study.

Lateral ankle instability, resulting from the inability of ankle ligaments to heal after injury, is believed to cause a change in the articular contact mechanics that may promote cartilage degeneration. Considering that lateral ligaments' insufficiency has been related to rotational instability of the talus, and that few studies have addressed the contact mechanics under this condition, the aim of this work was to evaluate if a purely rotational ankle instability could cause non-physiological changes in contact pressures in the ankle joint cartilages using the finite element method. A finite element model of a healthy ankle joint, including bones, cartilages and nine ligaments, was developed. Pure internal talus rotations of 3.67°, 9.6° and 13.43°, measured experimentally for three ligamentous configurations, were applied. The ligamentous configurations consisted in a healthy condition, an injured condition in which the anterior talofibular ligament was cut, and an injured condition in which the anterior talofibular and calcaneofibular ligaments were cut. For all simulations, the contact areas and maximum contact pressures were evaluated for each cartilage. The results showed not only an increase of the maximum contact pressures in the ankle cartilages, but also novel contact regions at the anteromedial and posterolateral sections of the talar cartilage with increasing internal rotation. The anteromedial and posterolateral contact regions observed due to pathological internal rotations of the talus are a computational evidence that supports the link between a pure rotational instability and the pattern of pathological cartilaginous load seen in patients with long-term lateral chronic ankle instability.

Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability.

When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. Level IV, retrospective case series.

Arthroscopic Deltoid Ligament Repair

Category: Arthroscopy Introduction/Purpose: Background: Recent studies have underscored the importance of open repair of the deltoid ligament for rotational ankle instability in purely ligamentous injuries as well as with ankle fractures. With the advent of successfull arthroscopic lateral ligament techniques the authors have explored the use of similar arthroscopic techniques for deltoid repair. This study aimed to describe a novel arthroscopic technique for deltoid ligament repair and relate the proximity of anatomic structures at risk. Purpose: To evaluate the proximity of anatomic structures for a novel arthroscopic deltoid ligament stabilization technique and to define ideal landmarks and “safe zones” for this repair. Methods: Methods: Five human cadaveric ankle specimens were screened for the study. All specimens underwent arthroscopic deltoid ligament repair with a suture passer and suture anchor technique. Five cadaveric specimens were dissected to determine the proximity of anatomic structures after repair. Several distances were measured, including those of different anatomic structures to the suture knot to determine the “safe zones.” Measurements were obtained and statistical analysis was performed. Results: Results: None of the specimens revealed entrapment of the suture knots to the posterior tibial tendon (PTT) or saphenous nerve. The safe zone between the PTT and saphenous vein was a mean of 20 mm (range, 16-25 mm). On average, a 16 mm (range, 12-20 mm) safe distance was maintained from the suture knot to the PTT. The saphenous vein was in close proximity to the suture knot at a mean distance of 3 mm (range, 0-9 mm). Conclusion: The results indicate that there is a relatively wide safe zone between the PTT and the saphenous vein when performing the arthroscopic deltoid ligament stabilization technique. While none of the critical anatomic structures (except for saphenous vein) were entrapped by the suture knot, it was evident that the variable course of the saphenous vein renders it at risk for entrapment. This study further defines the proximity of adjacent anatomic structures and establishes the anatomic safe zones for the arthroscopic deltoid ankle stabilization procedure. By defining this relatively risk-free zone, surgeons less experienced with arthroscopic ligament repair techniques may approach arthroscopic suture passage with more confidence.

Chronic Rotational Ankle Instability- A case series study

BackgroundThis study shall assess the clinical outcome of anatomical ligamentous reconstruction of normally aligned ankles with chronic rotational instability, i.e. combined lateral and medial ankle instability. Materials and MethodsNineteen cases (11 female, 8 male) with clinical and radiological evidence of rotational ankle instability and no evidence of hindfoot mal-alignment, were treated by anatomical surgical reconstruction. Cases were followed a minimum of six months postoperatively. Results18 out of 19 patients (94.7%) returned to sport and full-time work within three months postoperatively. One patient (5.3%) returned after six months and had pain-free range of motion and walking. One case (5.3%) had persistent lateral ankle instability. ConclusionsAnatomical reconstruction of chronic, rotationally unstable, ankle with normal hindfoot alignment may yield a favourable short-term outcome. However, there is a need for a larger cohort to examine both short and long term clinical outcome in such cases. Level of evidenceLevel 4, case series.

Varus External Rotation Stress Test for Radiographic Detection of Deep Deltoid Ligament Disruption With and Without Syndesmotic Disruption

External rotation stress is used intraoperatively for diagnosing medial ankle and syndesmotic instability in rotational ankle fractures after reduction and fixation of the fibula. However, external rotation includes hindfoot, midfoot, and ankle motion. The purpose of this study was to determine the effect of hindfoot positioning when using the external rotation stress test. Isolated deep deltoid ligament (DDL) instability and combined DDL and syndesmotic instability were modeled. An intact fibula was used as a surrogate for an anatomically fixed fibula fracture. Six cadaver specimens with full-length tib-fib articulations were used. Specimens were fixed into a Taylor Spatial Frame (Smith&Nephew, Memphis, TN) with 4 to 5 points of fixation in the tibia and the foot. Specimens were mounted in ankle and foot neutral position. Metal markers were placed at the medial gutter and syndesmosis. Anteroposterior (AP) and mortise radiographs were obtained in 3 positions: neutral hindfoot, valgus external rotation stress, and varus external rotation stress. For both valgus and varus external rotation stress, the frame was loosened and stressed to a hard end point and then locked. Three modes were studied: intact ligaments, DDL transected, and DDL+ syndesmosis transected. Digital radiographs were used to measure the displacement of the markers. The varus external rotation stress test demonstrated significant widening of the medial gutter in specimens with isolated DDL instability, in both AP (P = .01) and mortise (P = .02) views. Both maneuvers demonstrated significant medial gutter widening with combined DDL and syndesmosis disruption (P ≤ .01), although the varus external rotation stress test produced nearly twice as much displacement (10.7 vs 5.4 mm). Syndesmotic widening was not significant with either maneuver. Varus external rotation stress was more effective than valgus external rotation stress in demonstrating displacement of markers at the medial gutter and on AP and mortise radiographs for both DDL and DDL with syndesmotic instability. These findings may lead to improved clinical detection of rotational ankle instability from combined DDL and syndesmotic disruption, which may affect decision making for using syndesmotic fixation when using intraoperative stress fluoroscopy images. Occult DDL instability may be underdiagnosed, and this may affect future directions of the treatment of rotational ankle fractures and severe sprains.

Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction

Deltoid ligament injuries are a source of valgus and rotational ankle instability and often occur as a result of athletic injury. The anatomy of the medial ankle ligament complex is reviewed and pertinent radiological findings are emphasized. The clinical evaluation of athletes with medial ankle instability as well as methods of repair and reconstruction of the deltoid ligament complex in those patients requiring surgical care are described.

Chronische Instabilität des oberen Sprunggelenks

Chronic ankle instability represents a typical sports injury. After an acute ankle sprain 20-40% of the injured develop chronic ankle instability. From an orthopaedic point of view chronic ankle instability can be subdivided into lateral and medial instability or a combination of both, the so-called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of neuromuscular control. For the physician chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy often surgical. This review on chronic ankle instability deals with the pathomechanisms, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, such as ligamentous osteoarthritis.

Chronische Instabilität des oberen Sprunggelenks im Sport - ein Review für Sportärzte

Chronic ankle instability represents a typical sports injury which can mostly be seen in basketball, soccer, orienteering and other high risk sports. 20 to 40 % of the acute ankle sprains develop into chronic ankle instability. From a sports orthopaedic point of view, chronic ankle instability can be subdivided into a lateral, medial or a combination of both so called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of the neuromuscular control. For the sports physician, the chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy usually surgical. This review on chronic ankle instability addresses pathomechanism, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, as ligamentous osteoarthritis.