Treatment Of Lateral Ankle Instability Research Articles

Operative Treatment of Lateral Ankle Instability.

Chronic lateral ankle instability can occur in a subset of patients following ankle inversion sprains. Operative treatment to restore stability in the ankle and hindfoot and to prevent further degenerative changes may be indicated in cases in which nonoperative treatment has failed. Anatomical direct repair with use of native ligament remnants with or without reinforcement of the inferior retinaculum is the so-called gold standard operative strategy for the treatment of lateral ankle instability. The procedure has shown promising short and long-term outcomes. Candidates for the procedure have ligament remnants of sufficient quality that are amendable to direct repair. Anatomical reconstruction with use of autograft or allograft is reserved for patients with insufficient ligament remnants to fashion a direct repair, failed previous lateral ankle repair, high body mass index, or generalized ligamentous laxity. A wide variety of autografts have been described, each with potential advantages and disadvantages. These procedures can provide good-to-excellent short-term outcomes. However, there is no available information on their long-term clinical results. Non-anatomical lateral ligament reconstruction typically involves the use of the adjacent peroneal brevis tendon and has been applied in cases in which only poor-quality ligament remains. The procedure can provide good to excellent short-term outcomes, although reported long-term outcomes have differed among studies. The particular tendon used for the graft should be carefully considered given the potential alterations in the kinematics of the ankle and hindfoot. Arthroscopic ligament repair is becoming increasingly popular as it is minimally invasive. This procedure is restricted to patients who have good-quality ligament remnants. Good-to-excellent clinical outcomes have been reported after short and long-term follow-up, although a relatively high rate of complications-including nerve damage-has been reported following the procedure and therefore warrants further investigation before widespread adoption can be advocated.

Technique for Single-Graft Lateral Ankle Stabilization: A Cadaveric Biomechanical Study

Several surgical procedures have been described for treatment of lateral ankle instability with varying degrees of success and complications. The purpose of this study was to describe a modification to the Brostrom procedure that allows for repair when lateral soft tissues are insufficient for primary repair. Cadaveric specimens were tested in a Telos Stress Device with lateral ligaments intact, transected, and with a single-graft repair. Talar tilt angle and anterior displacement index were measured and compared between each phase of the study. There was no significant difference between talar tilt angle of specimens with ligaments intact and ligaments grafted (p = .2295). There was no significant difference between anterior displacement index of specimens with ligaments intact and ligaments grafted (p= .6482). A cadaveric model is used to demonstrate that lateral ankle ligaments can be repaired using a new single-graft technique, and is comparable to presectioned intact lateral ankle ligaments.

A Biomechanical Comparison of an Open vs. Arthroscopic Approach for the Treatment of Lateral Ankle Instability (SS-57)

Introduction Ankle sprains are the most common musculoskeletal injury, accounting for 2 million emergency department visits annually. Most sprains involve the lateral ligament complex secondary to an inversion force on a plantar flexed foot. The diagnosis of chronic ankle instability is considered when repetitive sprains or persistent symptoms of giving way are present. The current clinical standard is the open modified Brostrom procedure (open). Many surgeries in orthopedics have evolved with minimally invasive approaches. The purpose of this study was to biomechanically compare a minimally invasive arthroscopic technique for the treatment of ankle instability to the open technique. Methods Twenty matched lower extremity cadaver specimens were tested (mean 40 ± 12 years). Specimens were examined for gross instability or anatomic lesions. Steinman pin wires were inserted into the tibia and the talus, and six sensors were rigidly affixed to each of the wires to establish relative planes of movement. Specimens were placed in a Telos ankle stress apparatus and loaded to 1.7 N-m in two orientations simulating the anterior drawer and talar tilt clinical exam tests. For each of these tests the ankle was held in three orientations: 15° plantar-flexion, neutral alignment, and 15° dorsiflexion. During testing, the movement of the sensors was measured in three separate planes using the Optotrak Computer Navigation System. The difference in translation between the talus and the tibia in the loaded anterior drawer test and the angle between the tibia and talus in the loaded talar tilt test were calculated and compared to the unloaded state to determine the differences in translation and angle. Following intact testing, the anterior talofibular ligament and the calcaneofibular ligament were both sectioned from the fibula to simulate an unstable ankle and retested in all test modes. Sectioned ligaments were then repaired using two 3.5mm diameter corkscrew suture anchors. One anchor was placed at the ATFL origin and the other at the CFL origin. Ten of the specimens were repaired using the standard open repair; while the remaining 10 contralateral specimens were repaired using an arthroscopic technique. All test modes were retested following repair. Statistically significant differences in displacement within treatment groups were analyzed using a repeated measures ANOVA. A paired t-test was used to determine differences between the open and arthroscopy groups. Results There was significantly more motion in the sectioned ankles compared to intact and both treated groups for all but one test mode (anterior drawer in dorsiflexion, p=0.054). The arthroscopic and open repair techniques were biomechanically similar with the exception of the inversion in plantar flexion. However, the difference in total combined motion was not statistically significant and both repair groups were statistically superior to the sectioned state. Conclusion Our findings suggest similar improvement in biomechanical function with both the arthroscopic and open repairs when compared to the sectioned state. Both techniques were shown to be comparable to the intact state suggesting that biomechanically effective ankle stabilizations may be able to be performed through a minimally invasive approach.

Reconstruction of the Lateral Ankle Ligament With a Long Extensor Tendon Graft of the Fourth Toe

Background: The treatment of lateral ankle instability is challenging when the remaining ligamentous tissue is insufficient. Anatomic reconstruction with a tendon graft is a good option that can produce a stable ankle and avoid the complications of a nonanatomic tenodesis procedure. Hypothesis: A new technique for anatomically reconstructing the lateral ligaments of the ankle using an extensor digitorum longus tendon graft of the fourth toe will be effective for treating lateral ankle instability with chronic ligamentous insufficiency. Study Design: Case series; Level of evidence, 4. Methods: Twenty-four patients were treated with anatomic reconstruction of the ligaments using the long extensor tendon of the fourth toe. The mean age was 35.7 years (range, 16-53 years). The minimum follow-up was 24 months (range, 24-57 months; mean, 37 months). There were 17 cases of chronic ligamentous insufficiency, 3 failed Brostrom operations, and 4 others. Preoperative and postoperative Karlsson scales were used to analyze the functional results. The anterior displacement and the talar tilt angle on standard stress radiography of the talocrural joint were measured preoperatively and at the time of last follow-up for comparison. Results: The results on the Karlsson scale increased from 48.0 ± 4.2 points preoperatively to 92.2 ± 3.8 points at the latest follow-up (P < .01). Radiographically, the mean anterior displacement was 6.7 ± 1.2 mm before operation and 3.4 ± 0.6 mm at the latest follow-up (P < .01). The mean talar tilt angle was 12.3° ± 1.1° before the operation and 4.3° ± 0.8° at the latest follow-up (P < .01). Conclusion: Anatomic reconstruction of the lateral ankle ligaments using the long extensor tendon of the fourth toe appears to be an effective surgical option for chronic insufficiency of the lateral ankle ligament.

Treatment of lateral ankle ligament injuries and ankle instability with semitendinosus tendon graft

Objective To explore the effectiveness of ipsilateral autologous semitendinosus ten don graft in treatment of lateral ankle ligament injuries and ankle instability. Methods Two patients including one male (25 years old) and one female (17 years old) with chronic lateral instability of the ankle were enrolled in the study. Both patients had the history of repeated ankle sprain in supination position and had grade Ⅲ injury of the lateral ankle ligament according to the American College of Foot and Ankle Surgeons Grading System. Anterior drawer test and talar tilt test were all positive. The stress-inversion radiograph demonstrated the average inclination of the talus for 21 ° and the lateral radiograph demonstrated anterior dislocation of the talus. The chronic ankle instabilities in two patients were treated by using the ipsilateral autologous semitendinosus tendon graft to reconstruct the lateral ankle ligament. Results The two patients were followed up for mean eight months, which revealed that the active and passive range of motion was good, with no pain or swelling. The anterior drawer test and talar tilt test were all negative. The stress-inversion radiograph demonstrated that the average inclination of the talus was less than 5°, with no anterior dislocation of the talus. According to the Mazur grading system, the clinical outcome was excellent in one patient and good in one. The two patients were satisfied with the stability of the ankle. Conclusions ( 1 ) Lateral ankle ligament injury is a common cause of chronic ankle instability,even the ankle osteoarthritis. ( 2 ) Brostr(o)m method can attain satisfactory result for fresh lateral injury of the ankle, but not for the old injuries. ( 3 ) Ipsilateral autologous semitendinosus tendon graft is simpleand effective for treatment of lateral ankle ligament injuries and chronic ankle instability and may play an important role in the treatment of lateral ankle instability and prevention of the occurrence of ankle osteoarthritis. Key words: Ankle joint; Sprains and strains; Lateral ligament,ankle

Talar Anchor Placement for Modified Brostrom Lateral Ankle Stabilization Procedure

The modified Brostrom procedure has been a proven procedure with excellent utility in the treatment of lateral ankle instability within limitation. Multiple variations of the original technique have been described in the literature to date. Included in these variations are differences in anchor placement, suture technique, or both. In this research study, we propose placing a bone screw anchor into the lateral shoulder of the talus rather than the typical placement at the lateral malleolus for anatomic reconstruction of the lateral ankle ligaments.

Treatment of lateral ankle instability with transfer of the extensor digitorum brevis muscle

Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, some injuries may be followed by chronic lateral pain and instability, and surgical stabilization is sometimes necessary. In select cases, there is little or no residual ligament or scar tissue remaining for late reconstruction. Proximal transfer of the origin of the extensor digitorum brevis muscle as a substitute for deficient ligament tissue can be used in these difficult cases. During the years 1971 to 1992, 13 ankles in 10 patients underwent surgery using the proximal extensor digitorum brevis muscle transfer method. At follow-up, all the ankles manifested functional stability and were stable with no clinical drawer sign. All had a normal range of motion in the ankle joint but showed a desired decreased supination range of motion throughout the hindfoot and ankle. The functional Karlsson scores were 84.5 ± 18.8 before injury, 26.4 ± 18.7 before surgery, and 83.6 ± 18.7 at follow-up. Thus, the extensor digitorum brevis muscle transfer seems to be a useful alternative method of long-term ankle stabilization in these difficult chronic case; the results correlate well with a few other studies using this method. (The Journal of Foot & Ankle Surgery 42(4):183-192, 2003)

Review of the Dockery procedure for lateral ankle instability. A seven-year retrospective analysis.

This article presents a critical review of the Dockery procedure (autogenous peroneus longus free graft technique) for the treatment of lateral ankle instability. Those patients with gastrocnemius equinus were treated with gastrocnemius recession during surgery. The authors reviewed 33 stabilizations performed over a period of 7 years to analyze the effectiveness of the procedure with and without the addition of the gastrocnemius recession. Assessed were the type and length of conservative therapy, the time to return to regular activity, complications experienced, and the recurrence rate. The results show a reinjury rate of 3%. The complications included infection, prolonged healing, and occasional screw irritation requiring screw removal. In light of the low incidence of reinjury, this technique is a valid procedure for treating lateral ankle instability.