Arthroscopic anterior deltoid plication with bone anchor is an effective procedure to control residual talar anterior translation after lateral ligament repair.

PURPOSE: Residual symptoms can be observed after ankle lateral ligament repairs commonly due to hyperlaxity, severe ankle instability or a failed stabilization. In order to increase joint stability, ligament or capsular-ligament plication has been used in other joints. Given that the anterior portion of the deltoid is a stabilizer against anterior talar translation, it could be used as an augmentation to restrict anterior talar translation. The aim of this study was to describe an arthroscopic anterior deltoid plication with a bony anchor as an augmentation to the lateral stabilization. The results in a series of eight patients were presented. METHODS: Eight patients (seven males, median age 31 [range, 22-43] years) presented residual instability after arthroscopic all inside lateral collateral ligament repair. Arthroscopic anterior deltoid ligament plication was performed in these patients. Median follow-up was 22 (range, 15-27) months. Using an automatic suture passer and a knotless anchor, the anterior deltoid was arthroscopically plicated to the anterior aspect of the medial malleolus. RESULTS: During the arthroscopic procedure, only an isolated detachment of the anterior talofibular ligament was observed without any deltoid open-book injury in any case. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligament repair and the anterior deltoid plication with a bony anchor. On clinical examination, the anterior drawer test was negative in all patients. The median American Orthopedic Foot and Ankle Society score increased from 68 (range, 64-70) preoperatively to 100 (range, 90-100) at final follow-up. CONCLUSION: The arthroscopic anterior deltoid plication is a feasible procedure to augment stability and control anterior talar translation when treating chronic ankle instability in cases of residual excessive talar translation. LEVEL OF EVIDENCE: Level IV.

Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle.

PURPOSE: When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. METHODS: Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. RESULTS: A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. CONCLUSION: Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. LEVEL OF EVIDENCE: Level IV.

The deltoid ligament is constantly formed by four fascicles reaching the navicular, spring ligament complex, calcaneus and talus.

PURPOSE: The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament. METHODS: Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken. RESULTS: The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures. CONCLUSION: The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries. LEVEL OF EVIDENCE: Not applicable (cadaveric study).

Arthroscopic repair of the tibiotalar fascicle of deltoid ligament is feasible through anterior ankle arthroscopy.

PURPOSE: Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy. METHODS: Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture. RESULTS: In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer. CONCLUSIONS: The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy. LEVEL OF EVIDENCE: Not applicable.

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

PURPOSE: 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. METHODS: 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). The same 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. RESULTS: 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. CONCLUSIONS: 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 OF EVIDENCE: Level II, prospective comparative.

Arthroscopic all-inside ligament repair has similar or superior clinical outcomes compared to open repair for chronic ankle instability without concomitant intra-articular pathology at 5 years follow-up.

PURPOSE: Open ligament repair is widely considered the gold standard treatment for chronic ankle instability. Nevertheless, arthroscopic treatment of ankle instability has gained popularity becoming the preferred technique for many surgeons. This study aimed to compare the clinical outcomes of all-inside arthroscopic versus open lateral ligament repair for chronic ankle instability at 5 years follow-up. METHODS: Ninety consecutive patients were surgically treated for chronic ankle instability without concomitant intra-articular pathology observed on MRI: 41 patients [median age 28 (range 15-54) years] underwent an open lateral ligament repair (OLR); 49 patients [median age 30 (range 19-47) years] underwent an all-inside arthroscopic ligament repair (ALR). Functional outcomes using the Foot Functional Index (FFI), the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score, and the Foot and Ankle Ability Measure-Sports Subscale (FAAM-SS) were assessed preoperatively and at the latest follow-up. At the latest follow-up, the satisfaction rate and complications were also recorded. RESULTS: The mean follow-up was 58 ± 17.6 (range 47-81) months. In both groups FFI, AOFAS and FAAM-SS score significantly improved compared to preoperative values (p < 0.001). There was no statistically significant difference in postoperative outcomes between groups in the AOFAS (n.s) and FAAM-SS (n.s), but the FFI results were significantly better in the ALR group (p < 0.05). No major complications were reported in either group. CONCLUSION: Open and arthroscopic ligament repair to treat chronic ankle instability without concomitant intra-articular pathology produced excellent comparable clinical outcomes at 5 years follow-up. The complications were minimal in both study groups with no significant differences in AOFAS and FAAM-SS scores. However, arthroscopic repair showed significantly better results on the FFI. Therefore, when treating chronic lateral ankle instability, surgeons should consider arthroscopic ligament repair. LEVEL OF EVIDENCE: III.

All-inside arthroscopic repair of the anterior talofibular ligament: a case series.

INTRODUCTION: The all-inside arthroscopic repair of the anterior talofibular ligament (ATFL) is a technically challenging and still-recent procedure to treat chronic ankle instability (CAI). Favourable clinical outcomes have been shown from originator centers, but this is one of the first series from a non-originator centre. The purpose of the present study is to present the clinical and functional results of patients with CAI underwent arthroscopic all-inside ATFL repair. METHODS: This is a series of cases of 18 consecutive patients who underwent the all-inside arthroscopic ATFL repair, for CAI, after the failure of conservative treatment performed for six months. The evaluation was made using the American Orthopaedic Foot and Ankle Score (AOFAS), visual analog pain scale (VAS), anterior drawer, and talar tilt tests. RESULTS: All 18 patients were evaluated for a mean follow-up period of 12 months. There was an improvement in the AOFAS (p < 0.001), with the mean improving from 69.6 points to 98.1, standard deviation (SD) = 11.09, and in the mean VAS score (p < 0.001), from 5.0 to 0.5 points (SD = 0.78). All ankles were stable, as assessed by the anterior drawer test and talar tilt test. The only complication found was neurapraxia of the superficial fibular nerve in one patient (5%). All of the patients classified the treatment as good or excellent and returned to sports activities without limitations. CONCLUSION: Treatment of CAI by the all-inside arthroscopic ATFL repair was able to restore ankle stability and showed good clinical results and high satisfaction rates.

Arthroscopic anterior cruciate ligament repair with and without suture augmentation: technical note.

Anterior cruciate ligament (ACL) tears are routinely treated with an ACL reconstruction. This is based on historical literature reporting high failure rates after ACL repairs in addition to the limited healing potential of the ACL. Recently, improved understanding of pathophysiology of ligamentous healing has led to increasing interest in treating proximal avulsions with excellent tissue quality in the acute setting, as this technique allows for ACL healing. Potential advantages of ACL repair include preservation of native proprioceptive and kinematics of the knee, avoidance of graft harvesting morbidity and the possibility to perform a primary ACL reconstruction in case of failure. As a consequence, several techniques for ACL repair have been proposed that can be performed in isolation or with suture augmentation. The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. The secondary aim of the current study is to review the indications, patient selection and advantages of the technique.

Arthroscopic Assessment and Treatment of Medial Collateral Ligament Complex.

An increased interest in ankle instability has led to description of new concepts such as ankle microinstability or rotational ankle instability and the development of new arthroscopic techniques treating ankle instability. Ankle instability is constantly associated to intraarticular pathologies that contribute to generate pain and dysfunction. Arthroscopy plays an important role in identifying and treating all intraarticular abnormalities including ligament injuries. Despite a few studies are available in literature on arthroscopic treatment of medial collateral ligament injury, an arthroscopic all-inside repair of lateral and medial ankle ligaments has been proposed showing promising clinical results.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey.

PURPOSE: Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. METHODS: A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency". RESULTS: A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm. CONCLUSION: The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. LEVEL OF EVIDENCE: Level IV.

Arthroscopic-Assisted Versus All-Arthroscopic Ankle Stabilization Technique.

BACKGROUND: Both the percutaneous technique with arthroscopic assistance, also known as arthroscopic Broström (AB), and the arthroscopic all-inside ligament repair (AI) are widely used to treat chronic lateral ankle instability. The aim of this study was to compare the clinical outcomes of these 2 arthroscopic stabilizing techniques. METHODS: Thirty-nine consecutive patients were arthroscopically treated for chronic ankle instability by 2 different surgeons. The AB group comprised 20 patients with a mean age of 30.2 (range, 18-42) years and a mean follow-up of 19.6 (range, 12-28) months. The AI group comprised 19 patients with a mean age of 30.9 (range, 18-46) years and mean follow-up of 20.7 (range, 13-32) months. Functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog pain scale (VAS) were assessed pre- and postoperatively. Range of motion (ROM) and complications were recorded. RESULTS: In both groups the AOFAS and VAS scores significantly improved compared with preoperative values (P < .001) with no difference (P > .1) between groups. In the AB group the mean AOFAS score improved from 67 (range, 44-87) to 92 (range, 76-100) and the mean VAS score from 6.4 (range, 3-10) to 1.2 (range, 0-3). In the AI group the mean AOFAS score changed from 60 (range, 32-87) to 93 (range, 76-100) and the mean VAS score from 6.1 (range, 4-10) to 0.8 (range, 0-3). At the final follow-up 8 complications (40%) were recorded in the AB group. In the AI group 1 complication (5.3%) was observed (P < .05). CONCLUSION: Both the AB and AI techniques are suitable surgical options to treat chronic ankle instability providing excellent clinical results. However, the AB had a higher overall complication rate than the AI group, particularly involving a painful restriction of ankle plantarflexion and neuritis of the superficial peroneal nerve. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality.

PURPOSE: An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality. METHODS: Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair. RESULTS: Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up. CONCLUSION: Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality. LEVEL OF EVIDENCE: IV, retrospective case series.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The arthroscopic all-inside ankle lateral collateral ligament repair is a safe and reproducible technique.

PURPOSE: Neurovascular structures around the ankle are at risk of injury during arthroscopic all-inside lateral collateral ligament repair for the treatment of chronic ankle instability. This study aimed to evaluate the risk of damage to anatomical structures and reproducibility of the technique amongst surgeons with different levels of expertise in the arthroscopic all-inside ligament repair. METHODS: Twelve fresh-frozen ankle specimens were used for the study. Two foot and ankle surgeons with different level of experience in the technique performed the procedure on 6 specimens each. The repair was performed following a standardized procedure as originally described. Then, an experienced anatomist dissected all the specimens to evaluate the outcome of the ligament repair, any injuries to anatomical structures and the distance between arthroscopic portals and the superficial peroneal nerve (SPN) and sural nerve. RESULTS: Dissections revealed no injury to the nerves assessed. Mean distance from the anterolateral portal and the SPN was of 4.8 (range 0.0-10.4) mm. The mean distance from the accessory anterolateral portal to the SPN and sural nerve was of 14.2 (range 7.1-32.9) mm and 28.1 (range 2.8-39.6) mm, respectively. The difference between the 2 surgeons' groups was non-statistically significant for any measurement (mm). In all specimens both fascicles of the anterior talofibular ligament were reattached onto its original fibular footprint. The calcaneofibular ligament was not penetrated in any specimen. CONCLUSIONS: The all-inside arthroscopic lateral collateral ligament repair is a safe and reproducible technique. The clinical relevance of this study is that this technique provides a safe and anatomic reattachment of the anterior talofibular ligament, with minimal risk of injury to surrounding anatomical structures regardless of the level of experience with the technique.

Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair.

PURPOSE: Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament's (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL's distal fascicle transfer for the treatment of chronic ankle instability. METHODS: Five unpaired cadaver ankles underwent arthroscopic ATiFL's distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL's distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported. RESULTS: All specimens revealed successful transfer of the tibial origin of the ATiFL's distal fascicle onto the talar insertion of anterior talofibular ligament's (ATFL) superior fascicle. The fibular origin of the ATiFL's distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8 mm. The median distance between the distal AL portal and SPN was 3.9 mm. CONCLUSION: An all-arthroscopic approach to an ATiFL's distal fascicle transfer is a reliable method to reconstruct the ATFL's superior fascicle. Transfer of ATiFL's distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL's distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.

Surgical treatment of displaced intraarticular calcaneal fractures by a minimally invasive technique using a locking nail: A preliminary study.

BACKGROUND: The aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail®). METHODS: Between January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail®. The Böhler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24-78). Mean final follow-up was 18 months (range, 12-24). RESULTS: Six fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Böhler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60-96). CONCLUSIONS: The Calcanail® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.

Arthroscopic All-Inside Anterior Talofibular Ligament Repair Through a Three-Portal and No-Ankle-Distraction Technique.

BACKGROUND: Ankle instability is a common consequence of ankle sprains. Injury of the anterior talofibular ligament (ATFL) is the most common cause of ankle instability1. Arthroscopic treatment of ankle instability is an emerging field attracting increased interest among surgeons2-10. The arthroscopic all-inside ATFL repair allows the surgeon to explore the ankle joint, treat concomitant pathology when encountered, and reattach the injured ATFL to its fibular anatomical location. The aim of this article is to describe the arthroscopic all-inside ATFL repair through a 3-portal no-ankle-distraction technique. DESCRIPTION: After patient positioning, anteromedial and anterolateral portals are created. An accessory anterolateral portal is created just anterior to the fibula and about 1 cm proximal to the tip of the lateral malleolus. The arthroscope is introduced through the anteromedial portal, and the instruments are introduced through the anterolateral portal. Recognition of the ligament and evaluation of the ligament tear with a probe are required. The footprint for the fibular attachment of the ATFL is debrided. The ligament is penetrated with a suture passer. A nitinol loop is pushed and then is pulled out through the accessory portal. The nitinol wire is replaced by a double high-resistance suture. The limbs of the suture located in the accessory portal are passed through the anterolateral portal. Next, one or both limbs of the suture are passed through the loop suture. Pulling of the suture limbs introduces the loop into the joint and the ligament is grasped by the suture. The tunnel for the anchor is drilled. The knotless anchor is loaded with the suture, and the anchor and suture are introduced with the ankle in dorsiflexion and valgus. Postoperatively, the ankle is immobilized with a removable walking boot for 4 weeks. Once use of the walking boot is discontinued, physical therapy is started. ALTERNATIVES: Nonoperative treatment with physiotherapy or sports restriction can be an alternative for patients with surgical contraindications or as a first step of treatment. Open techniques (repair or reconstruction) or other arthroscopic-assisted techniques (arthroscopic introduction of anchors and percutaneous passage of sutures, or arthroscopic-assisted reconstruction) are possible surgical alternatives to the described technique to treat ankle instability. RATIONALE: The described technique has the advantage of being done with a minimally invasive approach and providing an anatomical repair of the ligament. Concomitant intra-articular pathology can be addressed during the procedure through the same arthroscopic approaches. Early rehabilitation and the lack of intra-articular knots are additional benefits of the technique.

Tendoscopic Treatment of Peroneal Intrasheath Subluxation: A New Subgroup With Superior Peroneal Retinaculum Injury.

BACKGROUND: Snapping peroneal tendons is a rare cause of lateral ankle pain. Two subgroups have been described: chronic subluxation with superior peroneal retinaculum (SPR) injury and intrasheath subluxation with SPR intact. The aim of the study was to report the tendoscopic findings and results in patients affected by snapping peroneal tendons without evident dislocation. METHODS: Between 2010 and 2015, a total of 18 patients with a retromalleolar "click" sensation and no clinical signs of peroneal tendon dislocation underwent tendoscopy. Mean age was 29 years (range, 18-47). Mean follow-up was 45 months (range, 18-72). RESULTS: Tendoscopic examination revealed an intact SPR in 12 patients. Of these 12, a space-occupying lesion was present in 7, a superficial tear of peroneus brevis in 4, and a shallow fibular groove in 7. An SPR injury without peroneal tendon dislocation was observed in the remaining 6 patients. All these 6 patients presented a shallow fibular groove. Although the SPR was injured, they had been diagnosed as intrasheath subluxation. Patients with intrasheath subluxation and intact SPR underwent debridement of a space-occupying lesion in 11 cases and fibular groove deepening in 5 cases. Patients with intrasheath subluxation and SPR injury underwent fibular groove deepening without addressing the SPR. At follow-up, the mean American Orthopaedic Foot & Ankle Society score increased from 76 (range, 69-85) preoperatively to 97 (range, 84-100). No recurrence or major complications were reported. Conclusion Intrasheath subluxation of peroneal tendons was successfully treated tendoscopically. A new subgroup of intrasheath subluxation with SPR injury but no clinically evident peroneal tendon dislocation is reported. LEVEL OF EVIDENCE: Level IV, case series.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review.

BACKGROUND: Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Broström-Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies. METHODS: A systematic literature review using PubMed/Medline databases was performed (July 1972-July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed. RESULTS: The total ankles treated with an open Broström ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months-27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60-100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months-14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44-100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases. CONCLUSIONS: The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.