Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity.

BACKGROUND: To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL). METHODS: From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0. RESULTS: The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up. CONCLUSION: Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Comparison of Midterm Outcomes between All-Inside Arthroscopic and Open Modified Broström Procedures as Treatment for Chronic Ankle Instability.

Background: Although the all-inside arthroscopic modified Broström operation (AMBO) and open modified Broström operation (OMBO) for chronic lateral ankle instability (CLAI) showed favorable outcomes up to 1-year short-term follow-up, concerns about the long-term stability of AMBO are still present. Therefore, we aimed to compare midterm outcomes between the 2 methods by extending the observation period. Methods: Fifty-four patients undergoing ankle surgery between August 2013 and July 2017 were included in the AMBO (n = 37) and OMBO (n = 17) groups. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS) were used to evaluate the clinical outcomes. Anterior drawer test and talar tilt angle were used to evaluate the radiological outcomes. The mean follow-up duration was 59.69 months. Results: The 2 groups both showed improved clinical and radiological results statistically. In addition, they did not differ in age, sex, or preoperative AOFAS ankle-hindfoot scale score, VAS score, anterior drawer test, or talar tilt angle. No significant difference in the final follow-up postoperative clinical scores or radiological outcomes was observed. Conclusions: AMBO and OMBO as treatments for CLAI did not yield differing clinical or radiological outcomes at a mean follow-up time point of 59.69 months.

All-Inside Arthroscopic and Open Techniques of the Modified Broström Procedure for the Treatment of Lateral Ankle Instability: Comparison of the Times to Return to Play.

Background and Objectives: Lateral ankle injuries are commonly encountered injuries, and the open modified Broström operation (OMBO) is the primary treatment option. Recently, an arthroscopic modification of the Broström operation (AMBO) was developed; many studies have shown that there are no significant differences in clinical and radiological outcomes between the two surgical methods. However, no studies have been conducted comparing the two surgical methods in terms of return to play (RTP) time. This study assesses the time to RTP and the functional clinical outcomes. Materials and Methods: Sixty patients were enrolled from January 2012 to July 2014. They were segregated into two cohorts: the AMBO group comprised 30 patients, while the OMBO group comprised another 30 patients. Each participant underwent standardized treatment and rehabilitation regimens and RTP time was measured using seven questions that explored the times to return of painless walking, running, jumping, squatting, climbing stairs, and rising up on the heels and toes. We compared the time intervals from the onset of instability to the date of surgery. Clinical outcomes were evaluated before the surgery, 6 weeks after surgery, and 6 months after surgery. The assessments included the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the pain visual analog scale (VAS) score, subjective satisfaction with rehabilitation, and activity level. Results: In terms of RTP, AMBO was associated with a shorter interval to walking without pain (7.07 ± 2.96 weeks) relative to OMBO (11.03 ± 8.58 weeks). No disparities were observed in the time to return to play (RTP) between OMBO and AMBO. While there were no discrepancies in the 6-month postoperative AOFAS or VAS scores, the 6-week postoperative VAS score was notably lower in the AMBO group compared to the OMBO group. AMBO provided a faster RTP in terms of two of the seven questions in a group exhibiting high-level physical activity. The rate of subjective satisfaction with rehabilitation was higher for AMBO than for OMBO. Conclusions: Aside from walking, the duration to return to play and the clinical outcomes were similar between AMBO and OMBO treatments for lateral ankle instability. AMBO is a good treatment option and should be carefully considered for athletes with lateral ankle instability. AMBO demonstrated positive outcomes in a group with higher activity levels compared to others, particularly in terms of time to RTP, subjective satisfaction, and postoperative pain.

Enhancing Post-Surgical Rehabilitation Outcomes in Patients with Chronic Ankle Instability: Impact of Subtalar Joint Axis Balance Exercises Following Arthroscopic Modified Broström Operation.

Background and Objectives: This study aimed to evaluate the effects of subtalar joint axis-based balance exercises on the anterior talofibular ligament (ATFL) thickness, ankle strength, and ankle stability after an arthroscopic modified Broström operation (AMBO) for chronic ankle instability (CAI). Materials and Methods: The study included 47 patients diagnosed with CAI who underwent AMBO and were randomly divided into three groups: control (n = 11), general balance exercise (n = 17), and subtalar joint axis balance exercise (n = 19), regardless of the affected area. Participants in the exercise rehabilitation group performed exercises for 60 min twice a week for six weeks, starting six weeks after AMBO. ATFL thickness, ankle strength, and ankle dynamic stability were measured using musculoskeletal ultrasonography, Biodex, and Y-balance test, respectively, before and after treatment. Results: Compared with the remaining groups, the subtalar joint axis balance exercise group had reduced ATFL thickness (p = 0.000), improved ankle strength for eversion (p = 0.000) and inversion (p = 0.000), and enhanced ankle stability (p = 0.000). Conclusions: The study results suggest that subtalar joint axis-based balance exercises may contribute to the early recovery of the ankle joint after AMBO.

Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature.

INTRODUCTION: The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported. AIMS AND OBJECTIVES: The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery. MATERIALS AND METHODS: We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included. MAIN RESULTS: After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play. CONCLUSION: Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00532-0.

Arthroscopic modified Broström operation versus open reconstruction with local periosteal flap in chronic ankle instability.

INTRODUCTION: The modified Broström operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure. Comparative studies on the surgical therapy of CAI are limited and generally refer to similar surgical procedures. Aim of this study was to compare the arthroscopic MBO and the RPF. MATERIALS AND METHODS: We retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. We compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. RESULTS: Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively. Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out. Also in terms of complications and follow-up operations, no significant difference was found between the two procedures. CONCLUSIONS: Both surgical procedures give very good results one year postoperatively in terms of pain, instability, function and complication rate. With significantly better results regarding pain and instability three months postoperatively, the MBO allows a faster recovery in patients operated with this technique.

Is generalized ligamentous laxity a contraindication for a modified Broström operation to treat chronic lateral ankle instability? A systematic review.

BACKGROUND: To investigate whether generalized ligamentous laxity (GLL) really is a contraindication for use of the modified Broström operation to treat chronic lateral ankle instability (CLAI). METHODS: Case series and cohort studies of the clinical outcomes of the use of the modified Broström operation to treat patients with CLAI and GLL were systematically reviewed and a meta-analysis conducted. RESULTS: A total of 447 patients (458 ankles) from 2 case series and 3 cohort studies were systematically analyzed, with mean follow-up times that ranged from 12 to 108 months. Postoperative foot and ankle values analyzed included foot and ankle outcome scores, foot and ankle ability measurements, Karlsson-Peterson ankle scores, American orthopedic foot and ankle society (AOFAS) ankle-hindfoot scores, Tegner activity level scores, anterior talar translations (ATT), talar tilt angles (TTA) and adverse events. Reliable postoperative ankle stability was achieved in CLAI patients with GLL in the 2 case series without major complications. Suture-tape augmentation combined with a modified Broström operation was employed in 1 case series, and the modified Broström operation was only performed in CLAI patients with GLL if the contralateral uninjured ankle showed normal TTA and ATT in another case series. In the 3 cohort studies, 2 reported poorer outcomes and a significantly greater failure rate in patients with GLL compared with those without GLL, and 1 reported equivalent clinical results. In the further pooled data analysis, there was a significant difference in the postoperative TTA value between the GLL and non-GLL groups (SMD: 0.885, 95% CI [0.599-1.171], P = 0.000; I2 = 98%, P = 0.000). The incidence of postoperative recurrent instability was significantly higher in the GLL group (RR: 6.265, 95% CI [2.563-15.309], P = 0.000; I2 = 0%, P = 0.985). Two studies reported the preoperative Beighton score in 7 ankles with postoperative recurrent instability, 6 of which had a preoperative Beighton score ≥7. CONCLUSIONS: GLL may not be a contraindication to the modified Broström operation being used to treat CLAI. However, some augmentation operations may be combined with the classic modified Broström operation, especially for those patients with preoperative Beighton scores ≥7, or with abnormal ATT and TTA in the contralateral ankle. This assertion should be further confirmed by a prospective, large-sample cohort and control study focused on this special population who are at a higher risk of developing postoperative instability. LEVEL OF CLINICAL EVIDENCE: Level 3.

Return to Play after Modified Broström Operation for Chronic Ankle Instability in Elite Athletes.

BACKGROUND: This study assessed the average time to return to training and official game participation after modified Broström operation (MBO) in elite athletes. METHODS: Sixty athletes diagnosed with lateral ankle instability underwent MBO from October 2011 to December 2013. Their average age was 19.3 years, and the average follow-up time was 28.8 months. We measured the time sequence of three phases of rehabilitation: start of personal training, start of team training, and start of the first official game after recovery. Patients were divided into an early return to play (RTP) group and late RTP group. The groups were compared to identify possible risk factors affecting the RTP time. RESULTS: The mean length of time to return to personal training was 1.9 months, return to team training was 2.9 months, and return to competitive play was 3.9 months. There were no significant differences of any variables including age, sex, body mass index, level of sports, grade of instability, presence of os subfibulare, and preoperative functional score between the early RTP and late RTP groups. CONCLUSIONS: The RTP was 83.3% at 4 months after lateral ankle ligament repair and 100% at 8 months postoperatively. The results provide reference data for orthopedic surgeons in evaluating surgical results and informing patients about expectations after surgery in terms of performance level and timing of return to sports.

Comparison of Outcomes in Patients With Generalized Ligamentous Laxity and Without Generalized Laxity in the Arthroscopic Modified Broström Operation for Chronic Lateral Ankle Instability.

BACKGROUND: The arthroscopic modified Broström operation (MBO) has been frequently used to treat chronic lateral ankle instability (CLAI). However, no reports comparing the clinical outcomes between patients with or without generalized ligamentous laxity (laxity or no laxity, respectively) currently exist. The purpose of this study was to compare the clinical outcomes of the 2 groups with CLAI. METHODS: Between January 2013 and November 2015, arthroscopic MBO was performed on 99 patients with CLAI. Patients were divided into 2 groups: the laxity group (24 ankles) and no laxity group (75 ankles). Generalized ligamentous laxity was defined as a Beighton score of 4 or more points. Evaluation tools included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot ankle score, a pain visual analog scale (VAS), and talar tilt angle. RESULTS: The change in talar tilt angle from preoperative to 12 months postoperative was significantly greater in the laxity group (-6.9 ± 5.2) compared with the no-laxity group (-4.2 ± 4.2) ( P = .03). The final follow-up AOFAS hindfoot ankle score and pain VAS in both groups showed improvement compared with the preoperative values. CONCLUSION: All groups achieved successful clinical and radiological final follow-up outcomes. Arthroscopic MBO should be considered a reasonable method in patients who have chronic lateral ankle instability, regardless of generalized ligamentous laxity. LEVEL OF EVIDENCE: III, comparative study.

Comparison of All-Inside Arthroscopic and Open Techniques for the Modified Broström Procedure for Ankle Instability.

BACKGROUND: No reported study has compared clinical and radiologic outcomes between an all-inside arthroscopic modified Broström operation (MBO) and an open MBO. The purpose of this study was to compare clinical and radiologic outcomes of all-inside arthroscopic and open MBOs. METHODS: From August 2012 to July 2014, 48 patients were included. They were divided into 2 groups: all-inside arthroscopic MBO (25 patients) and open MBO (23 patients). The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, and Karlsson score were used to evaluate clinical outcomes. Anterior talar translation and talar tilt were used to evaluate radiologic outcomes. All patients had lateral ankle instability. MBO was performed in 87 patients. Of these, 50 patients met the inclusion criteria. All patients had giving way, persistent pain, and an inability to resume their preinjury activity level for more than 6 months. Patients were randomized into 2 groups, all-inside arthroscopic MBO and open MBO, using a permuted block randomization method. Clinical outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum of 12 months postoperatively using the Karlsson score, the AOFAS ankle-hindfoot score, and pain VAS scores. Radiologic outcome evaluations were performed preoperatively and at 1 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle. RESULTS: After randomization, 25 ankles were allocated to the all-inside arthroscopic MBO group and 25 to the open MBO group. Two ankles in the open MBO group were excluded from the analysis because they were lost to follow-up. Thus, evaluations were performed for 25 ankles in the all-inside arthroscopic MBO group and 23 in the open MBO group. There was no difference in age, gender, symptom duration, preoperative AOFAS, VAS, Karlsson scores, anterior talar translation, or talar tilt between the 2 groups (all P > .05). At the final follow-up, the AOFAS, VAS, and the Karlsson scores had improved significantly in both groups (P < .001). There was no difference in the Karlsson, AOFAS, or VAS scores, anterior talar translation, or talar tilt between the 2 groups at final follow-up (all P > .05). CONCLUSIONS: There was no difference in the clinical or radiologic outcome between the all-inside arthroscopic MBO and open MBO for the treatment of lateral ankle instability at up to 1 year after surgery. An all-inside arthroscopic MBO should be considered carefully in patients who have lateral ankle instability. LEVEL OF EVIDENCE: Level I, randomized controlled trial.