Quantitative assessment of anterior talofibular ligament quality in chronic lateral ankle instability using magnetic resonance imaging T2* value.

OBJECTIVE: To determine T2* normal reference values for anterior talofibular ligament (ATFL) and to investigate the feasibility of the quantitative ATFL quality evaluation in chronic lateral ankle instability (CLAI) using T2* values. MATERIALS AND METHODS: This study enrolled 15 patients with CLAI and 30 healthy volunteers. The entire ATFL T2* values from the MRI T2* mapping were measured. The prediction equation (variables: age, height, and weight) in a multiple linear regression model was used to calculate the T2* normal reference value in the healthy group. T2* ratio was defined as the ratio of the actual T2* value of the patient's ATFL to the normal reference value for each patient. A Telos device was used to measure the talar tilt angle (TTA) from the stress radiograph. RESULTS: T2* values of ATFL in the healthy and CLAI groups were 10.82 ± 1.84 ms and 14.36 ± 4.30 ms, respectively, which are significantly higher in the CLAI group (P < 0.05). The prediction equation of the normal reference T2* value was [14.9 + 0.14 × age (years) - 4.7 × height (m) - 0.03 × weight (kg)] (R2 = 0.65, P < 0.0001). A significant positive correlation was found between the T2* ratio and TTA (r = 0.66, P = 0.007). CONCLUSION: MRI T2* values in patients with CLAI were higher than those in healthy participants, and the T2* ratio correlated with TTA, suggesting that T2* values are promising for quantitative assessment of ATFL quality preoperatively.

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability.

PURPOSE: Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique. METHODS: All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared. RESULTS: A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference. CONCLUSION: Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients. LEVEL OF EVIDENCE: Level III.

High incidence of post-operative re-sprain following suture tape implantation for anterior talofibular ligament insufficiency and risk factors for post-operative re-sprain.

PURPOSE: Anterior talofibular ligament (ATFL) insufficiency encompasses situations in which (i) frequent sprains cause ATFL loss, as evidenced by ATFL non-visualization on preoperative magnetic resonance imaging; or (ii) minimal healthy ATFL tissue for repair is left after the removal of the large os subfibulare. Suture tape implantation can be indicated for these cases rather than conventional ligament repair. This study was designed to investigate the incidence of post-operative re-sprain in patients who underwent suture tape implantation for ATFL insufficiency, and risk factors influencing the occurrence of post-operative re-sprain were identified. METHODS: A total of 68 patients who underwent suture tape implantation for ATFL insufficiency from January 2016 to December 2021 were retrospectively evaluated. The minimum follow-up duration for inclusion was 2 years after surgery. All included patients were divided into two groups according to the presence of post-operative re-sprain during the follow-up period. Multiple clinico-radiographic parameters were measured, and binary logistic regression analysis was performed to determine the factors influencing post-operative re-sprain. RESULTS: Post-operative re-sprain occurred in 19 of the 68 patients (27.9%), and multiple re-sprains persisted in 7 patients (10.3%). Post-operative re-sprain was more likely to occur in patients who smoked after surgery (odds ratio [OR], 3.510), had generalized ligament laxity (OR, 4.364) and engaged in occupations requiring high physical activity levels (OR, 4.421), including soldiers, professional athletes, student-athletes and mailmen. CONCLUSION: The incidence of multiple post-operative re-sprains was high after suture tape implantation for ATFL insufficiency. Caution is particularly warranted in patients with risk factors, necessitating meticulous attention to their care. Careful consideration of strategies to mitigate risks when performing the surgery is also recommended. LEVEL OF EVIDENCE: Level III.

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

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

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability.

PURPOSE: Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI. MATERIALS AND METHODS: Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed. RESULTS: The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain. CONCLUSIONS: Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

Clinical significance of posterior talofibular ligament injury in chronic lateral ankle instability.

PURPOSE: Although arthroscopic repair of the anterior talofibular ligament (ATFL) is widely performed, the effect of posterior talofibular ligament (PTFL) injury on clinical outcomes remains unclear. This study aimed to evaluate the magnetic resonance imaging (MRI) findings of the PTFL in chronic lateral ankle instability (CLAI) and determine whether the presence or absence of PTFL injury affected the postoperative outcomes of arthroscopic ATFL repair. MATERIALS AND METHODS: Forty ankles of 35 patients who underwent arthroscopic repair for CLAI were included in this study as the experimental group, together with 25 ankles of 24 patients without CLAI as the control group. The PTFL thickness (PTFLT) and PTFL cross-sectional area (PTFLCSA) were measured using MRI and compared between the control and CLAI groups. The clinical outcomes of arthroscopic repair were compared between ankles with and without PTFL injuries. RESULTS: The mean PTFLT and PTFLCSA values were significantly higher in the CLAI group than in the control group. The PTFLT and PTFLCSA in the PTFL injury group were significantly larger than those in the non-injury group in the CLAI group. Postoperatively, there were no significant differences in clinical scores and talar tilt angles on stress radiographs between ankles with and without PTFL injury; however, instability recurrence was frequently observed in ankles with PTFL injury (32.1%) compared to the ankles without PTFL injury (16.7%). Poor-quality ATFL remnant, ATFL inferior fascicle, and calcaneofibular ligament injuries were frequently observed in ankles with PTFL injuries. CONCLUSIONS: Our findings indicate that PTFL injury is highly associated with CLAI but it does not affect postoperative clinical scores. However, postoperative instability recurrence was more often observed in ankles with PTFL injuries, given that they frequently have poor-quality ATFL remnants and CFL injuries. EVIDENCE LEVEL: Level III.

Comparison of Direct Repair Versus Anatomic Graft Reconstruction of the Anterior Talofibular Ligament: A Biomechanical Cadaveric Study.

The goal of our study is to compare the stability of the anatomic reconstruction of the anterior talofibular ligament (ATFL) with direct repair of the ATFL, in a cadaver model. We performed the following techniques in 18 cadaveric ankles: the intact ATFL was cut, after which a direct repair using 2 anchors was performed. The repair was sectioned, and anatomic reconstruction was then performed with a tendon autograft. We measured angular displacement in 3 anatomic planes (axial, coronal, sagittal) for each situation in response to the anterior drawer test (ADT), talar tilt test (TTT) and pivot test (PT), using a specifically constructed arthrometer. The sectioned ATFL was inferior to the intact ATFL in the axial plane with the ADT (p = .012), in the axial plane with the PT (p = .001) and in the axial and coronal planes with the TTT (p = .013 and p = .016, respectively). Direct anatomic repair was inferior to the intact ATFL in the axial plane upon the PT (p = .009). No differences could be found between anatomic graft reconstructions and the intact ATFL with any manoeuver, nor when comparing anatomic graft reconstruction and direct repair with 2 anchors. We were able to conclude that anatomic graft reconstruction of the ATFL reproduces angular stability of the native ligament in a cadaver model. While we could not detect if anatomic graft reconstruction was superior to direct repair, the latter proved to be less stable in the axial plane upon internal rotation (pivot test) versus the intact ATFL.

Arthroscopic modified Broström may improve function while anatomic reconstructions could enhance stability for chronic lateral ankle instability: A network meta-analysis.

PURPOSE: The purpose of this systematic review and network meta-analysis was to compare the efficacy of different surgical treatments, including open and arthroscopic modified Broström procedures (MB), anatomical reconstructions, and suture tape augmentations (STA), for chronic lateral ankle instability (CLAI). METHODS: We conducted a systematic search for comparative studies that included adult patients with CLAI who underwent open MB, arthroscopic MB, reconstruction with autografts or allografts, and STA. We used a random-effects model to present the NMA results, with mean differences and 95 % confidence intervals (CI) for continuous measures and relative ratios with 95 % CI for dichotomous variables. Surface under the cumulative ranking curve analysis (SUCRA) was used for treatment ranking. RESULTS: The results, based on surface under the cumulative ranking curve analysis, showed that arthroscopic MB likely improves functional outcomes the most as measured by change in American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. Anatomical graft reconstructions with allografts or autografts demonstrated greater reduction in anterior talar translation (ATT) and talar tilt angle (TTA). Arthroscopic MB and STA were associated with fewer complications. CONCLUSIONS: Arthroscopic MB may be associated with better functional outcomes, while anatomical reconstructions appear to provide greater improvements in stability for CLAI. Additionally, arthroscopic techniques seem to have lower complication risks compared to open procedures. These potential differences in outcomes and risks between techniques could help guide surgical decision-making.

Allogeneic tendons in the treatment of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability.

BACKGROUND: The aim of this study is to report our institution's experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability. METHODS: This retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints. RESULTS: Thirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24-35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01). CONCLUSION: In this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.

Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side.

PURPOSE: To evaluate the clinical outcomes of anatomic repair procedure for chronic anterior talofibular ligament (ATFL) injury at the talar side, and to compare the outcomes between patients with and without concomitant avulsion fractures. It was hypothesized that anatomic repair procedure could produce similarly satisfactory outcomes for those two groups. METHODS: Thirty-nine consecutive patients with chronic ATFL injuries at the talar side who underwent anatomic repair procedure at the department of sports medicine at Peking University Third Hospital between 2013 and 2018, were retrospectively evaluated. The pain visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Tegner score, and Foot & Ankle Outcome Score (FAOS) were recorded as the primary outcomes. Time to return to sports (RTS), surgical satisfaction, deficiency of ankle range of motion (ROM), recurrent sprain, and postoperative complications were recorded as the secondary outcomes. Outcomes were compared between patients with (Group A, 16 cases) and without (Group B, 23 cases) concomitant avulsion fractures. RESULTS: The mean follow-up time was 79.4 ± 17.0 and 76.6 ± 18.5 months for Group A and B, respectively. VAS, AOFAS, Tegner, FAOS, and all subscale scores of FAOS were significantly improved in both groups at the final follow up. Patients in group A had inferior postoperative VAS, AOFAS, FAOS, and pain score of FAOS compared to group B (1.1 ± 1.1 vs. 0.4 ± 0.5, 89.1 ± 10.1 vs. 95.2 ± 5.2, 87.2 ± 7.2 vs. 91.5 ± 4.1, and 88.4 ± 11.3 vs. 96.7 ± 3.5, respectively).The mean time to RTS, rate of satisfaction and recurrent sprain had no significant differences between group A and B (6.1 ± 2.8, 93.8%, and 18.8% vs. 5.2 ± 2.2, 100.0%, and 13.0%, respectively), and the rate of ROM deficiency was significantly higher in group A (37.5 vs. 8.7%). Avulsion fracture was identified as an independent risk factor for inferior pain score of FAOS. CONCLUSION: Anatomic repair procedure for chronic ATFL injuries at the talar side produces favourable results for patients with and without avulsion fractures at 5 to 10 years follow-up, however, avulsion fracture is associated with more pain. LEVEL OF EVIDENCE: III.

One double-loaded suture anchor is sufficient for all-inside arthroscopic anterior talofibular ligament repair.

PURPOSE: All-inside anterior talofibular ligament (ATFL) repair using anchors is frequently used to manage chronic lateral ankle instability (CLAI) with satisfactory functional outcomes. It remains unclear whether there are differences in the functional results between the use of one or two double-loaded anchors. METHODS: This retrospective cohort study included 59 CLAI patients who underwent an all-inside arthroscopic ATFL repair procedure from 2017 to 2019. Patients were divided into two groups according to the number of anchors used. In the one-anchor group (n = 32), the ATFL was repaired with one double-loaded suture anchor. In the two-anchors group (n = 27), the ATFL was repaired with two double-loaded suture anchors. At the last follow-up time point, the Visual Analogue Scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), and the rate of return to sports in both groups were compared. RESULTS: All the patients were followed up for at least 24 months. Improvement in the functional results (VAS, AOFAS, KAFS, ATT, and AJPS) were recorded at the final follow-up time point. No significant differences were observed regarding VAS, AOFAS, KAFS, ATT, and AJPS between the two groups. CONCLUSION: In patients with CLAI undergoing all-inside arthroscopic ATFL repair, the use of either one or two double-loaded suture anchors produces comparable and predictably good functional outcomes. LEVEL OF EVIDENCE: Level III.

Arthroscopic modified Broström procedure achieved similar favorable short term outcomes to open procedure for chronic lateral ankle instability cases with generalized joint laxity.

PURPOSE: To compare the short-term clinical outcomes of the open versus arthroscopic modified Broström procedure in generalized joint laxity (GJL) patients. METHODS: From January 2018 to January 2020, 64 consecutive patients with chronic lateral ankle instability (CLAI) and GJL (Beighton score ≥ 4) were prospectively enrolled into two groups: those who underwent the open modified Broström procedure (open group, n = 32) and those who underwent the arthroscopic modified Broström procedure (arthroscopic group, n = 32). Patients underwent an open or arthroscopic modified Broström procedure based on the time when they attended the clinic for consultation. All patients were followed-up at 3, 6, 12, and 24 months postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Karlsson score, and the radiographic outcomes were assessed using stress radiography at 24 months postoperatively. The time to return to work and the failure rate were also evaluated and compared. RESULTS: Follow-up was completed for 31 patients in the open group and 30 patients in the arthroscopic group. No significant differences were found between the two groups in terms of demographic characteristics, Beighton score (6.2 ± 1.9 vs. 5.5 ± 1.4, n.s.), or duration of symptoms. There were no significant differences in the functional scores before surgery and at 6, 12 and 24 months postoperatively or in the mean anterior translation of the talus and talar tilt angle on stress radiography at 24 months postoperatively between the open and arthroscopic groups. Compared to the open group, the arthroscopic group showed a significantly earlier return to work (6.8 ± 2.1 vs. 8.1 ± 2.4 weeks, p = 0.006). There was no significant difference in terms of the failure rate between the open and arthroscopic groups (16.1% vs. 23.3%, n.s.). CONCLUSION: Arthroscopic modified Broström procedure achieved similar short-term outcomes to the open procedure for GJL patients. Arthroscopic modified Broström procedure showed an earlier return to work than the open modified Broström procedure and was an alternative to open surgery for CLAI patients with GJL. LEVEL OF EVIDENCE: III. CLINICAL TRIAL REGISTRATION: This study is a prospective study NCT05284188.

The lasso-loop technique is equivalent to the simple suture technique in arthroscopic anterior talofibular ligament repair.

PURPOSE: To compare the clinical outcomes of the lasso-loop and simple suture techniques in arthroscopic anterior talofibular ligament (ATFL) repair for the treatment of chronic lateral ankle instability (CLAI). METHODS: From 2018 to 2020, patients with CLAI who underwent arthroscopic ATFL repair using the lasso-loop or simple suture technique were matched 1:1 (arthroscopic lasso-loop [AL] group, n = 29; simple arthroscopic suture [AS] group, n = 29) based on age, sex, affected side, body mass index, and follow-up duration using propensity score matching and retrospectively evaluated. Karlsson score, visual analogue scale (VAS) score, Tegner score, anterior drawer test (ADT) results, complications, patient-reported satisfaction, and magnetic resonance (MR) re-evaluation findings of ATFL quality were used to describe the outcomes. RESULTS: The patient characteristics or follow-up durations did not significantly differ between the two groups. The Karlsson score, VAS score, and Tegner score improved significantly in both groups after a mean follow-up duration of 29.6 ± 2.8 months. The postoperative clinical scores, ADT results, satisfaction rates, complication rates and MR re-evaluation findings were not significantly different between the two groups at the latest follow-up. CONCLUSION: The lasso-loop technique was equivalent to the simple suture technique in arthroscopic ATFL repair for the treatment of CLAI after a minimum follow-up of 2 years, suggesting that the simple suture technique is sufficient for arthroscopic ATFL repair in most patients without the need to add a lasso loop. LEVEL OF EVIDENCE: Level III.

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

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

Quantitative evaluation of calcaneofibular ligament injury on the oblique coronal view of magnetic resonance imaging in chronic lateral ankle instability.

BACKGROUND: In the treatment of chronic lateral ankle instability (CLAI), the repair of the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) is still being discussed, possibly due to the difficulty in assessing CFL injuries. In particular, it is challenging to evaluate the extent of CFL deficiency quantitively. We hypothesized that CFL tension change would alter morphology of the CFL on magnetic resonance imaging (MRI) and that measuring this morphological change allows assessing CFL injury quantitatively. Thus, this study aimed to analyze the feasibility of quantitatively assessing CFL injuries using MRI. METHODS: Sixty-four ankles with CLAI were included and divided into two groups: with (ATFL and CFL group, 31 ankles) or without CFL repair (ATFL group, 33 ankles) in addition to arthroscopic ATFL repair. The angle between the CFL and calcaneal axis (CFLCA) and the bending angles of the CFL was defined as the flexed CFL angle (FCA) were measured on the oblique CFL view of preoperative MRI. The diagnostic abilities of these angles for CFL injury and correlations between these angles and stress radiographs were analyzed. RESULTS: The sensitivity and specificity of CFLCA were 86.7 % and 88.7 %, and those of FCA were 63.3 % and 77.4 %, respectively. The combination of CFLCA and FCA improved the sensitivity to 93.3 %. The cutoff points of CFLCA and FCA were 3.8° and 121.2°, respectively. There were significant moderate and weak correlations between the talar tilting angle and CFLCA or FCA (rs = -0.533, and rs = -0.402, respectively). The CFLCA and FCA were significantly smaller in the ATFL and CFL group than those in the other groups. CONCLUSIONS: Measurement of CFLCA and FCA in oblique CFL view on MRI could be useful for the quantitative evaluation of CFL injury in patients with CLAI． LEVEL OF EVIDENCE: Level IV. case-control study.

MRI signal intensity ratio reflects the quality of the anterior talofibular and calcaneofibular ligaments in patients with chronic lateral ankle instability.

BACKGROUND: Ligament quality can affect clinical outcomes of ligament repair in chronic lateral ankle instability (CLAI). Magnetic resonance imaging (MRI) is used to assess the morphological changes of ligaments, but the measurement of signal intensity enables quantitative evaluation, which can evaluate the degree of the ligament quality. This study aimed to evaluate the qualitative diagnostic capacity for anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injuries of the signal intensity on MRI. METHODS: Thirty-eight and 20 ankles with and without CLAI, respectively, were included. The regions of interest (ROIs) were set in the ATFL, CFL, and tibialis anterior tendon (TAT) on MRI, and the signal intensities were measured. The signal intensities of the ATFL and CFL were corrected using TAT as the signal intensity ratio (SIR). The SIRs of the ATFL and CFL in the control and CLAI groups were compared. The relationship between the SIR of the ATFL and the arthroscopic findings was analyzed. Finally, the SIRs of the CFL in CLAI with and without CFL repair were compared. RESULTS: The mean SIR of the ATFL in the CLAI group (6.1 ± 2.4) was significantly higher than that in the control (2.1 ± 0.4) (P < 0.01). The SIR of the ATFL was associated with the arthroscopic grading. The mean SIR of the CFL in the CLAI groups (4.1 ± 2.5) was significantly higher than that in the control (1.7 ± 0.4) (P < 0.01). The SIR of the CFL in patients with the requirement of the CFL repair (6.2 ± 1.9) was significantly higher than that without the CFL repair (2.1 ± 0.5) (P < 0.05). CONCLUSIONS: The SIR is useful for evaluating the quality of the ATFL and CFL, which enables the decision of the treatment strategy of the CLAI.

Comparison of the diagnostic value of measurements of transverse syndesmotic interval and 'lambda sign' in distinguishing latent syndesmotic diastasis in chronic lateral ankle instability: a cross-sectional study of 188 cases.

INTRODUCTION: Chronic lateral ankle instability (CLAI) could accompany with latent syndesmotic diastasis (LSD), which is difficult to distinguish before surgery. Tibiofibular interval width and extravasation of joint fluid ('lambda sign') on MRI are widely used in the diagnosis of syndesmotic injury, but the reliability of these methods in distinguishing the associated LSD in CLAI was rarely studied. Our objective was to compare the diagnostic value of the measurement of the transverse tibiofibular interval and 'lambda sign' on MRI in distinguishing LSD in CLAI and to investigate the radiological predictor that best matched the intraoperatively measured syndesmotic width. METHODS: 138 CLAI patients undergoing arthroscopy in our institute from March 2017 to June 2020 were enrolled (CLAI group). Anterior space width (ASW) and posterior space width (PSW) at 10 mm layer above tibial articular and fluid height above tibial articular surface (FH) were measured on preoperative MRI. The same parameters were measured on MRI of 50 healthy volunteers as control group. At arthroscopy, syndesmotic width was measured and the patients were divided into arthroscopic widening (AW) and arthroscopic normal (AN) subgroup taking 2 mm as critical value. The CLAI group was compared with the control group to explore the interval changes related to CLAI. The AW and AN subgroups were compared to explore the potential diagnostic indicators and reference values for the LSD. RESULTS: All parameters showed significant difference between CLAI group and control group (p < 0.05), but only PSW (p = 0.004) showed significant difference between AW and AN subgroups other than FH (p = 0.461). Only PSW was involved in formula of multiple-factor analysis (p = 0.005; OR, 1.819; 95%CI, 1.196-2.767). ROC analysis showed critical value of PSW was 3.8 mm (sensitivity, 66%; specificity, 66%; accuracy, 66.7%), while accuracy of lambda sign was 41.3%. CONCLUSIONS: Transverse tibiofibular interval measurements were more reliable than the 'lambda sign' in distinguishing associated LSD in CLAI patients. The PSW ≥ 3.8 mm could be a predictor of syndesmotic diastasis.

Anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation for chronic lateral ankle instability with poor remnant quality: results and complications.

PURPOSE: Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients. METHODS: One hundred and eight patients with CLAI, who were treated surgically using anatomic reconstruction with allograft tendon and suspensory fixation between April 2016 and January 2018 at our hospital, were retrospectively analysed. None of the patients had sufficient ligament remnants for the modified Broström procedure during the intraoperative evaluation. Eighteen patients were excluded. Seventeen patients were lost to follow-up and 73 patients completed the study. The mean duration of instability symptoms was 39.1 months (range, 6-480 months). The mean follow-up time was 57.5 months (range, 48-69 months). Clinical results were evaluated using the Karlsson scoring scale, American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score, visual analogue scale (VAS), patients' subjective satisfaction, and incidence of complications. Mechanical stability was evaluated using the varus talar tilt angle (TTA) and anterior talar displacement (ATD). RESULTS: The AOFAS-AH scores significantly improved from 67.7 ± 8.5 points to 89.8 ± 9.5 (p < 0.001). The Karlsson scoring scales evolved from 58.8 ± 16.5 to 88.4 ± 11.2 (p < 0.001). VAS scores significantly decreased from 2.9 ± 1.3 to 1.1 ± 1.0 (p < 0.001). On stress radiographs, TTA decreased from 15.1 ± 2.5 degrees to 5.8 ± 2.1 degrees (p < 0.001), whereas ATD reduced from 13.4 ± 2.9 mm to 5.7 ± 1.5 mm (p < 0.001). Patients' subjective satisfaction indicated 46 excellent, 20 good, 5 fair, and 2 bad results. Postoperatively, 15 cases (20.5%) did not achieve complete relief of discomfort or swelling, 9 cases (12.3%) experienced joint stiffness or decreased range of motion, and 6 cases (8.2%) had soft tissue irritation. Residual instability and reoperation are rare. Allograft rejection or wound infection was not observed. CONCLUSION: For the CLAI patients with poor remnant quality, anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation is an effective procedure, while the top three complications in incidence were residual discomfort, joint stiffness, and soft tissue irritation. LEVELS OF EVIDENCE: Level IV, retrospective case series.

A new method of anterior talofibular ligament reconstruction: Arthroscopically artificial ligament reconstruction with tensional remnant-repair.

PURPOSE: To investigate the clinical effects of arthroscopically artificial ligament reconstruction with tensional remnant-repair in patients who are obese, and/or with demand for highly intensive sports, and/or with poor-quality ligament remnants. METHODS: A retrospective case series study was performed on patients treated by arthroscopically anterior talofibular ligament (ATFL) reconstruction with tensional remnant repair technique from January 2019 to August 2021. General data, including demographics, surgical time, and postoperative adverse events, were recorded. The American Orthopaedic Foot and Ankle Society score (AOFAS), foot and ankle ability measure (FAAM), visual analog scale (VAS), and anterior talar translation were measured preoperatively and at 6 weeks, 3 months, and 2 years postoperatively. Ultrasonography examination was performed preoperatively and 2 years postoperatively to evaluate the ATFL. Data were analyzed using SPSS 19.0. F test was used to analyze the pre- and postoperative VAS, FAAM, and AOFAS scores. The significance was set at p < 0.05. RESULTS: There were 20 males and 10 females among the patients with a mean age of (30.71 ± 5.81) years. The average surgical time was (40.21 ± 8.59) min. No adverse events were observed after surgery. At 2 years postoperatively, the anterior talar translation test showed grade 0 laxity in all patients. VAS score significantly decreased from preoperatively to 6 weeks, 3 months, and 2 years postoperatively (p < 0.001). Improvement of FAAM score and the AOFAS score from preoperatively to 6 weeks, 3 months, and 2 years postoperatively was statistically significant (p < 0.001). At 3 months postoperatively, most patients (23/30) could return to their pre-injured activities of daily living status. At 2 years postoperatively, all patients were able to return to their pre-injured activities of daily living status, and almost every patient (18/19) who expected highly intensive sports returned to sports with only 1 obese patient failing to achieve the goal. The ultrasonography examination at 2 years postoperatively showed that there was a linear band structure of soft tissue on the tension-rich fiber tape image from the fibular to the talar attachment sits of ATFL. CONCLUSION: The novel arthroscopically artificial ligament reconstruction with tensional remnant-repair technique for ATFL achieved satisfactory clinical outcomes in the short and medium term after operation, and allowed early return to pre-injured activities, which could be a reliable option for patients with chronic lateral ankle instability.

Determining the Feasibility of Arthroscopic Anterior Talofibular Ligament Repair Utilizing a Novel Classification System.

The purposes of this study were to classify anterior talofibular ligament injuries (ATFL), to find out the feasibility of arthroscopic ATFL repair according to injury type and to investigate the diagnostic validity of magnetic resonance imaging (MRI) of ATFL injuries by comparing MRI and arthroscopic findings. The 197 ankles (93 right, 104 left, and 12 bilateral) of 185 patients (90 men and 107 women; mean age, 33.5 years, range: 15-68 years) were treated by arthroscopic modified Broström procedure after a diagnosis of chronic lateral ankle instability. ATFL injuries were classified according to their grade and location (type P: partial rupture, type C1: fibular detachment, type C2: talar detachment, type C3: midsubstance rupture, type C4: absence of ATFL, type C5: os subfibulare). Among the 197 injured ankles, according to ankle arthroscopy, 67 were type P (34%), 28 were type C1 (14%), 13 were type C2 (7%), 29 were type C3 (15%), 26 were type C4 (13%), and 34 were type C5 (17%). The kappa value for the agreement between the arthroscopic findings and MRI findings was also high (0.85; 95% confidence interval, 0.79-0.91). Our results also supported the use of MRI for diagnosing ATFL injuries and showed that it is an informative tool during the preoperative period.