Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

INTRODUCTION: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS: Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION: A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Incidence of Injuries Associated With Anterior Talofibular Ligament Injury Based on the Reporting of Magnetic Resonance Imaging.

Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan done or had ankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDs found in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

Current concepts in the surgical management of chronic ankle lateral ligament instability.

Background/aims: Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI). Methods: The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI. Results: Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes. Conclusion: Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Calcaneal fracture with a concomitant unstable subtalar dislocation: A case report.

BACKGROUND: Traumatic dislocation of the subtalar joint is an infrequently occurring injury, first described by DuFaurest in 1811. They were later on classified by Broca as medial, lateral, posterior and anterior dislocations based on the direction of the dislocation. CASE REPORT: We present a case of a 30 year old male who presented after a 5 m height fall and direct right foot trauma. Investigations done in the emergency department revealed a right subtalar lateral dislocation with associated calcaneal intraarticular displaced fracture. Open reduction internal fixation of the calcaneal fracture was decided alongside with reduction of the subtalar joint. Intraoperatively the subtalar reduction was totally unstable due to the deficiency of the lateral collateral ligament. A decision of reconstruction of the calcaneofibular ligament using a synthetic ligament was taken. This reconstruction resulted in an adequate intraoperative stability of the subtalar joint. On a 2 year follow up the patient was asymptomatic with no residual subtalar instability. DISCUSSION: These injuries must be suspected after high energy trauma or twisting forces in the foot. They occur more frequently in men than in women and predominately affect people in their mid-30 s. Our case is unique in that the reconstruction of the calcaneofibular ligament was done using a synthetic graft to stabilize an acute unstable subtalar joint dislocation. CONCLUSION: Subtalar dislocation is a rare injury with post reduction instability being even rarer. Care has to be taken not to overlook the frequently associated bony injuries, due to their impact on treatment decision and prognosis.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments: A technical simplification.

Anatomical reconstruction of the lateral ankle ligaments has become a pivotal component of the treatment strategy for chronic ankle instability. The recently described arthroscopic version of this procedure is indispensable to ensure that concomitant lesions are appropriately managed, yet remains technically demanding. Here, we describe a simplified variant involving percutaneous creation of the calcaneal tunnel for the distal attachment of the calcaneo-fibular ligament. The rationale for this technical stratagem was provided by a preliminary cadaver study that demonstrated a correlation between the lateral malleolus and the distal footprint of the calcaneo-fibular ligament. The main objectives are simplification of the operative technique and decreased injury to tissues whose function is crucial to the recovery of proprioception.