Arthroscopic Anatomic Reconstruction of the Anterior Talofibular and Calcaneofibular Ligaments Through a 2-Portal Technique.

Arthroscopic anatomic lateral ligament reconstruction of the ankle joint has proven to be a safe option in the treatment of chronic ankle instability (CAI), with good functional results as well as allowing simultaneous management of associated lesions. We described an arthroscopic technique for anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament using only 2 arthroscopic portals. This surgical technique to treat CAI is technically less demanding than other described techniques that use 3 or 4 arthroscopic portals. Moreover, as an anatomic technique, it has the advantage of preserving the biomechanics and kinematics of the ankle joint.

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.

Reconstruction of the interosseous talocalcaneal ligament using allograft for subtalar joint stabilization is effective.

PURPOSE: The aim of this study was to assess the biomechanical effects of subtalar ligament injury and reconstruction on stability of the subtalar joint in all three spatial planes. METHODS: Fifteen fresh frozen cadaveric legs were used, with transfixed tibiotalar joints to isolate motion to the subtalar joint. An arthrometer fixed to the lateral aspect of the calcaneus measured angular displacement in all three spatial planes on the inversion and eversion stress tests. Stress manoeuvres were tested with the intact joint, and then repeated after sequentially sectioning the inferior extensor retinaculum (IER), cervical ligament (CL), interosseous talocalcaneal ligament (ITCL), arthroscopic graft reconstruction of the ITCL, and sectioning of the calcaneo-fibular ligament (CFL). RESULTS: Sectioning the ITCL significantly increased angular displacement upon inversion and eversion in the coronal and sagittal planes. Reconstruction of the ITCL significantly improved angular stability against eversion in the axial and sagittal planes, and against inversion in the axial and coronal planes, at the zero time point after reconstruction. After sectioning the CFL, resistance to eversion decreased significantly in all three planes. CONCLUSION: Progressive injury of ligamentous stabilisers, particularly the ITCL, led to increasing angular displacement of the subtalar joint measured with the inversion and eversion stress tests, used in clinical practice. Reconstruction of the ITCL using tendon graft significantly stabilised the subtalar joint in the axial and sagittal planes against eversion and in the axial and coronal planes against inversion, immediately after surgery.

Results of Anatomical Arthroscopic Repair of Anterior Talofibular Ligament in Chronic Lateral Ankle Instability Patients.

BACKGROUND: To assess the clinical and functional outcomes of all-inside arthroscopic anatomical repair of anterior talofibular ligament (ATFL) for management of chronic lateral ankle instability (CLAI) in a considerable number of patients during medium-term follow-up. METHODS: A retrospective analytic study was performed on 100 patients with CLAI who presented between August 2015 and July 2020 (average age: 32.9 years; range: 16-54 years). All-inside arthroscopic ATFL direct repair was performed in all patients through 2 portals only with fixation using 2 knotless anchors. Associated intraarticular lesions were treated in the same procedure. Outcomes were assessed with pre- and postoperative visual analog scale (VAS), the ankle-hindfoot score of the American Orthopaedic Foot & Ankle Society (AOFAS), and the Karlsson Ankle Functional Score (KAFS). RESULTS: All patients were followed for 24-48 months. At the final follow-up, ankle pain had improved significantly. Both the ankle anterior drawer test and the ankle varus stress tests were negative. There was no loss of ankle range of motion compared with preoperative measures, and all patients returned to normal gait. The mean VAS score decreased to 0.39 ± 0.63, the AOFAS score increased to 95.17 ± 4.7, and the KAFS score increased to 95 ± 4.07. All the follow-up indexes significantly improved compared to those before surgery. CONCLUSION: At minimum 24-month follow-up, the all-inside arthroscopic ATFL repair used to treat CLAI was found to restore ankle stability and yield good clinical outcomes with a relatively low complication rate. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increased subtalar rotational motion in patients with symptomatic ankle instability under load and stress conditions.

PURPOSE: Differentiating subtalar and ankle instability in the clinical setting is challenging. This study aims to analyze the rotational laxity of the subtalar joint bilaterally in patients with asymptomatic and symptomatic ankle instability under simulated load and stress-induced position of the subtalar joint. METHODS: A case-control study was conducted using an adjustable load device (ALD). Patients with chronic ankle instability and healthy volunteers were included. Each subject underwent a CT scan under mechanical stress and simulated weight-bearing conditions, maintaining maximum eversion and inversion hindfoot positions. The images were obtained in a single model, allowing calculations of the motion vector as well as the helical axis. The helical axis was defined by a rotation angle and a translation distance. RESULTS: A total of 72 feet were included in the study. Thirty-one patients with unilateral symptoms and five healthy controls were selected, defining two groups: symptomatic (n = 31) and asymptomatic (n = 41). An absolute difference of 4.6º (95%CI 2-11.1) rotation angle was found on the helical axis of the symptomatic vs. asymptomatic group (p = 0.001). No significant differences were detected in the translation distance (n.s.) between the groups. Additionally, a significant positive correlation was found between the rotation angle and translation distance through the helical axis in the asymptomatic group (r = 0.397, p = 0.027). CONCLUSION: Patients with chronic ankle instability suspected of having subtalar joint instability showed a wider subtalar range of laxity in terms of rotation about the helical axis. Furthermore, differences in kinematics between symptomatic and asymptomatic hindfeet was demonstrated when both feet were compared. LEVEL OF EVIDENCE: III.

Arthroscopic Flexor Halluces Longus Transfer and Percutaneous Achilles Tendon Repair for Distal Traumatic Ruptures.

The Achilles tendon is the largest and strongest tendon in the human body. It is the tendon that most often suffers injury and accounts for 20% of all tendon ruptures. These types of ruptures often occur 2 to 6 cm proximal to the stumps in an area of reduced vascularity. One such injury, the distal acute Achilles tendon rupture, is quite uncommon. For distal repairs, there have been studies that used a pullout technique, a button technique, and the use of local tendons for open-fashion augmentation. Although percutaneous repair and endoscopic flexor hallucis longus (FHL) tendon transfer techniques have been described for both acute midportion and chronic Achilles tendon rupture repair, there are no studies that describe the use of percutaneous sutures and biological augmentation with FHL transfer as a treatment option for acute distal injuries. The purpose of this Technical Note is to describe a novel approach to repair. It combines arthroscopic FHL tendon transfer with a percutaneous Achilles tendon repair technique for traumatic distal ruptures.

Biomechanical study of autograft anatomic reconstruction in lateral ankle instability. / Estudio biomecánico de la reconstrucción ligamentosa anatómica con autoinjerto en la inestabilidad lateral de tobillo.

INTRODUCTION: The purpose of this work is perform a biomechanical comparison of anatomic reconstruction of the anterior talofibular ligament (ATFL) with the intact ATFL. MATERIALS AND METHODS: We studied 18 fresh cadaveric ankles with intact ATFL. Each specimen was clinically assessed with the anterior drawer (AD) and varus tilt (VT) tests and the angular movement in the three spatial planes (axial, coronal and sagittal) was measured with an arthrometer using a sensor located in the talus. RESULTS: Statistically significant differences were found in the axial plane, between the intact ATFL versus the sectioned ATFL for AD test with p = 0.012, and for VT test with p = 0.013. Regarding the coronal plane, we also observed a statistically significant difference for VT test with p = 0.016. In the sagittal plane, there are no statistically significant differences in both maneuvers. No statistically significant differences were found when comparing the biomechanics of anatomic ligament reconstruction versus the intact ATFL. CONCLUSION: Autograft anatomic reconstruction of the ATFL showed biomechanical properties similar to those of the native ATFL, at the zero moment in a cadaveric model.

Anatomic Arthroscopic Graft Reconstruction of the Interosseous Talocalcaneal Ligament for Subtalar Instability.

Instabilities of the subtalar joint are commonly overlooked or mismanaged, and chronic instability is a debilitating condition leading to premature joint degeneration. Several methods of treatment have been described, mainly screw fixation, arthrodesis, or ligament reconstruction. Most studies describe open methods for ligament reconstruction. We describe an original technique for "all-inside" arthroscopic graft reconstruction of the interosseous talocalcaneal ligament for subtalar instability.

How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings.

INTRODUCTION: The posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages. METHODS: The fracture pattern of PM is classified according to Haraguchi or Bartonícek classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection. RESULTS: Posterolateral approach should be the election for Haraguchi I or III and Bartonícek 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartonícek 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartonícek 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach. CONCLUSION: To address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal.

BACKGROUND: Anatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström-Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability. METHODS: We reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months. RESULTS: The mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture. CONCLUSIONS: Chronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

Arthroscopic posterior subtalar arthrodesis for salvage of posttraumatic arthritis following calcaneal fractures.

BACKGROUND: Subtalar arthrodesis is a treatment option for pain due to posttraumatic arthritis following calcaneal fractures. The goal of this study is to examine the results of arthroscopic subtalar arthrodesis for posttraumatic arthritis following calcaneal fractures. PATIENTS AND METHODS: We performed a retrospective case series reviewing 37 consecutive patients (36 male) treated for posttraumatic arthritis following calcaneal fractures by arthroscopic subtalar arthrodesis. The fractures were due to high-energy injuries in 81% of cases, and 12 fractures (32.4%) had been previously treated with internal fixation. Average follow-up was 57.5 months. RESULTS: Average American Orthopedic Foot and Ankle Society (AOFAS) scores significantly improved from 49.0 ± 10.9 points preoperatively to 76.0 ± 8.0 points at final follow-up. Average time to union was 12.5 weeks. Six patients (16.2%) suffered complications: superficial wound infection (2.7%), symptomatic hardware that warranted removal (5.4%) and nonunion (8.1%) presented nonunion. All three cases had prior internal fixation through an extensile lateral approach, and fused after a repeat surgery. CONCLUSION: Arthroscopic subtalar arthrodesis offers consistent improvement in cases of posttraumatic arthritis following calcaneal fractures, with a union rate similar to published series of open arthrodesis. We observed more nonunions in patients who had been treated previously with internal fixation. In spite of this, we continue to recommend arthroscopic subtalar arthrodesis, as it preserves the soft tissue envelope better than open techniques.

Arthroscopic Subtalar Arthrodesis: Does the Type of Fixation Modify Outcomes?

The goal of the present study was to analyze a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, time to union, and the incidence of fusion after isolated arthroscopic posterior subtalar arthrodesis using either 1 or 2 screws of different diameters. We reviewed a consecutive series of 65 patients, mean age 50.0 ± 15.6 years, including 38 males (58.5%) and 27 females (41.5%), who had undergone arthrodesis from May 2004 to February 2011. The mean follow-up duration was 57.5 (range 24 to 105) months. The patients were divided into 3 groups according to the fixation method used: group 1 (n = 12; 18.5%) underwent fixation with one 6.5-mm screw; group 2 (n = 40; 61.5%) with one 7.3-mm screw; and group 3 (n = 13; 20%) with two 7.3-mm screws. An overall statistically significant (p <.0001) improvement was seen in the modified AOFAS scale score for all 3 fixation groups; however, the difference was not statistically significant (p = .79) among the fixation groups. Fusion was achieved in 62 patients (95.4%) after a mean of 12.1 (range 9 to 16) weeks. The difference in the time to union was not statistically significant (p = .781) among the fixation groups. Nine patients (13.8%) experienced complications, and nonunion was significantly (p = .005) more prevalent in the single 6.5-mm screw group. In conclusion, all 3 screw configurations led to improved modified AOFAS scale scores, although nonunion was more common among patients fixed with a single 6.5-mm screw.

Anatomical Arthroscopic Graft Reconstruction of the Anterior Tibiofibular Ligament for Chronic Disruption of the Distal Syndesmosis.

Injuries of the distal tibiofibular syndesmosis are commonly overlooked or mismanaged, and chronic instability is a debilitating condition leading to premature joint degeneration. Several methods of treatment have been described, mainly screw fixation, arthrodesis, or ligament reconstruction. Most clinical evidence is limited to case series, mainly screw fixation, and there is a general paucity of evidence regarding ligament reconstruction, which is considered to be more anatomic and to restore joint biomechanics. Most papers describe open techniques. We describe an original technique for all-inside anatomic arthroscopic graft reconstruction of the anterior-inferior tibiofibular ligament, which is simpler than other previously described reconstruction procedures. In addition to being performed through standard ankle arthroscopy portals, we believe this technique avoids potential complications.

Subtalar arthroscopic arthrodesis: Technique and outcomes.

PURPOSE: The goal of this study was to describe the surgical technique and our results with arthroscopic posterior subtalar arthrodesis. MATERIAL AND METHODS: Retrospective case series of 65 patients (38 men and 27 women) averaging 50 years of age (range 21-72 years) undergoing posterior arthroscopic subtalar arthrodesis using one or two percutaneous 6.5-7.3mm screws between May 2004 and February 2011, with a mean follow-up of 57.5 months (range 24-105 months). RESULTS: We achieved a 95.4% union rate after an average of 12.1 weeks (range 9 to 16 weeks). 12.3% of patients suffered complications, including superficial infection, nonunion and need for hardware removal. The AOFAS score improved from 51.5 points (19-61 points) preoperatively to 81.9 points (60-94 points) in the postoperative period. CONCLUSIONS: We describe the surgical technique for arthroscopic subtalar arthrodesis, which as proven to be a safe and reliable technique in our experience, with consistent improvements in AOFAS scores.

Clinical results following meniscal sutures: does concomitant acl repair make a difference?

INTRODUCTION: The purpose of this study is to analyze the clinical results of meniscal tears repaired with an all-inside suture with special attention to the results in stable versus anterior cruciate ligament (ACL)-deficient knees. METHODS: We studied 45 meniscal tears (32 medial, 13 lateral) repaired in 43 patients using a single all-inside suture system. The patients were divided in two groups and followed-up for at least 12 months. Group A (stable knees with isolated meniscal tears) consisted of 19 patients treated with all-inside sutures. Group B (ACL-deficient knees with meniscal tears) consisted of 24 patients treated with ACL reconstruction together with the meniscal repair. All the meniscal tears were located in red/red (35) or red/white (10) zone. Criteria for clinical success included absence of joint-line tenderness, locking, swelling, and a negative McMurray test. Preoperative and postoperative clinical evaluation also included the Tegner and Lysholm knee scores. RESULTS: The clinical success rate of the repairs was 86%. According to our criteria, six of 43 repaired menisci (14%) were considered failures. Mean Lysholm scores improved significantly in both groups (58 to 88.20) and the improvement was significantly greater in group B (From 54.47 to 88, p > 0.05). Twenty patients (83.3%) had an excellent or good result in group B and sixteen (84%) in group A, according to the Lysholm knee score. CONCLUSION: Our clinical results show that arthroscopic meniscal repair with all-inside devices provided a high rate of meniscus healing and seem to be safe and effective, for isolated meniscal tears as well as for ACL-deficient knees with meniscal tears. Final functional scores were similar for ACL-competent and ACL-deficient knees.