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.

Simplified arthroscopic anterior talofibular ligament repair with inferior extensor retinaculum reinforcement: technical notes and preliminary results.

PURPOSE: Compared with open surgery, arthroscopic anterior talofibular ligament (ATFL) repair has many advantages and good clinical outcome. Inferior extensor retinaculum (IER) reinforcement is a supplement procedure that increase the strength of the ATFL. There is still no gold standard for arthroscopic ATFL repair. The purposes of this study were to describe a simplified technique for arthroscopic ATFL repair with IER reinforcement and to analyze its preliminary clinical results. METHODS: Twenty-seven patients with chronic lateral ankle instability (CLAI) who underwent this simplified surgery were analyzed in this retrospective study. The patients' characteristics and operative times were evaluated. Intraoperative photos, radiographs from the anterior drawer test and talar tilt test and postoperative MR images were recorded. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) score were also recorded. With the assistance of a needle, we performed ATFL repair and IER reinforcement with one Pushlock anchor and nonabsorbable sutures. RESULTS: No complications namely skin necrosis, superficial fibular nerve injury or wound infection, were reported. The AOFAS score and VAS score improved from 64.74 ± 9.47 and 6.00 ± 1.56 to 90.74 ± 6.46 and 1.07 ± 1.09, respectively. The talar advancement and talar tilt angle were improved after surgery. One year after the operation, the ATFL appeared to be continuous on MR images. CONCLUSION: In this study, we proposed a simple and effective arthroscopic ATFL repair with IER reinforcement technique. The short-term follow-up examination revealed satisfactory clinical outcomes. Our technique might be a new surgical option for the treatment of CLAI.

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.

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.

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.

Clinical Outcomes for Arthroscopic Anterior Talofibular Ligament Repair After Suture Anchor Insertion Through the Anterolateral Portal vs the Lateral Accessory Portal.

BACKGROUND: Two types of suture anchor insertion pathways (anterolateral portal vs lateral accessory portal) are used in arthroscopic anterior talofibular ligament (ATFL) repair. However, it is not clear which one is the better choice. This study aims to compare the clinical outcomes of these 2 suture anchor insertion pathways when performing arthroscopic ATFL lasso-loop repair for the treatment of chronic lateral ankle instability (CLAI). METHODS: From 2019 to 2021, patients with CLAI who underwent arthroscopic ATFL lasso-loop repair were retrospectively reviewed and divided into the anterolateral portal (ALP) group and the lateral accessory portal (LAP) group. A 1:1 propensity score matching was used to control confounding factors based on age, sex, body mass index, follow-up duration, preoperative visual analog scale (VAS) score, and Tegner score (ALP group, n = 26; LAP group, n = 26). Karlsson score, VAS score, Tegner score, operation time, anterior drawer test results, patient symptoms, and magnetic resonance (MR) evaluation of ATFL quality were used to describe the outcomes. RESULTS: The patient characteristics and follow-up durations were similar between the 2 groups. After a mean follow-up duration of 28.8 ± 2.3 months, the ALP group had significantly better Karlsson score, VAS score, and Tegner score improvement than the LAP group, with fewer symptoms. Seven patients in the LAP group still had a feeling of ankle instability, and 3 of them exhibited ankle laxity. CONCLUSION: In this study, we found that inserting the suture anchor through the anterolateral portal was associated with better outcomes compared to that through the lateral accessory portal when performing arthroscopic ATFL lasso-loop repair for CLAI patients. The improvement was greater for pain relief and function and was associated with a lower frequency of subjective ankle instability.

Analysis of a Chronic Lateral Ankle Instability Model in the Rat: Conclusions and Suggestions for Future Research.

The purpose of this study was to evaluate potential osteoarthritic alterations within the ankle using a surgically-induced chronic lateral ankle instability (CLAI) model. Twelve rats were assigned randomly to either the control (n = 4) or CLAI group (n = 8). Surgery was performed on the right ankle. Osteoarthritis was assessed through in-vivo micro-CT at 8 weeks and a clinical analysis. Macroscopic analysis, high-resolution ex-vivo micro-CT and histological examination were conducted after euthanasia at 12 weeks. Three subgroups (SG) were analyzed. SG1 comprised the operated ankles of the CLAI group (n = 8). SG2 consisted of the non-operated ankles of the CLAI group (n = 8). SG3 included both sides of the control group (n = 8). In-vivo micro-CT revealed no significant differences among the three subgroups when analyzed together (p = 0.42), and when comparing SG1 with SG2 (p = 0.23) and SG3 (p = 0.43) individually. No noticeable clinical differences were observed. After euthanasia, macroscopic analysis employing OARSI score, did not demonstrate significant differences, except between the medial tibia of SG1 and SG3 (p = 0.03), and in the total score comparison between these two subgroups (p = 0.015). Ex-vivo micro-CT did not reveal any differences between the three subgroups regarding bony irregularities and BV/TV measurements (SG1 vs. SG2 vs. SG3: p = 0.72; SG1 vs. SG2: p = 0.80; SG1 vs. SG3: p = 0.72). Finally, there was no difference between the three subgroups regarding OARSI histologic score (p = 0.27). These findings indicate that the current model failed to induce significant osteoarthritis. However, they lay the groundwork for improving the model's effectiveness and expanding its use in CLAI research, aiming to enhance understanding of this pathology and reduce unnecessary animal sacrifice.

Central imaging based on near-infrared functional imaging technology can be useful to plan management in patients with chronic lateral ankle instability.

BACKGROUND: Near infrared brain functional imaging (FNIRS) has been used for the evaluation of brain functional areas, the imaging differences of central activation of cognitive-motor dual tasks between patients with chronic lateral ankle instability (CLAI) and healthy population remain unclear. This study aimed to evaluated the role of central imaging based on FNIRS technology on the plan management in patients with CLAI, to provide insights to the clinical treatment of CLAI. METHODS: CLAI patients treated in our hospital from January 1, 2021 to June 31, 2022 were selected. Both CLAI patients and health controls were intervened with simple task and cognitive-motor dual task under sitting and walking conditions, and the changes of oxygenated hemoglobin concentration in bilateral prefrontal cortex (PFC), premotor cortex (PMC) and auxiliary motor area (SMA) were collected and compared. RESULTS: A total of 23 participants were enrolled. There were significant differences in the fNIRS ΔHbO2 of barefoot subtractive walking PFC-R and barefoot subtractive walking SMA-R between experimental and control group (all P < 0.05). There was no significant difference in ΔHbO2 between the experimental group and the control group in other states (P > 0.05). There was no significant difference in ΔHbO2 between the experimental group and the control group in each state of the brain PMC region. CONCLUSION: Adaptive alterations may occur within the relevant brain functional regions of individuals with CLAI. The differential activation observed between the PFC and the SMA could represent a compensatory mechanism emerging from proprioceptive afferent disruptions following an initial ankle sprain.

Modified Gracilis Autograft Preparation for Arthroscopic Anterior Talofibular and Calcaneofibular Ligament Anatomic Reconstruction: Technical Tip.

Visual AbstractThis is a visual representation of the abstract.

Comparative analysis of arthroscopic technique for anterior talofibular and calcaneofibular ligament reconstruction versus open modified brostrom-gould procedure in chronic lateral ankle instability management.

BACKGROUND: Chronic Lateral Ankle Instability (CLAI) is a common condition treated using either Anterior Talofibular and Calcaneofibular Ligament (ATFL and CFL) reconstruction or Modified Brostrom Procedure (MBP). However, the comparative efficacy of these approaches is not well-studied. METHODS: In this study, clinical data were retrospectively collected from 101 patients diagnosed with CLAI who underwent either ATFL and CFL reconstruction (n = 51) or the MBP (n = 50). Patients were comparable in terms of age, sex, Body Mass Index (BMI), post-injury duration, preoperative American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, Visual Analog Score (VAS), Anterior Talar Translation, and Talar Tilt Angle. RESULTS: The post-operative measures showed no significant differences in AOFAS Score, Karlsson Score, and VAS between both treatment groups. However, patients who underwent ATFL and CFL reconstruction showed significantly lower follow-up Anterior Talar Translation (mean = 4.1667 ± 1.3991 mm) and Talar Tilt Angle (mean = 5.0549 ± 1.6173°) compared to those who underwent MBP. Further, patients treated with ATFL and CFL reconstruction experienced a significantly longer postoperative recovery time (median = 6 weeks) compared to MBP (median = 3 weeks). CONCLUSIONS: Although both therapeutic techniques were generally effective in treating CLAI, the ATFL and CFL reconstruction approach delivered superior control of Anterior Talar Translation and Talar Tilt Angle. However, its longer recovery time merits further study to optimize the balance between therapeutic efficacy and recovery speed.

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.

Broström ankle ligament repair augmented with suture tape : Results of magnetic resonance imaging evaluation.

BACKGROUND: The Broström procedure is an established procedure in cases of primary lateral ankle ligament repair (LALR). To improve postoperative stability an augmentation device, InternalBrace™ (Arthrex, Naples, FL) has been introduced. This study evaluates remodelling of the anterior talofibular ligament (ATFL) in patients undergoing a tape augmented Broström technique as well as clinical outcomes. METHODS: In this study 32 patients with chronic lateral ankle instability (CLAI) receiving augmented LALR were included. Clinical outcomes were evaluated at a one-time postoperative visit between 12 and 18 months. A 3 T magnetic resonance imaging (MRI) was done to evaluate the morphology of the ATFL. Statistical analysis was completed with the free software and environment R version 3.6.3 (Bell Laboratories, Murray Hill, NJ, USA) and P-values < 0.05 were considered statistically significant. RESULTS: The mean follow-up time was 15.3 ± 1.8 months with a return to sport time of 4.0 ± 2.4 months. The average AOFAS (American Orthopaedic Foot and Ankle Society Score) score was 94.4 ± 7.2, the FAOS (Foot and Ankle Outcome Score) demonstrated 87.3 ± 10.4 points and the FFI (Foot Function Index - 2 scores (pain and function score)) was 22.9 ± 20.1 and 15.4 ± 10.4, respectively. The MRI findings demonstrated an average length of the ATFL of 18.6 ± 4.3 mm and the width was 3.6 ± 0.9 mm. A clear differentiation between the ATFL and the augmentation device could be shown in 28 cases. The Fisher's exact test could not depict a significant correlation between the presence of a bone marrow edema and the tension of the augmentation device with a level of significance of α = 0.05. CONCLUSION: An anatomical healing tendency of the ligament repair and good integrity of the augmentation device could be shown based on MRI findings. The lateral ligament repair augmented with suture tape is an effective and safe procedure regarding surgical treatment in chronic lateral ankle instability producing good clinical outcome.

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.

Clinical Outcomes and Return to Preinjury Sports After Anatomic Reconstruction With a Gracilis Autograft Versus the Modified Broström Procedure in Patients With Generalized Joint Laxity.

Background: Generalized joint laxity (GJL) is a risk factor for inferior outcomes after the modified Broström procedure for chronic lateral ankle instability, while anatomic reconstruction with tendons is more inclined to be recommended. However, whether anatomic reconstruction could achieve better results than the modified Broström procedure in patients with GJL is unknown. Purpose: To compare clinical outcomes and return to sports between anatomic reconstruction and the modified Broström procedure in patients with GJL. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with GJL (Beighton score ≥4) who underwent either the modified Broström procedure or anatomic reconstruction with gracilis autografts between 2017 and 2020 were reviewed. Included were 19 patients who underwent anatomic reconstruction (reconstruction group) and 49 patients who underwent the modified Broström procedure (MBP group). Clinical outcomes were compared using the Foot and Ankle Outcome Score (FAOS) and the Karlsson score. The rates of return to preinjury level in high-demand sports, sprain recurrence, and range of motion between the 2 groups were also compared. Results: The mean follow-up duration was 38.3 months in the reconstruction group and 43.7 months in the MBP group. The FAOS and Karlsson scores improved significantly after surgery in both groups (P < .001 for all), with the reconstruction group having significantly higher postoperative FAOS-Sports scores (87.9 ± 8.9 vs 80.5 ± 11.6; P = .015) and Karlsson scores (86.9 ± 6.1 vs 82 ± 8.4; P = .025) than the MBP group. The rate of return to preinjury high-demand sports was higher in the reconstruction group than in the MBP group (73.3% vs 38.9%; P = .034). The MBP group had a significantly higher rate of sprain recurrence (22.4% vs 0%; P = .027). More patients reported dorsiflexion restriction in the reconstruction group (n = 4; 21.1%) than in the MBP group (n = 1; 2%) (P = .019); nonetheless, there was no noticeable effect on daily life and sports. Conclusion: Better clinical outcomes, less sprain recurrence, and a higher rate of return to preinjury high-demand sports were found after anatomic reconstruction with free tendons compared with the modified Broström procedure in patients with GJL. Anatomic tendon reconstruction can be recommended for such patients, especially those participating in high-demand sports.

A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure.

BACKGROUND: Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability. METHODS: Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years. RESULTS: Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001). CONCLUSION: A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Evaluation of Open Versus Arthroscopic Anterior Talofibular Ligament Reconstruction for Chronic Lateral Ankle Instability With Talar and Subtalar Cartilage MRI T2 Mapping: A 3-Year Prospective Study.

BACKGROUND: Previous studies have examined patients with chronic lateral ankle instability (CLAI) undergoing open and arthroscopic anterior talofibular ligament (ATFL) reconstruction, reporting equivalent clinical results between the 2 procedures. However, data on the magnetic resonance imaging (MRI) outcomes on cartilage health after the 2 procedures are limited. PURPOSE: To compare the cartilage MRI T2 values of the talar and subtalar joints between patients with CLAI undergoing open and arthroscopic ATFL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A prospective study was conducted on patients who underwent open or arthroscopic ATFL reconstruction between January 2018 and December 2019, with a mean follow-up duration of 3 years. MRI scans and American Orthopaedic Foot & Ankle Society (AOFAS) and Tegner score estimations were completed by patients ≤1 week before surgery, as a baseline measurement, and at a 3-year follow-up. A total of 21 healthy volunteers were included who underwent MRI at baseline. Cartilage health was evaluated using MRI T2 mapping. The talar and subtalar cartilage regions were segmented into 14 subregions. RESULTS: At baseline, patients with CLAI had substantially higher T2 values in the medial anterior, medial center, medial posterior, and lateral center regions on the talus compared with the healthy controls (P = .009, .003, .001, and .025, respectively). Remarkable increases in T2 values in the lateral posterior region on the talus were observed from baseline to follow-up in the open group (P = .007). Furthermore, T2 values were considerably higher in the medial center, medial posterior, lateral posterior, and lateral posterior calcaneal facets of the posterior subtalar joint at follow-up in the arthroscopic group compared with the baseline values (P = .025, .002, .006, and .044, respectively). No obvious differences in ΔT2 values were noted between the 2 groups at follow-up. The AOFAS and Tegner scores remarkably improved from baseline to follow-up for the 2 groups (open: 3.25 ± 0.58 vs 5.13 ± 0.81, P < .001; arthroscopic: 3.11 ± 0.90 vs 5.11 ± 1.08, P < .001), with no considerable difference between them. CONCLUSION: The elevated T2 values of cartilage could not be fully recovered after open or arthroscopic ATFL reconstruction. Both arthroscopic and open ATFL reconstruction displayed similar effects on cartilage health concerning ΔT2, but the arthroscopic group demonstrated more degenerative cartilage subregions than the open group.

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.

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.

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.