Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

PURPOSE: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). METHODS: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. RESULTS: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. CONCLUSIONS: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. LEVEL OF EVIDENCE: Level III.

Postoperative Magnetic Resonance Evaluation of Anterior Talofibular Ligament Following Arthroscopic Brostrom Procedure: Analysis and Outcomes of 40 Repairs at 12 Months.

Lateral ankle sprains are one of the most common orthopedic injuries. When conservative treatment fails, surgical correction is often performed using either open or arthroscopic techniques. We hypothesize that MRI evaluation of the arthroscopic brostrom repair will show intact repair and decrease in thickness of the anterior talofibular ligament (ATFL) at 1 year, with statistically significant improvement of patient function and pain scores. Postoperative MRI was utilized at minimum 1-year follow-up to evaluate the integrity of the arthroscopic brostrom repair, as well as comparison of ATFL thickness to literature validated average thickness. A musculoskeletal fellowship trained radiologist performed all MRI reads. In addition, 3 fellowship trained foot and ankle specialists from a single institution all performed measurements of the ATFL. Surgical satisfaction using 1 to 100 scale, and Karlsson-Peterson (KP) were measured at 1 year postoperatively. In addition, pre- and postoperative Foot Function Index (FFI), American Orthopedic Foot and Ankle (AOFAS) hindfoot scores, and Visual Analog Scale (VAS) were measured using unpaired t tests. All repairs were shown to be intact at minimum 1-year follow-up via MRI evaluation, with ATFL thickness of 2.21 mm. Preoperative FFI, AOFAS, and VAS were 54.9, 46.4, and 7.1 respectively. Postoperative scores were 11.0, 91.7, and 1.3 respectively. Surgical satisfaction was 88.2, KP was 75.3. Comparison of pre- and postoperative scores (VAS, FFI, AOFAS) were shown to be statistically significant, p < .05. No significant difference in demographic data was observed at 1 year. The data from this study offers evidence that the arthroscopic brostrom repair provides patients with good outcomes as well as an intact ATFL with normal morphology at 1 year postoperatively.

Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury.

BACKGROUND: Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE: To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS: One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS: Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION: BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.

Comparative Evaluation of Metallic and Biodegradable Suture Anchors in Arthroscopic Repair of Anterior Talofibular Ligament Injury: A Short-term Study on Clinical and Functional Outcomes.

BACKGROUND With the development of arthroscopy and suture anchor, the modified BrostrÓ§m technique has made remarkable progress. However, it is unclear which material is most suitable for treating anterior talofibular ligament injury (ATFL). This study evaluated the short-term efficacy of 2 suture anchors (metal vs biodegradable materials) in arthroscopic ATFL repair. MATERIAL AND METHODS From January 2018 to December 2019, 82 patients with ankle disorders (51 men and 31 women) with ATFL injury received arthroscopic repair with suture anchor through the BrostrÓ§m-Gould procedure. The mean age was 38.70±9.35 years (range, 18-54 years). Each patient was followed up. American Orthopedic Foot and Ankle Society score (AOFAS), Karlsson Ankle Functional Score (KAFS), and the Visual Analogue Scale (VAS) were used to evaluate functional status and pain. RESULTS All patients were followed up for 21.21±2.19 months (range, 18-25 months). No complications were found either group. Preoperative clinical and functional scores in both groups had no significant difference (P>0.05). The functional score increased significantly in both groups (P<0.001). At the last follow-up, the mean AOFAS score was 93.00 (90.00, 96.00) in the Biodegradable group and 93.50 (91.00, 96.00) in the Metallic group (P=0.31). The mean KAFS score was 91.50 (85.00, 95.00) in the Biodegradable group and 93.00 (90.00, 95.50) in the Metallic group (P=0.10); the mean VAS score was 1.50 (1.00, 1.80) in the Biodegradable group and 1.30 (0.98, 1.70) in the Metallic group (P=0.22). CONCLUSIONS Arthroscopic repair of ATFL injury with suture anchors can improve the prognosis of CAI. There were no statistically significant differences in clinical and functional outcomes with metal or biodegradable suture anchors at short-term follow-up.

Biomechanical improvement of anterior talofibular ligament by augmentation repair of ligament advance reinforcement system: a cadaver study.

BACKGROUND: Ankle sprain are one of the most frequent sports injuries. Some individuals will develop chronic lateral ankle instability (CLAI) after ankle sprain and suffer from recurrent ankle sprain. Current surgical treatment of CAI with anterior talofibular ligament (ATFL) rupture fails to restore the stability of the native ATFL. Ligament Advance Reinforcement System (LARS) augmentation repair of ATFL was developed to improve its primary stability after repaired. METHODS: This study was performed to evaluate whether LARS augmentation repair of ATFL had similar stability as the modified Broström repair and the intact ATFL to maintain ankle construct stability. Standardized surgical techniques were performed on eighteen fresh frozen cadaver ankle specimens. The intact ATFL group has just undergone an ATFL exploratory surgery. The modified Broström procedure is based on anatomical repair of the ATFL with a 2.9 mm suture anchor, and the LARS procedure is an augmentation procedure of the ATFL using LARS ligaments based on the modified Broström procedure. A dynamic tensile test machine was used to assess load-to-failure testing in the three groups. The ultimate failure load and stiffness were calculated and reported from the load-displacement curve. A one-way analysis of variance was used to detect significant differences (p < 0.05) between the LARS augmentation repair, the modified Broström repair and the intact ATFL, followed by least significant difference (LSD) post-hoc tests. RESULTS: The LARS augmentation repair group showed an increased in ultimate failure to load and stiffness compared to the other two groups. There were no significant differences in ultimate failure to load and stiffness between the modified Broström and the intact ATFL, the LARS ligament for ATFL augmentation allows for improved primary stability after repair and reduced stress on the repaired ATFL, which facilitates healing of the remnant ligament. CONCLUSIONS: The LARS augmentation repair of ATFL represents a stable technique that may allow for the ankle stability to be restored in patients with CAI after surgery.

Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury.

BACKGROUND: Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis. METHODS: A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters. RESULTS: The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86-1.0) and a cut-off value of 71.68 mm2 that shows a sensitivity and specificity of 95.5% and 81.8%, respectively. CONCLUSION: This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced. LEVEL OF EVIDENCE: III, retrospective comparative study.

Evaluation of chronic ankle instability and subtalar instability using the angle between the anterior talofibular ligament and calcaneofibular ligament.

PURPOSE: A series of studies have reported a change in the length or thickness of the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments in patients with chronic ankle instability. However, no study has examined the changes in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability. Therefore, this study analyzed the change in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability to confirm its relevance. METHODS: This retrospective study included 60 patients who had undergone surgery for chronic ankle instability. Stress radiographs comprising the anterior drawer test, varus stress test, Broden's view stress test, and magnetic resonance imaging (MRI) were performed in all patients. The angle between the ATFL and CFL was measured by indicating the vector at the attachment site, as seen on the sagittal plane. Three groups were classified according to the angle between the two ligaments measured by MRI: group I when the angle was > 90°, Group II when the angle was 71-90°, and Group III when the angle was ≤ 70°. The accompanying injuries to the subtalar joint ligament were analyzed via MRI. RESULTS: A comparison of the angles between the ATFL and CFL measured on MRI in Group I, Group II, and Group III with the angles measured in the operating room revealed a significant correlation. Broden's view stress test revealed a statistically significant difference among the three groups (p < 0.05). The accompanying subtalar joint ligament injuries differed significantly among the three groups (p < 0.05). CONCLUSION: The ATFL-CFL angle in patients with ankle instability is smaller than the average angle in ordinary people. Therefore, the ATFL-CFL angle might be a reliable and representative measurement tool to assess chronic ankle instability, and subtalar joint instability should be considered if the ATFL-CFL angle is 70° or less. LEVEL OF EVIDENCE: Level III.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years.

BACKGROUND: An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation. METHODS: Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used. RESULTS: Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability. CONCLUSION: At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone. LEVEL OF EVIDENCE: Level II, retrospective cohort study.

Surgical treatment of ankle instability in children with os subfibulare.

INTRODUCTION: Ankle instability in children due to soft tissue injury usually resolves after non-operative treatment. However, some children and adolescents with chronic instability require surgical treatment. A rarer cause of developing ankle instability is injury to the ligament complex in the presence of os subfibulare, an accessory bone inferior to the lateral malleolus. The aim of this study was to assess the results of operative management of chronic ankle instability in children with os subfibulare. MATERIALS AND METHODS: 16 children with os subfibulare and chronic ankle instability who failed non-operative treatment were enrolled prospectively into the study. One child was lost to follow-up and excluded from analysis. The mean age at the time of the surgery was 14 years and 2 months (range 9.5-17 years). The mean follow-up time was 43.2 months (range 28-48 months). Surgical treatment in all cases involved removal of os subfibulare and a modified Broström-Gould lateral complex reconstruction with anchors. Ankle status was assessed before and after surgery with The 100 mm Visual Analogue Scale and Foot and Ankle Outcome Score questionnaire. RESULTS: The mean Foot and Ankle Outcome Score improved from 66.8 to 92.3 (p < 0.001). Pain level improved from 67.1 preoperatively to 12.7 (p < 0.001). All children reported improvement in their ankle stability. There was one case of scar hypersensitivity that improved during observation and one superficial wound infection that resolved with oral antibiotics. One child reported intermittent pain without symptoms of instability following another injury. CONCLUSIONS: Ankle joint sprain with associated injury to os subfibulare complex can lead to chronic instability in children. If conservative management fails, then surgical treatment with modified Broström-Gould technique and excision of accessory bone is a safe and reliable method.

Risk Factors for the Recurrence of Instability After Lateral Ankle Ligament Repair.

BACKGROUND: Arthroscopic anterior talofibular ligament (ATFL) repair is widely performed for chronic lateral ankle instability (CLAI). Although many studies have reported excellent outcomes with this procedure, the recurrence of instability remains a common concern. Therefore, this study aimed to analyze the risk factors for the recurrence of instability after arthroscopic repair for CLAI. METHODS: Fifty-six ankles of 53 patients with a mean age of 31.8 ± 14.7 years were retrospectively reviewed. All patients underwent arthroscopic ATFL repair. If instability remained immediately after ATFL repair, calcaneofibular ligament (CFL) repair was performed. The Ankle Activity Score (AAS) was assessed preoperatively, and clinical outcomes including the Japanese Society for Surgery of the Foot scale, Karlsson-Peterson scores, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were evaluated preoperatively and at the final follow-up. Talar tilt angle (TTA) was assessed preoperatively and 1 year postoperatively. Ankles were divided into 2 groups-nonrecurrence (postoperative TTA, <6 degrees) and recurrence (postoperative TTA, ≥6 degrees)-and clinical outcomes were compared. RESULTS: Sixteen ankles showed recurrent instability, whereas 40 did not. AAS, TTA, and social functioning in the SAFE-Q were significantly higher in the recurrence group than those in the nonrecurrence group preoperatively. In addition, the rate of poor ATFL remnant quality and the number of CFLs not repaired despite the preoperative injury diagnosis were significantly higher in the recurrence group than in the nonrecurrence group. CONCLUSION: Arthroscopic repair for ATFL and CFL deficiencies with preoperative high activity, poor remnant quality, and neglected CFL injury can result in the recurrence of instability. Appropriate surgical procedures to prevent the recurrence of instability should be selected for these ankles. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults.

BACKGROUND: Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability. METHODS: A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine. RESULTS: Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization. CONCLUSION: Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Acute Distal Rupture of the Calcaneus-Fibular Ligament Near the Calcaneus Insertion: Magnetic Resonance Imaging for Diagnostic Value and Comparison to Surgical Findings-A Retrospective Case Series Study.

Distal rupture of the calcaneus-fibular ligament (CFL) was unique and important, because it is crucial to diagnose this type of injury before surgical intervention. In the present study, we collected several imaging characteristics based on MRI and tried to determine whether those clues can be used to diagnose distal rupture of CFL specifically and sensitively. Several imaging characteristics based on MRI were collected and used to diagnose and determine the location of CFL injury. All these clues on preoperative MRI were verified by operative findings and postoperative roentgenography. The interobserver agreement for the quality of the MRI images had a p value of .6 (McNemar test) and a Cohen's kappa of 65.2% (confidence interval, 50.5%-79.9%), and the agreement of the 2 observers was categorized as substantial. The sensitivity and specificity of distal rupture of CFL between 2 observers were 76.3%, 91.4% and 72.2%, 85.55%, respectively. The sensitivity and specificity of MRI clues were calculated as follows: hyperintense signal changes (86.1%, 38.6%), peroneal sheath fluid (63.9%, 74.7%), wave or laxity of the ligament (80.6%, 51.8%), fluid exudation around the ligament (80.6%, 51.8%), bone marrow edema on the calcaneus insertion (2.8%, 91.6%), avulsion fracture of the calcaneus (0%, 96.4%), incongruency or disruption of the ligament (69.4%, 77.1%), and exudation on the subtalar joint (52.8%, 71.1%). Preoperative MRI scans are a useful tool to diagnose distal injury of the CFL.

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.

Double-bundle reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon.

BACKGROUND: Anatomic anterior talofibular ligament (ATFL) reconstruction with autologous single-bundle tendon has been widely used in the treatment of ATFL injury. However, there are few clinical reports of using the peroneus brevis tendon (PBT) for double-bundle ATFL reconstruction. The aim of this study was to investigate the clinical effect of double-bundle ATFL reconstruction with PBT. METHODS: This was a retrospective review of all patients diagnosed with ATFL injury presenting from August 2019 to December 2021. Fifty-three patients were selected after screening based on the inclusion and exclusion criteria. The following data were compared before and after surgery: Visual Analogue Scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), the pain interference (PI) and physical function (PF) scores of the Patient-Reported Outcomes Measurement Information System (PROMIS), the diameter and width of PBT in ultrasound and muscle strength. RESULTS: All functional scores (VAS, PI/PF, AO-FAS, KAFS) and muscle strength were significantly improved at the last follow-up (P < 0.05). The diameter and width of the PBT on ultrasound postoperation were smaller than those preoperatively. CONCLUSION: Double-bundle ATFL reconstruction with the partial PBT technique is a feasible, anatomic reconstruction technique for chronic lateral instability of the ankle, which meets the anatomical characteristics of the double bundle of the ligament, and the absence of partial PBT does not affect the peroneal muscle strength. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Stepwise decision making for CFL repair in addition to arthroscopic ATFL repair yields good clinical outcomes in chronic lateral ankle instability regardless of the remnant quality.

BACKGROUND: Although arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed, there are several issues such as the efficacy of the isolated ATFL repair for the ATFL and calcaneofibular ligament (CFL) injury and the influence of the poor remnant on the clinical outcomes to be discussed. This study aimed to evaluate clinical outcomes of the arthroscopic ATFL repair with the stepwise decision regarding the requirement of CFL repair and the influence of remnant qualities on clinical outcomes. METHODS: Forty-four ankles underwent arthroscopic surgery to repair the lateral ankle ligament for CLAI. After arthroscopic ATFL repair, CFL repair was performed if instability remained. Clinical outcomes including the Karlsson-Peterson (KP) scores, Japanese Society for Surgery of the Foot (JSSF) scale, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were assessed at the final follow-up. ATFL remnants were classified into excellent, moderate, and poor according to the arthroscopic findings, and the clinical outcomes of each remnant group were compared. RESULTS: Twenty-five ankles were required for CFL repair after ATFL repair. K-P score was significantly improved from 66.1 ± 5.3 to 94.8 ± 6.5 points (p < 0.01). JSSF scale was significantly improved from 70.5 ± 4.5 to 95.9 ± 6.0 points (p < 0.01). The SAFE-Q was also significantly improved on all subscales. There were no significant differences in clinical outcomes among excellent, moderate, and poor remnants. CONCLUSIONS: Stepwise decision for CFL repair in addition to arthroscopic ATFL repair gave satisfactory clinical outcomes in CLAI regardless of the remnant quality.

Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI.

PURPOSE: Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI. METHODS: Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed. RESULTS: Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery). CONCLUSION: Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex. LEVEL OF EVIDENCE: Level III.

Ultrasonography view for acute ankle injury: comparison of ultrasonography and magnetic resonance imaging.

INTRODUCTION: We aim to asses the diagnostic performance of ankle ultrasonography in patients presenting with acute ankle sprain injury, with comparison to MRI (Manyetik Rezonans Imaging). MATERIALS AND METHODS: The study included patients who applied to the hospital within 48 h after an ankle sprain, and who presented with signs of pain, swelling, and tenderness in the ankle. Ankle ultrasonography examination was performed and an ankle MRI took place the same day. RESULTS: 30 patients were included in the study. 53.3% (n = 16) were female. The mean age was 30 ± 6.4 years. The ultrasonography examination determined 76.6% (n = 23) of the patients to have anterior talofibular ligament (ATFL) injury, 33.3% to have (n = 10) CFL injury, and 33.3% to have (n = 10) anterior inferior tibia-fibular ligament (AITFL) injury. The MRI of the patients determined 73.3% (n = 22) of the patients to have ATFL injury, 43.3% (n = 13) to have calcaneal fibular ligament (CFL) injury, and 33.3% to have (n = 10) AITFL injury. The ATFL, CFL, and AITFL injuries diagnosed on ultrasonography correlated with the MRI results (ICC = 0.875, ICC = 0.879, and ICC = 0.858). However, among the ATFL injuries observed on MRI, 26.6% (n = 8) were grade I, 26.6% (n = 8) were grade II, and 20% (n = 6) were grade III injuries. Of the ATFL injuries observed on ultrasonography, 46.6% (n = 14) were grade I, 8.6% (n = 2) were grade II, and 30.4% (n = 7) were grade III injuries. CONCLUSIONS: Findings on all types of ATFL, CFL and AITFL appear to have a higher degree of correlation. Ultrasonography could have an added role as a triaging tool, to fast-track MRI.

Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study.

PURPOSE: Portable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress. METHODS: Ten fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior-inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior-inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy. RESULTS: When assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy. CONCLUSION: P-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.

Arthroscopic assessment of syndesmotic instability: Are we pulling correctly in the coronal plane?

BACKGROUND: While the lateral hook test (LHT) has been widely used to arthroscopically evaluate syndesmotic instability in the coronal plane, it is unclear whether the angulation of the applied force has any impact on the degree of instability. We aimed to determine if changing the direction of the force applied while performing the LHT impacts the amount of coronal diastasis observed in subtle syndesmotic injuries. METHODS: In 10 cadaveric specimens, arthroscopic evaluation of the syndesmotic joint was performed by measuring anterior and posterior-third coronal plane diastasis in the intact state, and repeated after sequential transection of the 1) anterior inferior tibiofibular ligament (AITFL), 2) interosseous ligament (IOL), and 3) posterior inferior tibiofibular ligament (PITFL). In all scenarios, LHT was performed under 100 N of laterally directed force. Additionally, LHT was also performed under: 1) anterior inclination of 15 degrees and 2) posterior inclination of 15 degrees in intact and AITFL+IOL deficient state. RESULTS: Compared to the intact state, the syndesmosis became unstable after AITFL +IOL transection under laterally directed force with no angulation (p = 0.029 and 0.025 for anterior and posterior-third diastasis, respectively), which worsened with subsequent PITFL transection (p = <0.001). Moreover, there was no statistical difference in anterior and posterior-third coronal diastasis in both intact and AITFL+IOL deficient states under neutral, anterior, and posteriorly directed force (p-values ranging from 0.816 to 0.993 and 0.396-0.80, respectively). However, in AITFL+IOL transected state, posteriorly directed forces resulted in greater diastasis than neutral or anteriorly directed forces. CONCLUSIONS: Angulation of the applied force ranging from 15 degrees anteriorly to 15 degrees posteriorly during intraoperative LHT has no effect on coronal plane measurements in patients with subtle syndesmotic instability. On the other hand, posteriorly directed forces result in more sizable diastasis, potentially increasing their sensitivity. CLINICAL RELEVANCE: When arthroscopically evaluating subtle syndesmotic instability, clinicians should assess coronal diastasis with the hook angled 15 degrees posteriorly.

Mouse model of subtalar post-traumatic osteoarthritis caused by subtalar joint instability.

BACKGROUND: Common ankle sprains are often accompanied by injury to the subtalar joint, which eventually leads to subtalar joint instability. Because the clinical manifestations for subtalar joint instability are similar to ankle joint injuries, these are often overlooked. This study aimed to establish an animal model of subtalar joint instability to study post-traumatic osteoarthritis of the subtalar joint caused by long-term subtalar joint instability and to provide a reference for future clinical research on chronic subtalar joint instability. METHODS: In all, 24 C57BL/6 male mice were randomly divided into three groups: Sham, cervical ligament (CL) transection and CL + calcaneofibular ligament (CFL) transection groups. One week after surgical operation, all mice were trained to run in the mouse rotation fatigue machine every day. During this period, a balance beam test was used to evaluate the motor level and coordination ability of the mice before the operation and three days, one week, four weeks, eight weeks, and twelve weeks after operation. Further, post-traumatic osteoarthritis of the subtalar joint was quantified via micro-CT and histological staining. RESULTS: The mice in the partial ligament transection group took significantly longer than those in the Sham group to pass through the balance beam and showed an increased number of hindfoot slips. Micro-CT analysis showed that the subtalar bone volume fraction in the CL + CFL transection group and CL transection group was 5.8% and 2.8% higher than that in the Sham group, respectively. Histological staining showed obvious signs of post-traumatic osteoarthritis (PTOA) in the subtalar joint of the ligament transection group. CONCLUSIONS: The transection of CL and CL + CFL can cause instability of the subtalar joint in mice, resulting in a decrease in motor coordination, and long-term instability of the subtalar joint in mice can cause PTOA of the subtalar joint, which is manifested as destruction and loss of articular cartilage.