Diagnostic accuracy of ultrasonography in acute lateral ankle ligament injury: A systematic review and meta-analysis.

BACKGROUND: The gold standard diagnostic method for acute lateral ankle ligament sprain is magnetic resonance imaging (MRI). However, it is hardly accessible and is time-consuming. Therefore, additional diagnostic methods are warranted. Point-of-care ultrasound, on the other hand, is inexpensive, widely available, time-efficient testing method. PURPOSE: Therefore, the aim of this meta-analysis is to determine the diagnostic accuracy of ultrasound for acute ankle ligament injuries compared to MRI. METHODS: In our systematic review and meta-analysis, we followed the recommendations of the Cochrane Handbook. We searched the following databases from inception to March 31, 2022: Medline (PubMed), EMBASE, and Cochrane Library. Eligible studies investigated the diagnostic accuracy of US compared to MRI for diagnosing acute lateral ankle ligament injuries. Finally, we calculated pooled sensitivity and specificity with a 95 % confidence interval (CI). RESULTS: Eight studies met our eligibility criteria, involving 434 patients. For anterior tibiofibular ligament (ATFL) injury, the summary sensitivity and specificity were Se = 0.97 (CI: 0.89-0.99) and Sp = 0.93 (CI: 0.84-0.97). For calcaneofibular ligament (CFL) injury, the summary sensitivity and specificity were Se.: Se = 0.81 (CI: 0.58-0.93) and Sp = 0.92 [0,81;0,97]. In addition, subgroup analysis based on US performed by different types of investigators was comparable between each other (radiologist group Se = 0.98, CI: 0.24-1, and Sp = 0.91, CI: 0.74-0.97, and the orthopedic/ emergency department group Se = 0.96, CI: 0-1, and Sp = 0.97, CI: 0-1). CONCLUSION: Ultrasound showed high diagnostic accuracy for acute lateral ankle ligament injury, irrespective of the investigator. Therefore, based on the current available data, it could be used in primary diagnostics of acute lateral ankle ligament injury.

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.

MRI and single-cell RNA sequence results reveal the influence of anterior talofibular ligament injury on osteochondral lesions of the talus.

Anterior talofibular ligament injuries and osteochondral lesions of the talus present unique challenges to orthopedic surgeons. This study aimed to investigate the relevant relationship between them by analyzing the Magnetic resonance imaging (MRI) results of clinical patients and single-cell RNA sequence (scRNA seq) results of healthy talus cartilage to discuss the risk factors. Data from 164 patients from 2018 to 2023 was retrospectively analyzed. The correlation analysis between ATFL injury grade and the Hepple stage of OLT determined by MRI was performed. Publicly available single-cell RNA datasets were collected. Single-cell RNA datasets from five volunteers of healthy talus cartilage were analyzed. ATFL injury grade was relevant with the Hepple stage of OLT (P < 0.05). The results of multivariate logistic regression analysis showed that injured area was the independent influencing factor of the incidence rate and the severity of OLT (P < 0.05). The Hepple stage of OLT was relevant with AOFAS and VAS (P < 0.05). Single-cell RNA sequence results showed that among the 9 subtypes of chondrocytes, the interaction strength between HTC-A and HTC-B is the highest. Their physical interactions are mainly achieved through the CD99 signaling pathway, and factor interactions are mainly achieved through the ANGPTL signaling pathway. Anterior talofibular ligament injury may lead to osteochondral lesions of the talus. Early medical intervention should be carried out for ligament injuries to restore joint stability and avoid cartilage damage.

Arthroscopic anterior deltoid plication with bone anchor is an effective procedure to control residual talar anterior translation after lateral ligament repair.

PURPOSE: Residual symptoms can be observed after ankle lateral ligament repairs commonly due to hyperlaxity, severe ankle instability or a failed stabilization. In order to increase joint stability, ligament or capsular-ligament plication has been used in other joints. Given that the anterior portion of the deltoid is a stabilizer against anterior talar translation, it could be used as an augmentation to restrict anterior talar translation. The aim of this study was to describe an arthroscopic anterior deltoid plication with a bony anchor as an augmentation to the lateral stabilization. The results in a series of eight patients were presented. METHODS: Eight patients (seven males, median age 31 [range, 22-43] years) presented residual instability after arthroscopic all inside lateral collateral ligament repair. Arthroscopic anterior deltoid ligament plication was performed in these patients. Median follow-up was 22 (range, 15-27) months. Using an automatic suture passer and a knotless anchor, the anterior deltoid was arthroscopically plicated to the anterior aspect of the medial malleolus. RESULTS: During the arthroscopic procedure, only an isolated detachment of the anterior talofibular ligament was observed without any deltoid open-book injury in any case. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligament repair and the anterior deltoid plication with a bony anchor. On clinical examination, the anterior drawer test was negative in all patients. The median American Orthopedic Foot and Ankle Society score increased from 68 (range, 64-70) preoperatively to 100 (range, 90-100) at final follow-up. CONCLUSION: The arthroscopic anterior deltoid plication is a feasible procedure to augment stability and control anterior talar translation when treating chronic ankle instability in cases of residual excessive talar translation. LEVEL OF EVIDENCE: Level IV.

Mechanisms of lateral ankle ligament sprains in professional netball: A systematic video analysis.

OBJECTIVES: To undertake a systematic analysis of 17 medical attention and time-loss lateral ankle ligament sprain (LALS) events from televised Australian professional netball games during the 2020-2023 seasons. DESIGN: Case series. METHODS: Three analysts independently assessed the video footage and then convened to review and discuss each case until a consensus was reached. RESULTS: When in possession (7 cases) a player was commonly performing an agility-based manoeuvre to break free from an opponent and reposition themselves to be a passing option (5/7 cases). When out of possession (10 cases) a player was either attempting to intercept a pass (6 cases) or marking an opponent (4 cases). Players tended to land on the anterior one-third of the plantar surface of the foot - forefoot or shoe tip (7 cases). Players often landed on either the ground (7 cases) or the opponent's shoe then the ground (8 cases). In 9 cases the ankle-foot was considered to be in a neutral alignment in the frontal plane at landing. At the estimated index frame the players' weight tended to be all on the foot on the injured side (11 cases) or favouring the foot on the injured side (5 cases). Inversion and adduction was a common injury mechanism. Plantar-flexion was rarely involved. CONCLUSION: Landing on the anterior one-third of the plantar surface of the foot and subsequent weight transference onto the injured limb side was more important than ankle-foot inversion at initial ground contact. Exercises involving external perturbations that challenge the control of frontal and transverse plane ankle-foot motion and improve proprioception, neuromuscular control, and dynamic balance are warranted.

Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair.

PURPOSE: The aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization. METHODS: CAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up. RESULTS: A total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups. CONCLUSION: Elastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization. STUDY DESIGN: Cohort study; Level of evidence, 3.

Diagnostic value of ultrasonography for injury of anterior talofibular ligament and anterior inferior tibiofibular ligament distal fascicle in patients with ankle fractures. / è¶ å£°è¯„ä¼°è¸å ³èŠ‚éª¨æŠ˜æ‚£è€ è·è “å‰éŸ§å¸¦åŠä¸‹èƒ«è “å‰éŸ§å¸¦è¿œä¾§æŸæŸä¼¤çš„ä»·å€¼.

OBJECTIVES: To explore the diagnostic value of ultrasonography for injuries of anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament distal fascicle (ATiFL-DF) in patients with ankle fractures. METHODS: Clinical data of 51 patients with ankle fractures who were clinically suspected of ligament injuries and underwent ankle ultrasonography examination and arthroscopy in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from April 2019 to March 2023 were retrospectively analyzed. Using arthroscopic results as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography in diagnosing ATFL and ATiFL-DF injuries were evaluated, and Kappa consistency test was performed. RESULTS: The sensitivity and specificity of ultrasonography in diagnosis of ATFL injury were 100.0% and 92.3%, with the PPV of 92.6% and NPV of 100.0%. Ultrasonography findings exhibited excellent concordance with arthroscopic results (kappa=0.849). The sensitivity and specificity of ultrasonography in diagnosis of ATiFL-DF injury was 86.7% and 33.3%, with the PPV of 90.7% and NPV of 25.0%. However, the consistency between ultrasonography and arthroscopic results was poor (kappa=0.168). CONCLUSIONS: Ultrasonography is reliable in assessing injuries of ATFL in patients with ankle fractures, but its specificity in diagnosing ATiFL-DF is poor. Therefore, ankle arthroscopy remains necessary for ankle fracture patients with negative findings of ATiFL-DF in ultrasonography.

Predictive Modeling for Functional Outcomes After All-Inside Arthroscopic Anterior Talofibular Ligament Repair of Chronic Ankle Instability.

BACKGROUND: Arthroscopic anterior talofibular ligament repair (AATFLR) is a surgical strategy to treat chronic ankle instability (CAI) patients. This study identified risk factors that influenced the functional outcomes of AATFLR for CAI and developed prognostic nomogram for predicting functional outcomes in future AATFLR cases. METHODS: Patients undergoing AATFLR from January 2016 to June 2022 with at least 10 months of follow-up were included in the study. The Karlsson Ankle Functional Score (KAFS) was evaluated preoperatively and at last follow-up visit. A total of 15 potential predictors including age, sex, body mass index, side affected, time from injury to surgery, sports-related injury, osteophyte, loose bodies, distal tibiofibular syndesmosis, ATFL avulsion fracture, Outerbridge classification of osteochondral lesions, postoperative immobilization method, ambulation time, walking time, and follow-up time, were recorded. We first used univariate binary logistic regression analysis to select the potential significant prognostic features, which were then subjected to the least absolute shrinkage and selection operator (LASSO) regression algorithm for final feature selection. A nomogram based on the regression model was developed to estimate the functional outcomes of patients. Models were validated internally using bootstrapping and externally by calculating their performance on a validation cohort. RESULTS: Overall, 200 ankles fit inclusion criteria. Of these 200, a total of 185 (92.5%) ankles were eligible and divided into development (n = 121) and validation (n = 64) cohorts. Four predictors were ultimately included in the prognostic nomogram model: age, sex, sports-related injury, and postoperative immobilization method. CONCLUSION: We found in our cohort that the significant predictors of poorer functional outcomes of AATFLR were postoperative immobilization with lower-leg cast, female sex, non-sports-related ankle sprain, and increasing age. Prognostic nomograms were created.

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery.

BACKGROUND: Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments. METHODS: A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention. RESULTS: Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months. CONCLUSION: The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes.

BACKGROUND: Posterior ankle impingement syndrome (PAIS) is sometimes complicated by bilateral cases and lateral ankle ligament injuries. Reports on bilateral surgery for PAIS and simultaneous surgery for lateral ankle ligament injury are scarce in the literature. METHODS: We present a 2-year follow-up of 76 athletic patients who underwent endoscopic hindfoot surgery for PAIS. Patients were divided into those who underwent unilateral or simultaneous bilateral surgery and PAIS surgery alone or simultaneous bilateral PAIS surgery without arthroscopic ankle lateral ligament repair. RESULTS: All patients returned to full athletic activities postoperatively. There was no difference in all subscales of the SAFE-Q score between groups except for mean days after surgery for full return to athletic activities. CONCLUSION: Simultaneous bilateral surgery and simultaneous arthroscopic lateral ankle ligament repair had no negative effect on subjective clinical evaluation 2 years after surgery in hindfoot endoscopic surgery for PAIS. LEVEL OF EVIDENCE: III, retrospective case-control study.

A Randomized Comparison Between Anterior Talofibular Ligament Repair Using Broström Operation with and without an Internal Brace.

The aim of the study was to compare the intermediate-term (>24 months) clinical outcomes between anterior talofibular ligament repair using Broström operation with and without an internal brace. Nineteen patients underwent surgery using an arthroscopic traditional Broström repair with an internal brace technique (IB) and Eighteen patients underwent surgery using an arthroscopic traditional Broström repair without an internal brace technique (TB) . All patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). According to FAAM, sports activity scores of TB and IB groups were 83.33 ± 5.66 and 90.63 ± 6.21 at the final follow-up (p = .02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Total medical expense was more in the IB group (p < .001). It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life.

The Relationship Between Calcaneofibular Ligament Injury and Ankle Osteoarthritis Progression: A Comprehensive Analysis of Stress Distribution and Osteophyte Formation in the Subtalar Joint.

BACKGROUND: Ankle osteoarthritis (OA) mainly arises from trauma, particularly lateral ligament injuries. Among lateral ligament injuries, ankles with calcaneofibular ligament (CFL) injuries exhibit increased instability and can be a risk factor ankle OA progression. However, the relationship between CFL injury and OA progression remains unclear. Therefore, this study aims to assess the relationship between CFL injuries and ankle OA by investigating stress changes and osteophyte formation in subtalar joint. METHODS: We retrospectively reviewed the magnetic resonance imaging (MRI) and plain radiographic evaluations of 100 ankles of 91 patients presenting with chronic ankle instability (CAI), ankle OA, or other ankle conditions. The association between CFL injuries on the oblique view of MRI and the severity of ankle OA (based on Takakura-Tanaka classification) was statistically evaluated. Additionally, 71 ankles were further subjected to CT evaluation to determine the association between the CFL injuries and the Hounsfield unit (HU) ratios of the subtalar joint and medial gutter, and the correlation between the subtalar HU ratios and osteophyte severity were statistically evaluated. RESULTS: CFL injury was observed in 35.9% (14/39) of patients with stage 0, 42.9% (9/21) with stage 1, 50.0% (10/20) with stage 2, 100% (9/9) with stage 3a, and 90.9% (10/11) with stage 3b. CFL-injured ankles exhibited higher HU ratios in the medial gutter and lower ratios in the medial posterior subtalar joint compared to uninjured ankles. A negative correlation was observed between medial osteophyte severity and the medial subtalar joint HU ratio. CONCLUSION: Our findings suggest that CFL injuries are common in severe ankle OA impairing the compensatory function of the subtalar joint through abnormal stress distribution and osteophyte formation.

Optimal assessment for anterior talofibular ligament injury utilizing stress ultrasound entails internal rotation during plantarflexion.

OBJECTIVES: An optimal load and ankle position for stress ultrasound of the injured anterior talofibular ligament (ATFL) are unknown. The objectives of this study were to compare stress ultrasound and ankle kinematics from a 6 degree-of-freedom (6-DOF) robotic testing system as a reference standard for the evaluation of injured ATFL and suggest cut-off values for ultrasound diagnosis. METHODS: Ten fresh-frozen human cadaveric ankles were used. Loads and ankle positions examined by the 6-DOF robotic testing system were: 40 N anterior load, 1.7 Nm inversion, and 1.7 Nm internal rotation torques at 30° plantarflexion, 15° plantarflexion, and 0° plantarflexion. Bony translations were measured by ultrasound and a robotic testing system under the above conditions. After measuring the intact ankle, ATFL was transected at its fibular attachment under arthroscopy. Correlations between ultrasound and robotic testing systems were calculated with Pearson correlation coefficients. Paired t-tests were performed for comparison of ultrasound measurements of translation between intact and transected ATFL and unloaded and loaded conditions in transected ATFL. RESULTS: Good agreement between ultrasound measurement and that of the robotic testing system was found only in internal rotation at 30° plantarflexion (ICC â€‹= â€‹0.77; 95% confidence interval 0.27-0.94). At 30° plantarflexion, significant differences in ultrasound measurements of translation between intact and transected ATFL (p â€‹< â€‹0.01) were found in response to 1.7 Nm internal rotation torque and nonstress and stress with internal rotation (p â€‹< â€‹0.01) with mean differences of 2.4 â€‹mm and 1.9 â€‹mm, respectively. CONCLUSION: Based on the data of this study, moderate internal rotation and plantarflexion are optimal to evaluate the effects of ATFL injury when clinicians utilize stress ultrasound in patients. LEVEL OF EVIDENCE: III.

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.

Comparative analyses of arthroscopic and open repairs of lateral ligament complex injuries of the ankle: a systematic review and meta-analysis of the medium-term outcomes.

PURPOSE: Little is known regarding the comparative analyses of the medium-term outcomes (with a mean minimum follow-up period of 24 months), between arthroscopic and open repairs of lateral ligament complex (LLC) injuries of the ankle. Thus, in this study, we aimed to explore the comparative analyses regarding the medium-term follow-up outcomes of these repairs, by conducting a systematic review and meta-analysis. METHODS: The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; data were extracted from the PubMed and Google Scholar databases. From an initial search, a total of 1182 abstracts (280 and 902 abstracts, from PubMed and Google Scholar, respectively) were found and screened in accordance with the eligibility criteria. Subsequently, six articles were found to be eligible for further review. RESULTS: A total of 419 patients underwent surgical repairs; 205 and 214 patients underwent arthroscopic and open repairs, respectively. The mean minimum follow-up period was 29.2 months. The medium-term follow-up for arthroscopic LLC repairs was found to be superior to that of open LLC repairs, with more favorable outcomes; as evidenced by better clinical scores, lower pooled complication rates, earlier return times to pre-injury sport, and higher early sport ratios. CONCLUSIONS: The findings of this systematic review and meta-analysis support near-future developments validating arthroscopic repair as the new gold standard for LLC repairs, similarly to arthroscopic ligament and tendon repairs, as well as arthroscopic reconstruction surgeries, of the knee and shoulder.

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.

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population.

OBJECTIVE: To determine sensitivity and specificity for anterior-inferior tibiofibular ligament (AiTFL) integrity and tibiofibular clear-space (TFCS) cut-off points for dynamic evaluation using ultrasound (US) in a pediatric population. DESIGN: Prospective cohort study. SETTING: Tertiary care university-affiliated pediatric hospital patients between the ages of 12 and 18 sustaining acute ankle trauma with syndesmotic injury. INTERVENTIONS: Participants were assigned to the syndesmotic injury protocol that included a standardized MRI and US. MAIN OUTCOME MEASURES: Anterior-inferior tibiofibular ligament integrity for static assessment and TFCS measurements for dynamic assessment on US. For dynamic assessment, the distance between the distal tibia and fibula was first measured in neutral position and then in external rotation for each ankle. The US results on AiTFL integrity were compared with MRI, considered as our gold standard. Optimal cut-off points of TFCS values were determined with receiver operating characteristics curve analysis. RESULTS: Twenty-six participants were included. Mean age was 14.8 years (SD = 1.3 years). Sensitivity and specificity for AiTFL integrity were 79% and 100%, respectively (4 false negatives on partial tears). For dynamic assessment, the cut-off points for the differences in tibiofibular distance between the 2 ankles in 1) neutral position (TFCS N I-U ) and 2) external rotation (TFCS ER I-U ) were 0.2 mm (sensitivity = 83% and specificity = 80%) and 0.1 mm (sensitivity = 83% and specificity = 80%), respectively. CONCLUSIONS: Static US could be used in a triage context as a diagnostic tool for AiTFL integrity in a pediatric population as it shows good sensitivity and excellent specificity.

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.

Using an Arthrometer to Quantify Ankle Laxity: An Infographic Summary.

Lateral ankle sprains are a common musculoskeletal injury. The anterior talofibular ligament (ATFL) is the primary ligament involved and is assessed via an anterior drawer test. Clinically assessing joint laxity has been a subjective task. Evaluating both magnitude of translation and quality of the endfeel has presented challenges. Until recently, a reliable and valid arthrometer to test joints other than the knee has not been available. The Mobil-Aider arthrometer has undergone bench testing for validity, reliability testing in healthy persons, and most recently the testing of participants for pathology. A summary of these studies is available in the Online Supplement. The goal of this study was to determine the ability of the arthrometer to objectively identify the anterior translation of the ankle and the relationship to the clinical diagnosis. The participant was evaluated by a physician and magnitude of ankle sprain was determined. An arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each) in the prone position. Both clinicians were blinded to the data of the other. There were 30 participants, 10 per group (uninjured, 1° sprain, 2° sprain). Mann-Whitney U testing found significant differences between the control and grade 1 ankle sprain groups (P < .001), the control and grade 2 ankle sprain groups (P < .001), and the grade 1 and grade 2 ankle sprain groups (P = .004). There was ± 0.31 mm difference in anterior translation between healthy ankles, whereas there was 1.11 mm and 2.16 mm difference between ankles in grade 1 and grade 2 sprains, respectively. The anterior drawer test is the gold standard for clinical ATFL testing, but the subjective nature of this test poses challenges. Technology is available to assess ankle joint laxity and enhance the objectivity of patient assessment and throughout the recovery process. An arthrometer is a valuable tool in quantifying orthopaedic examination.