Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients.

BACKGROUND: In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients. METHODS: Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated. RESULTS: Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively. CONCLUSION: We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport. LEVEL OF EVIDENCE: Level III, retrospective case control study.

MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?

BACKGROUND: No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction. PURPOSE: To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence. RESULTS: The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. CONCLUSION: The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

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.

Enhancing Post-Surgical Rehabilitation Outcomes in Patients with Chronic Ankle Instability: Impact of Subtalar Joint Axis Balance Exercises Following Arthroscopic Modified Broström Operation.

Background and Objectives: This study aimed to evaluate the effects of subtalar joint axis-based balance exercises on the anterior talofibular ligament (ATFL) thickness, ankle strength, and ankle stability after an arthroscopic modified Broström operation (AMBO) for chronic ankle instability (CAI). Materials and Methods: The study included 47 patients diagnosed with CAI who underwent AMBO and were randomly divided into three groups: control (n = 11), general balance exercise (n = 17), and subtalar joint axis balance exercise (n = 19), regardless of the affected area. Participants in the exercise rehabilitation group performed exercises for 60 min twice a week for six weeks, starting six weeks after AMBO. ATFL thickness, ankle strength, and ankle dynamic stability were measured using musculoskeletal ultrasonography, Biodex, and Y-balance test, respectively, before and after treatment. Results: Compared with the remaining groups, the subtalar joint axis balance exercise group had reduced ATFL thickness (p = 0.000), improved ankle strength for eversion (p = 0.000) and inversion (p = 0.000), and enhanced ankle stability (p = 0.000). Conclusions: The study results suggest that subtalar joint axis-based balance exercises may contribute to the early recovery of the ankle joint after AMBO.

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.

Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients.

BACKGROUND: To compare the clinical efficacies of arthroscopic anterior talofibular ligament suture augmentation repair and modified suture augmentation repair in patients with chronic ankle instability (CAI). METHODS: From October 2019 to August 2020, 100 patients with CAI were enrolled after propensity score matching analysis and observed for two years. Among them, 50 underwent modified suture augmentation repair and the other 50 underwent suture augmentation repair. The clinical efficacies of CAI treatments were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) clinical rating scale, visual analog scale (VAS), and anterior drawer test scores. RESULTS: The postoperative AOFAS score of the modified suture augmentation repair group (83.8 ± 11.3) was significantly higher than that of the suture augmentation repair group (76.3 ± 11.3; P = 0.001). The VAS (P = 0.863) and anterior drawer test (P = 0.617) scores were not significantly different between the two treatment groups. CONCLUSION: Both the modified suture augmentation repair and suture augmentation repair demonstrated good clinical efficacies. The AOFAS score of the modified suture augmentation repair group was superior to that of the conventional suture augmentation repair group. Thus, modified suture augmentation repair is a feasible and practical surgical technique for CAI treatment.

Anterior talofibular ligament's superior fascicle as a cause of ankle microinstability can be routinely identified by ultrasound.

PURPOSE: Chronic pain can affect up to 40% of patients after ankle inversion sprains. The current hypothesis to explain this high percentage of chronic pain is a partial/total rupture of anterior talofibular ligament (ATFL) superior fascicle, a structure that has recently been described as intra-articular and as having a different function than ATFL's inferior fascicle. This has created the need for diagnosing ATFL superior and inferior fascicles independently. Therefore, the objective of this study is to investigate if the ATFL's superior fascicle can be visualized on ultrasound, and to describe its ultrasonographic appearance. METHODS: Twenty fresh-frozen ankle specimens were used in this 4-phases study. First, the specimens were scanned on US to identify what was believed to be ATFL's superior fascicle. Second, ATFL's superior fascicle was sutured under direct arthroscopic vision. Next, the specimens were scanned on US to obtain an image of the sutured structure. Finally, the specimens were dissected to confirm that the suture was indeed placed on ATFL's superior fascicle. RESULTS: On the 20 specimens studied, full correlation was obtained between US, arthroscopic suture and specimen dissection. ATFL's superior fascicle US appearance is provided. CONCLUSION: ATFL's superior fascicle can be visualized on US, which will allow to undergo diagnosis of isolated injuries to that fascicle, a common finding in ankle microinstability. The results of this study will facilitate the diagnosis of partial or complete rupture of ATFL's superior fascicle, likely increasing the amount of ankle microinstability diagnosis, impacting clinical management of ankle sprain consequences.

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.

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.

Does a rupture of the lateral ankle ligament need to be repaired in supination-adduction type II (OTA/AO 44A2) fractures?

PURPOSE: To evaluate the outcomes of patients with supination-adduction (SAD) type II (OTA/AO 44A2) fractures who had a lateral ankle ligament rupture repaired compared with patients who did not have a lateral ankle ligament repaired using patients who underwent fibula fracture fixation as a control group. METHODS: A retrospective analysis of all 104 patients diagnosed with SAD type II fractures from January 2011 to December 2020 and managed operatively was performed. The patients were divided into three groups: 32 patients with ruptures of the lateral ligaments that were not repaired (group A), 34 patients with ruptures of the lateral ligaments that were repaired (group B), and 38 patients with fibula fracture fixation acting as the control group (group C). The objective outcomes including radiographic findings, the ankle range of motion, the manual ankle stress tests, and complications were gained from the record of the last time in outpatient clinics. The functional outcomes including the identification of functional ankle instability (IdFAI) scores were collected postoperatively at 12-month intervals to assess clinical outcomes. The Manchester Oxford Foot Questionnaire (MOXFQ) and Karlsson scoring scale were also recorded at the last follow-up. RESULTS: The mean follow-up of the objective and subjective functional outcomes was 23.4 (range, 13-42) and 76.9 (range, 25-134) months, respectively. There was no significant difference in the radiographic findings, the ankle range of motion and complications between the three groups. All ankles were found to be stable using the manual ankle stress test in both group A and group B. The IdFAI scores showed a significant difference between group A and group B (1.12 ± 1.3 vs 0.35 ± 0.69; p < 0.001) in the first year of follow-up and no significant difference after the first year. No differences were noted in MOXFQ scores or Karlsson scores among the groups. CONCLUSION: Directly repairing the lateral ligament could minimize the proportion of the first year of postoperative functional ankle instability, although the final stability of the ankle and clinical outcomes were not significantly different in SAD type II fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Outcome of percutaneous reconstruction of chronic lateral collateral ligament rupture.

PURPOSE: Many techniques have been described for the reconstruction of chronic lateral collateral ligament (LCL) rupture with different autograft options. The advantages of percutaneous LCL reconstruction include small incisions, minimal soft tissue disruption, less postoperative pain, and speedy rehabilitation and recovery. The aim of this study was to report the functional outcome of percutaneous LCL reconstruction and overall patient satisfaction in Africans. METHODS: This prospective and interventional study involving 51 patients with chronic LCL rupture who had percutaneous LCL reconstruction using peroneus longus autograft was conducted between January 2021 and December 2022 in National Orthopaedic Hospital, Dala-Kano, Nigeria. The inclusion criteria were patients between the ages of 18 and 45 years with chronic isolated LCL and not more than 1 injury of knee ligament. Exclusion criteria were active infection, and multi-ligament knee injury requiring 2-staged surgery. The knee functions were assessed preoperatively, 3 months, 6 months, and 12 months postoperatively using the Lysholm scoring system. Patient satisfaction with the outcome of the treatment was assessed using a 5-point Likert scale. Relevant information was recorded into Microsoft Excel sheet and data was analyzed using SPSS version 23.0 for windows. The paired samples t-test was used to compare the clinical outcomes as continuous variables. Statistical significance was considered at p < 0.05. RESULTS: The mean age of the patients was (30.10 ± 5.90) years. The median time from injury to surgery was 7 months (ranging from 3 to 28 months). The mean follow-up period was (14.07 ± 3.13) months. The mean preoperative and 1-year postoperative Lysholm scores were 44.33 ± 12.97 and 97.96 ± 1.23, respectively. CONCLUSION: Percutaneous LCL reconstruction using peroneus longus autograft significantly improves patient knee function and results in excellent patient satisfaction.

Comparative clinical study of the modified Broström procedure for the treatment of the anterior talofibular ligament injury-outcomes of the open technique compared to the arthroscopic procedure.

PURPOSE: To observe the clinical efficacy and safety of arthroscopic-modified Broström surgery for the treatment of anterior talofibular ligament injury. METHODS: The clinical data of 51 cases with anterior talofibular ligament injury were retrospectively analyzed, in which 23 patients were treated by arthroscopic-modified Broström surgery (arthroscopic surgery group) and 28 patients were treated by open-modified Broström surgery (open surgery group). The time to surgery, hospital stay, visual analog scale (VAS) scores of ankle pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and incidence rate of complications were compared between the two groups. RESULTS: (1) General results: compared with open surgery group, arthroscopic surgery group had shorter time to surgery and hospital stay ((33.8 ± 6.7) min, (42.1 ± 8.5) min, t = 1.468, P = 0.001; (2.2 ± 1.4) d, (5.8 ± 1.6) d, t = 1.975, P = 1.975, P = 0.002). (2) VAS scores of ankle pain: there was an interaction effect between the time and group factors (F = 0.378, P = 0.018); overall, there was no statistically significant difference in VAS scores of ankle pain between the two groups, i.e., there was no grouping effect (F = 1.865, P = 0.163); there was statistically significant difference in VAS score of ankle pain at different time points before and after operation, i.e., there was a time effect (F = 1.675, P = 0.000); the VAS scores of ankle pain showed a decreasing trend with time in both groups, but the decreasing trend was not completely consistent between the two groups ((7.78 ± 1.23), (1.23 ± 1.24), (1.03 ± 0.35), (1.01 ± 0.28), F = 0.568, P = 0.000. (7.45 ± 1.43), (1.45 ± 1.87), (1.23 ± 0.55), (1.04 ± 0.37), F = 1.358, P = 0.000); there was no statistically significant difference in VAS score of ankle joint pain between the two groups six and 12 months before and after surgery (t = 2.987, P = 0.055; t = 1.654, P = 2.542; t = 0.015, P = 0.078); the VAS scores of ankle pain in the arthroscopic surgery group was lower than that in the open surgery group three months after operation (t = 1.267, P = 0.023). (3) AOFAS ankle and hindfoot scores: there was an interaction effect between time and grouping factors (F = 2.693, P = 0.027); overall, there was no statistically significant difference in the AOFAS ankle and hindfoot scores between the two groups, i.e., there was no grouping effect (F = 1.983, P = 0.106); there was statistically significant difference in the AOFAS ankle and hindfoot scores at different time points before and after surgery, i.e., there was a time effect (F = 34.623, P = 0.000); the AOFAS ankle and hindfoot scores of the two groups showed an increasing trend with time, but the increasing trend of the two groups was not completely consistent ((48.19 ± 12.89), (89.20 ± 8.96), (90.24 ± 7.89), (91.34 ± 9.67), F = 25.623, P = 0.000; (49.35 ± 13.28), (86.78 ± 12.34), (88.78 ± 9.78),(91.43 ± 7.98), F = 33.275, P = 0.000); there was no statistically significant difference in the AOFAS ankle and hindfoot scores between the two groups 12 months before/after surgery (t = 2.145，P = 0.056；t = 2.879，P = 0.389); compared with open surgery group, the arthroscopic surgery group had higher AOFAS ankle and hindfoot scores 3/6 months after surgery (t = 1.346, P = 0.014; t = 1.874, P = 0.028). CONCLUSION: For the treatment of anterior talofibular ligament injury, arthroscopic surgery group is superior to open surgery group in ankle pain relief and functional recovery and has shorter operation time and hospital stay compared with open surgery group.

Prevalence and Injury Patterns of CFL Injury in Chronic Lateral Ankle Instability: An Observational Cross-Sectional Study Using Ultrasound.

The purpose of this paper is to assess the prevalence and injury patterns of the calcaneofibular ligament (CFL) in chronic lateral ankle instability (CAI) patients using ultrasound imaging. This retrospective study included 938 ankle ultrasound images from January 2016 to May 2018. The patients' demographic data and the injury pattern classified by the injury location and the remnant quality were recorded and correlated using t tests, Fisher's exact tests, and post hoc tests accordingly. Of the 938 CAI patients, CFL injury was found in 408/938 (44%). Among the 408 anterior talofibular ligament (ATFL) and CFL complex injury patients, 71/408 (17%) presented with a completely absorbed ATFL, whereas 13/71 (18%) presented with an absorbed CFL. The total CFL absorption proportion in all patients was relatively low (30/938 = 3%). Post hoc tests indicated a negative association between thickened ATFLs and complex injuries. In addition, a positive association existed between absorbed ATFLs and complex injuries as well as absorbed ATFLs and absorbed CFLs. Thus, the results indicated that total tearing and absorption injury patterns of the CFL in CAI are not common. Even when the ATFL is absorbed, only approximately one-fifth (13/71 = 18%) of CFLs require reconstruction, suggesting that it is unnecessary to routinely repair or reconstruct CFLs in all lateral ligament surgeries.

Comparison of Direct Repair Versus Anatomic Graft Reconstruction of the Anterior Talofibular Ligament: A Biomechanical Cadaveric Study.

The goal of our study is to compare the stability of the anatomic reconstruction of the anterior talofibular ligament (ATFL) with direct repair of the ATFL, in a cadaver model. We performed the following techniques in 18 cadaveric ankles: the intact ATFL was cut, after which a direct repair using 2 anchors was performed. The repair was sectioned, and anatomic reconstruction was then performed with a tendon autograft. We measured angular displacement in 3 anatomic planes (axial, coronal, sagittal) for each situation in response to the anterior drawer test (ADT), talar tilt test (TTT) and pivot test (PT), using a specifically constructed arthrometer. The sectioned ATFL was inferior to the intact ATFL in the axial plane with the ADT (p = .012), in the axial plane with the PT (p = .001) and in the axial and coronal planes with the TTT (p = .013 and p = .016, respectively). Direct anatomic repair was inferior to the intact ATFL in the axial plane upon the PT (p = .009). No differences could be found between anatomic graft reconstructions and the intact ATFL with any manoeuver, nor when comparing anatomic graft reconstruction and direct repair with 2 anchors. We were able to conclude that anatomic graft reconstruction of the ATFL reproduces angular stability of the native ligament in a cadaver model. While we could not detect if anatomic graft reconstruction was superior to direct repair, the latter proved to be less stable in the axial plane upon internal rotation (pivot test) versus the intact ATFL.

The Distal Fascicle of the Anterior Inferior Tibiofibular Ligament: A Potential Landmark for Lateral Ankle Ligament Reconstruction.

BACKGROUND: A reliable landmark and precise distances from the ligament attachments are needed for lateral ankle stabilization surgery. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) has been used to locate the anterior talofibular ligament (ATFL) or calcaneofibular ligament (CFL) centers on the fibula. However, there is no anatomic study to validate the distal fascicle of the AITFL as a landmark of lateral ankle ligament stabilization, and more importantly, the exact distances from the ATFL or CFL attachments to the distal fascicle of the AITFL are unknown. METHODS: Sixteen frozen cadaveric specimens (8 paired specimens) with no previous history of ankle injury were used in this study. Whether the distal fascicle of AITFL was present in each specimen was confirmed. Then, the distances from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL and CFL on the fibula were measured. All measurements were performed by 2 observers, and the intraobserver and interobserver reliabilities were analyzed by intraclass correlation coefficients (ICCs). RESULTS: The distal fascicle of the AITFL was found in all specimens (100%). The mean distance from the most distal insertion of the AITFL's distal fascicle to the footprint centers of the ATFL, CFL, and the intersection center of the 2 ligaments on the fibula was 6.0 to 7.1 mm, 11.5 to 13.2 mm, and 9.0 to 10.0 mm, respectively. Excellent interobserver and intraobserver agreement (all ICCs > 0.9, P < .01) was shown in the anatomic measurements of these distances. CONCLUSION: In this cadaveric study, we found that the distal fascicle was a constant structure of the AITFL in the lateral ankle. The distances from the most distal insertion of the AITFL's distal fascicle to the ligamentous footprint centers were reliable and may be used to identify the origins of the ATFL and CFL for lateral ankle ligament reconstruction. CLINICAL RELEVANCE: This anatomic study validates the AITFL's distal fascicle as a potential landmark and, more importantly, determines the range of distances from AITFL's distal fascicle to the attachment centers of lateral ankle ligaments by anatomic measurements. The data may be used to identify the ATFL and CFL for lateral ankle stabilization surgery and become particularly valuable for endoscopic or arthroscopic techniques.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability.

It is important to eliminate instability related to chronic lateral ankle instability (CLAI) to prevent osteoarthritis progression. We performed arthroscopic anterior talofibular ligament (ATFL) repair and performed calcaneofibular ligament (CFL) repair if instability remained. This study aimed to assess the clinical outcomes of our arthroscopic procedure compared to that of open surgery. Forty ankles underwent arthroscopic surgery and 23 ankles underwent open surgery to repair the lateral ankle ligaments for CLAI. In the arthroscopic surgery, varus stress was applied under fluoroscopy after ATFL repair, and CFL repair was performed if instability remained. Open surgery was performed using the Broström procedure with ATFL and CFL repair. To assess clinical outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) and Karlsson-Peterson (KP) scores were collected preoperatively and at the final follow-up. The talar tilt angle (TTA) was measured preoperatively and 1 year postoperatively. The arthroscopic group showed significantly higher AOFAS and KP scores at the final follow-up compared to the open surgery group. There was no significant difference in TTA at 1 year between the groups. In open surgery, 2 patients required revision surgery. There were no major complications, but scar-related pain in 2 cases of open surgery was reported. Arthroscopic ATFL repair with the CFL repair gave satisfactory clinical outcomes compared to open surgery in CLAI because of low invasive to soft tissue including the joint capsule. It is important to minimize soft tissue dissection in repairing the lateral ankle ligament in patients with CLAI.

Incidence of Medial Deltoid Ligament Instability in 226 Patients With Chronic Ankle Instability.

The deltoid ligament is vitally important in the stability of the ankle and preventing excessive medial ankle movement. Historically, the impact of medial ankle instability has not been well understood in the setting of chronic ankle instability. A retrospective review of 226 patients treated for ankle instability between 2017 and 2022 identified 40 patients who required both medial and lateral repair. Decision for medial deltoid repair was based upon patient presentation, MRI findings, intraoperative fluoroscopy and final confirmation via arthroscopic positive "drive-through sign". Preoperative and postoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores, Patient-Recorded Outcomes Measurement Information System (PROMIS) scores, and Karlsson-Peterson Ankle Function (K&P) scores were obtained and compared. There were statistically significant improvements found in all 3 scoring systems at a mean follow-up time of 11.7 months postoperatively. In the setting of chronic ankle instability, consideration should be given to the evaluation and potential repair of the deltoid ligament in order to provide sufficient stability to the medial ankle.

Radiographic Anatomy of the Lateral Ankle Ligament Complex: A Cadaveric Study.

BACKGROUND: When lateral ankle sprains progress into chronic lateral ankle instability (CLAI), restoring precise anatomic relationships of the lateral ankle ligament complex (LALC) surgically is complex. This study quantifies the radiographic relationships between the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and prominent osseous landmarks visible under fluoroscopy to assist in perioperative practices for minimally invasive surgery for CLAI. METHODS: Ten fresh frozen ankle specimens were dissected to expose the LALC and prepared by threading a radiopaque filament through the ligamentous footprints of the ATFL and CFL. Fluoroscopic images were digitally analyzed to define dimensional characteristics of the ATFL and CFL. Directional measurements of the ligamentous footprints relative to the lateral process of the talus and the apex of the posterior facet of the calcaneus were calculated. RESULTS: Dimensional measurements of the ATFL were a mean length of 9.3 mm, fibular footprint of 9.4 mm, and talar footprint of 9.1 mm. Dimensional measurements of the CFL were a mean length of 19.4 mm, fibular footprint of 8.2 mm, and calcaneal footprint of 7.3 mm. From the radiographic apparent tip of the lateral process of the talus, the fibular attachment of the ATFL was found 13.3 mm superior and 4.4 mm posterior, whereas the talar attachment was found 11.5 mm superior and 4.8 mm anterior. From the radiographic apparent posterior apex of the posterior facet of the calcaneus, the fibular attachment of the CFL was found 0.2 mm inferior and 6.8 mm anterior, whereas the calcaneal attachment was found 14.3 mm inferior and 5.9 mm posterior. CONCLUSION: The ATFL and CFL were radiographically analyzed using radiopaque filaments to outline the ligamentous footprints in their native locations. These ligaments were also localized with reference to 2 prominent osseous landmarks. These findings may assist in perioperative practices for keyhole incision placement and arthroscopic guidance. Perfect lateral ankle joint imaging with talar domes superimposed is required to be able to do this. CLINICAL RELEVANCE: Radiographic evaluation of the ATFL and CFL with reference to prominent osseous landmarks identified under fluoroscopy may assist in perioperative practices for minimally invasive surgery to address CLAI for keyhole incision placement and arthroscopic guidance.

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.

Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture.

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.