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.

A modified "outside-in" Broström-Gould procedure yielding favorable outcomes for the management of chronic lateral ankle instability-a retrospective study with mid-term follow-up.

Purpose: There are various surgical interventions available for the management of Chronic lateral ankle instability (CLAI). The Broström-Gould procedure has gained widespread recognition among foot and ankle specialists for its favorable surgical outcomes. However, with advancements in anatomical understanding and medical technology, further enhancements to the effectiveness of the Gould procedure are warranted. This study introduces a all-inside modified "outside-in" Broström -Gould procedure as an alternative approach for addressing lateral ankle instability. Methods: From August 2020 to October 2022, 40 patients with lateral ankle instability who underwent arthroscopic repair of the modified "outside-in" Broström-Gould procedure were retrospectively analyzed. All patients received standard non-surgical treatment before surgery for more than 6 months without symptom relief. Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) and Karlsson-Peterson score were used to evaluate the postoperative effect. Results: All patients were followed up for (14.62 ± 2.04) months. One year after operation, all patients could walk normally, ankle instability sensation disappeared, varus stress test and anterior drawer test were negative. The VAS , AOFAS and Karlsson-Peterson scores of all patients were significantly better compared with those before operation, and the difference between before and after operation was statistically significant. Conclusions: The modified "outside-in" Broström-Gould procedure can effectively treat CLAI, which can obtain satisfactory results. The procedure is straightforward, the impact is minimal, and the aesthetics are pleasing.

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

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

Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability.

PURPOSE: Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique. METHODS: All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared. RESULTS: A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference. CONCLUSION: Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients. LEVEL OF EVIDENCE: Level III.

The calcaneofibular ligament groove at the inferior fibula, an ultrasonographic anatomical landmark.

PURPOSE: Calcaneofibular ligament (CFL) injuries are harder to diagnose than anterior talofibular ligament (ATFL) ones. This study aimed to clarify the fibular attachment of the CFL and verify the bony landmark for evaluating the CFL on ultrasonography. METHODS: Fifty-nine ankles were used in this anatomical study. To confirm the control function of the CFL, we performed passive movement manually using cadaveric ankles and observed the ankle positions where the CFLs were tense. Histological observation of CFL attachment of the fibula was performed using Masson's trichrome stain. The ATFL and CFL were removed, and the bone morphology of the CFL attachment and inferior fibular end was imaged using a stereomicroscope and a 3D scanner. Using ultrasonography, we evaluated the bone morphology of the fibular attachment of the CFL in short-axis images of 27 healthy adult ankles. RESULTS: The CFL was tensed according to ankle motions: supination, maximum dorsi flexion, maximum plantar flexion, and mild plantar flexion-external rotation. Below the CFL attachment of the fibula was a slight groove between the inferior tip and the obscure tubercle of the fibula. This groove was observed in 81.5% of cases using short-axis ultrasonography. CONCLUSION: The CFL was tensed in various ankle positions to control the movements of the talocrural and subtalar joints. There was a slight groove at the inferior end of the fibula where the CFL coursed downward. We called it the CFL groove and proposed that it could serve as a landmark for the short-axis image of ultrasonography.

[Comparison of the clinical efficacy of all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure for the treatment of chronic lateral rotational ankle instability].

Objective: To compare the clinical efficacy of patients with chronic lateral rotational ankle instability(CLRAI) after all-inside arthroscopic lateral ligament augmentation procedure and Broström procedure. Methods: This is a retrospective cohort study. The clinical and imaging data of 106 CLRAI patients were collected at the Xuzhou Central Hospital from January 2021 to December 2022. The patients included 55 males and 51 females with an age of (32.6±8.2) years (range: 16 to 50 years). All patients were treated under all-inside arthroscopic, and were divided into Broström-Gould surgery group (n=54) and Broström surgery group (n=52) according to different ligament repair methods. At 3, 6, and 12 months after surgery, ankle inversion stress tests and anterior drawer tests were used to examine the stability of the ankle joint and observe gait. The American Orthopedic Foot and Ankle Society ankle hindfoot scale (AOFAS-AH) and Karlsson ankle function score (KAFS) were used to assess ankle function; Tegner score was used to assess the patient's level of exercise; the foot and ankle outcome score(FAOS)(including score of symptoms,pain,function, daily living,function, sports and recreational activities (sport); quality of life (QOL) was used to assess the patient's daily activity ability. Comparisons of data were made using independent sample t test, repeated measures analysis of variance, LSD-t multiple comparison method, χ2 test or Mann-Whitney U test. Results: All operations were successfully accomplished. All incisions healed by first intention, without evidence of postoperative complications of implant rejection, ligation reaction, and nerve and vessel injury. All patients were followed up at 3, 6, and 12 months after surgery. Ankle varus stress test and anterior drawer test were negative. No evidence supporting lateral ankle instability was obtained. All patients eventually regained normal gait. No patients underwent revision surgery. Repeated measurement analysis of variance showed that AOFAS-AH, Tegner, KAFS and FAOS scores in the Brostrom-Gould group and the Brostrom group were significantly higher than those before surgery (P<0.01). The change trends of Tegner score and FAOS-sport score were significantly different between the two groups (F=18.839, P<0.01; F=8.169, P=0.005). Multiple comparisons revealed that at 3-, 6-and 12-month follow-up, the Tegner scores (3 months: 3.7±0.5 vs. 3.3±0.5, t=-3.980, P<0.01; 6 months: 4.4±0.6 vs. 3.8±0.7, t=-4.792,P<0.01; 12 months: 5.8±0.9 vs. 5.1±1.0, t=-3.889,P<0.01), sport scores (3 months: 82.5±3.7 vs. 79.3±3.8, LSD-t=-4.316, P<0.01; 6 months: 88.5±4.9 vs. 85.7±3.8, LSD-t=-3.312,P=0.001;12 months: 90.1±4.3 vs. 88.2±5.1, LSD-t=-2.112,P=0.037) in the Broström-Gould surgery group were higher than those in the Broström surgery group, with statistical significances. Conclusions: Both Broström-Gould and Broström procedures under all-inside arthroscopic can make ankle stability and improve ankle function in the treatment of CLRAI. However, the former maybe shorten the time to return to exercise and achieve higher motor function.

[Evaluation of arthroscopic anterior talofibular ligament and calcaneofibular ligament repair separately for chronic lateral ankle instability in conjunction with subtalar instability].

Objective: To investigate the clinical efficacy of simultaneous arthroscopic repair of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) for treating chronic lateral ankle instability (CLAI) in conjunction with subtalar instability (STI). Methods: This is a retrospective case series study. The clinical data of 15 patients with ankle arthroscopic in the Department of Hand and Foot Surgery, the Second Affiliated Hospital of Soochow University from January 2019 to December 2022 were analyzed retrospectively. There were 11 male cases and 4 female cases, aged (28.6±1.5) years (range: 19 to 39 years). All the patients were evaluated by manual inversion stress X-ray and MRI before operation. Arthroscopically observing and then repairing the ATFL and CFL separately after further diagnostic confirmation. One year after operation, MRI was performed, and pain visual analogue score(VAS), American Orthopedic Foot and Ankle Society ankle hindfoot scale (AOFAS-AH) and Karlsson ankle functional scale(KAFS) were evaluated. Data were compared using paired sample t test. Results: The follow-up period was (23.6±2.3) months (range: 12 to 30 months). At last follow-up,the VAS decreased from 6.1±1.4 preoperatively to 1.4±1.2(t=9.482, P<0.01).The AOFAS-AH improved from 50.5±11.7 preoperatively to 94.2±6.1(t=-13.132, P<0.01), and the KAFS improved from preoperatively 44.3±10.8 to 90.8±6.4 (t=-12.510, P<0.01). There was no complication such as recurred instability or joint stiffness. Conclusions: Arthroscopically repairing the ATFL and CFL separately can effectively restore the stability of the ankle and subtalar joint with small trauma. Patients can recover quickly after surgery. It provides a new idea for the clinical treatment of CLAI combined with STI.

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.

Anterior Talofibular Ligament Repair in Combination With Anterior Tibiofibular Ligament Distal Fascicle Transfer for The Treatment of Chronic Lateral Ankle Instability: A Finite Element Analysis.

In recent years, anterior tibiofibular ligament-distal fascicle transfers for anterior talofibular ligament augmentation repair have proposed. However, a comprehensive biomechanical study on the anterior tibiofibular ligament-distal fascicle transfer is still lacking. We are established four distinct groups, namely the normal, the anterior talofibular ligament rupture, the anterior talofibular ligament repair, and the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer. We assessed the anterior drawer test and varus stress test of the ankle in each group. Moreover, we employed the model to simulate and compute the total displacement and von-Mises stress of the talus cartilage at varying gait phases, including foot strike, tibia vertical, and toe-off phases. The results of the anterior drawer test and varus stress test revealed that the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group exhibited greater closeness to the normal group. Regarding von-Mises stress in cartilage, the three gait instants had higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Nevertheless, regarding total displacement, the toe-off phases exhibited higher values in the anterior talofibular ligament repair + anterior tibiofibular ligament-distal fascicle transfer group than the other groups. Using ATiFL-DF transfer to augment ATFL repair is a potential feasible procedure. However, this procedure could potentially compromise the anterior tibiofibular ligament's contribution to the dynamic stability of the ankle. Therefore, we recommend conducting further in-depth research to ensure the suitability and success of this technique in a clinical environment.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Description of the lateral fibulotalocalcaneal ligament in fetal specimens and its potential clinical implications.

PURPOSE: The increase in ankle sprains in children is a reflection of the greater inclusion of this population in sports. This places the calcaneofibular (CFL) and the anterior talofibular (ATFL) ligaments in focus for study. In adults, the presence of arcuate fibers extending between these two ligaments suggests the existence of a new anatomical and functional complex called the lateral fibulotalocalcaneal ligament of the ankle (LFTCL), which can be associated with the persistence of instability of the talocrural joint in ankle sprains. This study aimed to verify the presence of arciform fibers between the CFL and ATFL in human fetuses and to study the topography of the lateral ankle region. METHODS: Forty matched fetal ankles aged between 28 and 38 weeks, fixed in 4% formalin, were macroscopically, chemically and mesoscopically dissected and analyzed in stereoscope. RESULTS: The ATFL was characterized as a capsular ligament consisting of two fascicles (proximal and distal). The CFL was characterized as an extracapsular ligament. The LFTCL complex was verified in all specimens, characterized by the arcuate fibers between the ATFL and the CFL. CONCLUSION: Such results suggest that this functional unit is congenital and that it should be taken into consideration in the treatment of persistent ankle instabilities in the pediatric population.

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners.

BACKGROUND: This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements. METHODS: Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests. RESULTS: Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance. CONCLUSION: The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.