The evolution of patient-reported outcome measures after a first lateral ankle sprain: A prospective study.

PURPOSE: A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain. METHODS: A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test. RESULTS: All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value <.0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value <.01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24. CONCLUSION: The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies. LEVEL OF EVIDENCE: Level II (prospective cohort study).

Reconstruction of the interosseous talocalcaneal ligament using allograft for subtalar joint stabilization is effective.

PURPOSE: The aim of this study was to assess the biomechanical effects of subtalar ligament injury and reconstruction on stability of the subtalar joint in all three spatial planes. METHODS: Fifteen fresh frozen cadaveric legs were used, with transfixed tibiotalar joints to isolate motion to the subtalar joint. An arthrometer fixed to the lateral aspect of the calcaneus measured angular displacement in all three spatial planes on the inversion and eversion stress tests. Stress manoeuvres were tested with the intact joint, and then repeated after sequentially sectioning the inferior extensor retinaculum (IER), cervical ligament (CL), interosseous talocalcaneal ligament (ITCL), arthroscopic graft reconstruction of the ITCL, and sectioning of the calcaneo-fibular ligament (CFL). RESULTS: Sectioning the ITCL significantly increased angular displacement upon inversion and eversion in the coronal and sagittal planes. Reconstruction of the ITCL significantly improved angular stability against eversion in the axial and sagittal planes, and against inversion in the axial and coronal planes, at the zero time point after reconstruction. After sectioning the CFL, resistance to eversion decreased significantly in all three planes. CONCLUSION: Progressive injury of ligamentous stabilisers, particularly the ITCL, led to increasing angular displacement of the subtalar joint measured with the inversion and eversion stress tests, used in clinical practice. Reconstruction of the ITCL using tendon graft significantly stabilised the subtalar joint in the axial and sagittal planes against eversion and in the axial and coronal planes against inversion, immediately after surgery.

Reconstruction of the cervical ligament in patients with chronic subtalar instability.

PURPOSE: Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI. METHODS: This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score. RESULTS: After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ± 13.5 (median 37, range 10-55) to a mean postoperative Karlsson score was 89.6 ± 8.5 (median 90, range 72-100) (P < 0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3). CONCLUSION: Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability. LEVEL OF EVIDENCE: Level III.

The different subtalar ligaments show significant differences in their mechanical properties.

BACKGROUND: Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint. METHODS: Eighteen paired fresh-frozen cadaveric feet were used to obtain bone-ligament-bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-interosseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load. RESULTS: The stiffness of ACaL-ITCL complex (mean: 150 ± 51 N/mm, 95% confidence interval (CI): 125.0-176.6 N/mm) was significantly higher than both CFL (mean: 55.8 ± 23.0 N/mm, CI: 43.8-67.7 N/mm) and CL (mean: 63.9 ± 38.0 N/mm, CI: 44.4-83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 ± 158 N, CI: 304.1-460.8 N) and the CFL (mean:320.4 ± 122.0 N, CI: 257.5-383.2 N) were significantly higher than that of the CL (mean:163.5 ± 58.0 N, CI: 131.3-195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens. CONCLUSION: The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.

The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis.

BACKGROUND: A lateral ankle sprain (LAS) is the most common musculoskeletal injury in the physically active population. It is uncertain what percentage of these patients develop persisting symptoms including pain, recurrent sprains and subjective instability. This systematic review was conducted to assess the presence and duration of persistent symptoms after a first LAS. METHODS: A systematic review of the Medline, Web of Sciences, Embase, CINAHL and Pedro databases was performed to identify peer-reviewed articles concerning the occurrence and duration of remaining symptoms after a first LAS. Inclusion criteria focused on selection of patients without previous ankle injuries and study quality. One of the following outcomes had to be described: subjective instability, resprains, remaining symptoms. RESULTS: In total, 15 studies were included. The occurrence of patients with subjective instability decreased from 37.9% (95%CI [6.0-69.7]) at 3 months to 16.1% (95%CI [7.8-24.3]) at 6 months and 8.1% (95%CI [3.3-13.3]) at 12 months. The occurrence of patients with a recurrent LAS was 15.8% (95%CI [6.3-25.3]) at 12 months. The occurrence of patients with residual pain decreased from 48.6% (95%CI [23.6-73.5]) at 3 months, to 21.5% (95%CI [2.8-40.2]) at 6 months and 6.7% (95%CI [3.2-10.1]) at 12 months. CONCLUSION: This study offers new insights in the presence of remaining symptoms after a first LAS and the development of chronic ankle instability. Twelve months following an initial LAS, a significant number of patients may still have symptoms. The incidence of subjective instability, and pain, continues to decrease until 12 months post-injury. This new information may suggest that a longer period of non-operative treatment may be warranted before recommending surgical intervention in patients with a first LAS.

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

PURPOSE: Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. METHODS: The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. RESULTS: For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. CONCLUSION: Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

The intrinsic subtalar ligaments have a consistent presence, location and morphology.

BACKGROUND: Chronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing the anatomy of the intrinsic subtalar ligaments is limited and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion. METHODS: In 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. RESULTS: The cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9 ± 1.5 mm, posterior length 18.5 ± 2.9 mm, talar width 13.6 ± 2.2 mm, calcaneal width 15.8 ± 3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations. CONCLUSION: This study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

Does subtalar instability really exist? A systematic review.

BACKGROUND: Subtalar joint instability (STI) is considered as a potential source of chronic lateral hindfoot instability. However, clinical diagnosis of STI is still challenging. This systematic review was conducted to assess the consistency of the clinical entity "subtalar instability", to investigate the reliability of available diagnostic tools and to provide a critical overview of related studies. METHODS: A systematic review of the Medline, Web of Sciences and EMBASE databases was performed for studies reporting on tests to investigate subtalar instability or lesions of the subtalar ligaments. To investigate the relation with chronic STI, studies focusing on sinus tarsi syndrome (STS) or acute lesions of the subtalar ligaments were also included in the search strategy and were assessed separately. RESULTS: This review identified 25 studies focusing on different topics: chronic STI (16), acute lesions of the subtalar ligaments (5) and STS (4). Twelve studies, assessing STI, demonstrated the existence of a subgroup with instability complaints related to abnormal increased subtalar motion (7) or abnormalities of the subtalar ligaments (6). We found insufficient evidence for measuring subtalar tilting using stress radiographs. MRI was able to assess abnormalities of the ligaments and stress-MRI detected abnormally increased motion. CONCLUSION: Complaints of instability can be related to subtalar ligaments injuries and an abnormally increased motion of the subtalar joint. Stress radiographs should be interpreted with caution and should not have the status of a reference test. Clinical diagnosis should rely on several parameters including MRI.

Currently used imaging options cannot accurately predict subtalar joint instability.

PURPOSE: To give a systematic overview of current diagnostic imaging options and surgical treatment for chronic subtalar joint instability. METHODS: A systematic literature search across the following sources was performed: PubMed, ScienceDirect, and SpringerLink. Twenty-three imaging studies and 19 outcome studies were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the methodologic quality of the imaging articles, while the modified Coleman Score was used to assess the methodologic quality of the outcome studies. RESULTS: Conventional radiographs were most frequently used to assess chronic subtalar joint instability. Talar tilt, anterior talar translation, and subtalar tilt were the three most commonly used measurement methods. Surgery often included calcaneofibular ligament reconstruction. CONCLUSION: Current imaging options do not reliably predict subtalar joint instability. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. Recognition of subtalar joint instability as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation. LEVEL OF EVIDENCE: Systematic Review of Level III and Level IV Studies, Level IV.

The Evolution of Sinus Tarsi Syndrome-What Is the Underlying Pathology?-A Critical Review.

Background and Objectives: Sinus tarsi syndrome (STS) is defined as pain located at the lateral opening of the tarsal sinus. The exact etiology of sinus tarsi syndrome is not completely understood. Some do not believe it to be a true pathology. This review aims to clarify the definition of sinus tarsi syndrome to better understand the underlying pathologies. We further propose an algorithm to evaluate sinus tarsi pain and provide advice for consecutive treatment options. Design: This is a narrative review. By searching PubMed, the available current literature was reviewed. Articles were critically analyzed to determine the pathoanatomy, biomechanics, and etiology of sinus tarsi pain. Algorithms for clinical evaluation, diagnosis, and treatment were also recorded. Finally, the authors approach to evaluating and treating sinus tarsi pain was included in this review. Results: Reviewing the available literature, STS seems to be a catch-all phrase used to describe any pain in this anatomic region. Many causes of sinus tarsi pain were listed, including impingement, subtalar instability, and many other pathologies around the ankle. Conclusions: A thorough evaluation of patients presenting with pain in the sinus tarsi or instability of the hindfoot is essential to determining the underlying cause. When the cause of pain is still not clear after clinical exam and radiologic assessment, subtalar arthroscopy can be helpful as both a diagnostic and treatment tool. We propose that the term of STS should be avoided and that a more accurate diagnosis be used when possible. Once a diagnosis is made, appropriate treatment can be initiated.