Background: Lateral ankle sprains account for 85% of ankle lesions.Hypothesis: Combined open and arthroscopic procedures could improve the diagnosis and management of intra-articular lesions and allow surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex.Study Design: Case series; Level of evidence, 4.Methods: Forty consecutive patients underwent ankle arthroscopy for recurrent (2 or more episodes) lateral ankle instability unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was confirmed at imaging (plain radiographs and magnetic resonance imaging [MRI]) and arthroscopic assessment. All patients underwent arthroscopic Brostrom-Gould repair for management of lateral ankle instability; secondary lesions were also managed. Postoperatively, the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to assess the functional status; clinical examination and conventional radiographs were performed in all patients.Resu...

Arthroscopic-Assisted Broström-Gould for Chronic Ankle Instability: A Long-term Follow-up

Acute lateral ankle ligament injuries are common. If left untreated, they can result in chronic instability. Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. Chronic lateral ankle instability is multifactorial. Failed nonsurgical management after appropriate rehabilitation is an indication for surgery. Of the many surgical options available, anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated. Ankle arthroscopy is an important adjunct to ligamentous repair and should be performed at the time of repair to identify and address intra-articular conditions associated with chronic ankle instability. Tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.

/pdf/management-of-acute-and-chronic-ankle-instability-onqgye86z2.pdf

Management of Acute and Chronic Ankle Instability

Background:Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term.Hypothesis:This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity.Study Design:Case series; Level of evidence, 4.Methods:We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Brostrom repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of deg...

http://journals.sagepub.com/doi/pdf/10.1177/0363546512474967

Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up.

The purpose of this study was to evaluate the functional and radiographic outcomes of a novel surgical technique devised to treat chronic lateral ankle instability. The technique involves direct repair of the anterior talofibular ligament and anatomic reconstructions of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using a free semitendinosus tendon allograft and interference screws. This retrospective study involved a review of the records of 27 patients (28 ankles) with chronic lateral ankle instability treated from 2007 to 2009. VAS pain scores, AOFAS scores, Karlsson–Peterson ankle scores (24 ankles), and patient satisfaction were evaluated at median of 19 (12–26) months postoperatively. Radiographically, talar tilt angles and anterior talar translation were assessed in pre- and postoperative ankle stress views. Median patient age at surgery was 36.5 (16–57) years. Median VAS pain score decreased from 6 (3–9) to 2 (0–4) (P < 0.05), and median AOFAS score improved from 63 (41–84) to 91 (81–100) preoperatively to final follow-up (P < 0.05). Median Karlsson–Peterson score also significantly improved from 55 (32–77) to 80 (59–100) (P < 0.05), whereas talar tilt decreased from 17.8° (10.0°–25.5°) to 6.7° (0.3°–13.0°) and the mean anterior drawer test decreased from 10.0 mm (0.6–19.4) to 4.5 mm (0.2–8.7) (P < 0.05). Eighty-eight percent (21/24) were satisfied with surgery. No complication, such as subtalar stiffness or recurrent instability, was encountered. The described technique, which involves anatomic reconstruction of the ATFL and CFL using the semitendinosus tendon and interference screws with direct repair of the capsule, is a viable option for treating lateral ankle instability with stable tendon fixation and provides satisfactory clinical outcomes. Case-series, Level IV.

Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws

This paper purpose is to suggest an in-depth approach to diagnose the causes and lesions associated with and consecutive to chronic ankle instability due to ankle collateral ligament laxity. The different therapeutic and medicosurgical options adapted to this diagnostic approach are identified. The diagnostic aim is to precisely locate the ligamentous injuries of the tibiofibular, subtalar, talar and calcanean system, to identify the predisposing factors such as the hindfoot morphology, and any lesions associated with chronicity: anterolateral impingement, fibular injury, osteochondral lesions of the talus dome and early osteoarthritis. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and laxity (ligament testing). There are also radiological tests, weight-bearing plain X-ray (stress X-ray), (alignment of the hind foot, with a Meary view [metal wire circling the heel], arthrosis), dynamic images to confirm and quantify laxity (manually, with a Telos device, with patient-controlled varus) and also more sophisticated techniques (ultrasound, CT arthrogramm, gadolinium enhanced MRI, MR arthrogramm) to identify ligament, tendon and cartilage damages. They are adapted to the lesions which have been identified in the diagnostic work-up: conservative first, to treat proprioceptive deficits (a new neuromuscular reprogramming technique which emphasizes muscle preactivation) and any static disorders (plantar orthotics); then surgical, to repair any collateral ligament (or sometimes subtalar) injury with three types of procedures: tightening the capsuloligamentous structures, ligament reconstruction with reinforcement (using the fibrous periosteum, the frondiform ligament (of Retzius) or tendinous reconstruction with the plantaris muscle, the peroneus tertius or even the calcanean tendon) and tendon tansfer procedures using all or part of the peroneus brevis (whole peroneus brevis and half peroneus brevis procedures). Any additional surgical procedures which may be indicated based on the results of the diagnostic work-up are performed at the same time as primary surgery when possible as needed (medial complex repair, calcaneal realignment osteotomies, talus osteochondral injuries debridment or fixation, anterior and posterior impingement suppression, tendon tears repair). The goal of this diagnostic and therapeutic approach is to stop the progression of laxity and to protect the ankle against degenerative arthritis, which is the main risk in these chronic conditions.

Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?

The management of chronic lateral instability of the ankle remains controversial. In general, the anterior talofibular ligament (ATFL) must be reconstructed in all patients. Some will also need reconstruction of the calcaneofibular ligament (CFL) (or its function) to regain stability of both the ankle and the subtalar joints, and to avoid recurrence of instability. After reconstruction, most authors report good to excellent results in 80% to 85% of patients. We describe the augmented reconstruction technique of ATFL and CFL with a semitendinosus tendon allograft through a peroneal bone tunnel fixed with biodegradable anchors, and advocate this procedure as a safe, effective method to manage lateral ankle instability.

Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability.

More than 150 operations have been described for the management of hallux valgus. The multitude of techniques indicates that no single operation can be considered as “the standard,” and none will address all the components of the deformity in all patients. Poorly planned or executed surgery may lead to high levels of patient dissatisfaction. One of the most common complications following distal metatarsal osteotomies is recurrence of the deformity, a direct consequence of inappropriate selection of the patient, incorrect surgical technique, and underestimated healing time of the osteotomy. Recently, a number of new osteotomies have been described, and choosing the most appropriate can be difficult.

Fabio Treia

Papers

Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability.

Distal First Metatarsal Osteotomy