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?

To evaluate the value of analyzing the anterior talofibular ligament (ATFL) on preoperative MRI as a decision-making tool to determine the surgical technique in patients undergoing surgery for chronic lateral ankle instability.
 A retrospective study of prospective data was performed. All patients who underwent surgery between 2013 and 2016 for arthroscopic stabilization of the ankle were included. The ATFL was evaluated on preoperative MRI including axial T2-weighted images by two readers who were blinded to arthroscopic results. The arthroscopic evaluation, which was considered to be the reference examination, was performed by one senior surgeon. The main judgment criteria were two features of the ATFL: (1) absent or thin (  3.2 mm in diameter) with or without a high intensity intraligamentous signal. Inter- and intraobserver reproducibility was evaluated by the kappa coefficient (k), and parameters of the diagnostic accuracy of preoperative MRI were analyzed.
 Twenty-two patients were included, 15 men/7 women mean age 30.3 ± 9.5 years. Fourteen patients (63.6%) underwent arthroscopic repair of the ATFL (Brostrom–Gould technique) and 8 patients (36.4%) an arthroscopic anatomical reconstruction of the ATFL. Intraobserver reproducibility of MRI findings was substantial (k = 0.68) and interobserver reproducibility moderate (k = 0.55) to nearly perfect (k = 0.87). Agreement between MRI and arthroscopic findings was substantial (k = 0.70). Diagnostic parameters of preoperative MRI were good for both observers: Se = 85.7–87.5%, Sp = 86.7–92.9%, PPV = 75–87.5%, NPV = 92.9%, and classification of patients was good = 86.4–90.9%. Preoperative MRI of the ATFL is a reliable and valid decisional tool to choose the surgical technique for stabilization of chronic lateral ankle instability. Level II; Diagnostic study—development of diagnostic criteria on the basis of consecutive patients.

Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability.

Peroneal tendon pathology: Pre- and post-operative high resolution US and MR imaging.

Usefulness of the oblique coronal plane in ankle MRI of the calcaneofibular ligament

3D isotropic T2-weighted fast spin echo (VISTA) versus 2D T2-weighted fast spin echo in evaluation of the calcaneofibular ligament in the oblique coronal plane.

Background:Knowledge of the normal MRI appearances of the ankle ligaments and tendons is particularly important in the diagnosis of ankle sprains. In most clinical practices, the ankle is imaged in...

Naofumi Matsunga

Papers

Kinematic MRI of the Normal Ankle Ligaments Using a Specially Designed Passive Device