Purpose. To evaluate the clinical results of arthroscopic repair and open Ahlgren Larsson method in patients with chronic lateral ankle instability. Methods. We retrospectively evaluated 87 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. 16 patients with osteochondral lesion, 5 patients with rheumatoid arthritis, 4 patients with ankle fractures of the same side, 2 patients with a history of active or previous malignancy were excluded. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS and VAS scores. Results. Sixty patients with chronic lateral ankle instability were evaluated. 28 patients, treated with Ahlgren-Larsson method and 32 patients, treated with arthroscopic repair. 36 of the patients were female and 24 were male; the mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, VKI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in pain and satisfaction of VAS in favor of arthroscopy group. Conclusions. Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer. METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series. DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination. CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability

Chronic lateral ankle instability (CLAI) is treated operatively, whereas acute ligament injury is usually treated nonoperatively. Such treatments have been widely validated. Apoptosis is known to cause ligament degeneration; however, few reports have focused on the possible role of apoptosis in degeneration of ruptured lateral ankle ligaments. The aim of our study is to elucidate the apoptosis that occurs within anterior talofibular ligament (ATFL) to further validate current CLAI treatments by adducing molecular and cellular evidence. Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Ruptured ATFL tissues were collected from 21 CLAI patients (group C) and 17 acute ankle fracture patients (group A). Apoptotic cells were counted using the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay. Western blotting for caspases 3, 7, 8, and 9 and cytochrome c, was performed to explore intrinsic and extrinsic apoptotic pathways. Immunohistochemistry was used to detect caspases 3, 7, 8, and 9 and cytochrome c, in ligament vessel endothelial cells. More apoptotic cells were observed in group C than group A in TUNEL assay. Western blotting revealed that the apoptotic activities of group C ligaments were significantly higher than those of group A (all p < 0.001). Immunohistochemistry revealed increased expression of caspases 3, 7, 8, and 9, and cytochrome c, in group C compared to group A. The ATFL apoptotic activities of CLAI patients were significantly higher than those of acute ankle fracture patients, as revealed biochemically and histologically. Our data further validate current CLAI treatments from a molecular and cellular perspective. Efforts should be made to reverse or prevent ATFL apoptosis in CLAI patients

Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of EUA & Arthroscopy in the management of these problems. Methods: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an examination under anaesthesia with stress views to determine instability proceeded by arthroscopic examination of the ankle. Results: Intra-articular bony lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14(32.5%). 23 patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Conclusion: Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

Introduction and Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all the structurally unstable joints require stabilisation. Method: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation program. All patients underwent an examination under anaesthesia with or without stress views to determine instability and this was preceded by arthroscopic examination of the ankle. Results: Intra-articular lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) were lost to follow-up and three (6.9%) needed further procedures. Conclusion: Arthroscopic assessment and treatment of intra-articular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

Aims Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of examination under anaesthesia (EUA) and arthroscopy in the management of these problems. Method We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an EUA with stress views to determine instability, proceeded by arthroscopic examination of the ankle. Results Intra-articular bony lesion was seen in 41.8% of cases. Fibrosis in the anterolateral gutter was found in 79.1%, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the anterior talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) needed supplementary procedures for other associated problems. Conclusion Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction

Introduction. This study was performed prospectively and randomly to compare clinical outcomes of modified-Brostrom procedure using single and double suture anchor for chronic lateral ankle instability. Material & Methods. Forty patients were followed up for more than 2 years after modified-Brostrom procedure for chronic lateral ankle instability. Twenty modified-Brostrom procedures with single suture anchor and 20 procedures with double suture anchor randomly assigned were performed by one surgeon. The mean age was 30.6 years, and the mean follow-up period was 2.6 years. The clinical evaluation was performed according to the Karlsson scale and Sefton grading system. The measurement of talar tilt angle and anterior talar translation was performed through anterior and varus stress radiographs. Results. At the last follow-up, the Karlsson scale had improved significantly from preoperative average 45.4 points to 90.5 points in single suture anchor group, from 46.2 points to 91.3 points in double suture anchor group. There were 8 excellent, 10 good, and 2 fair results according to the Sefton grading system in single anchor group, and 9 excellent, 8 good, 3 fair results in double anchor group. Therefore, 18 cases (90%) in single anchor group and 17 cases (85%) in double anchor group achieved satisfactory results. Talar tilt angle had improved significantly from preoperative average 15.7° to 6.1° in single anchor group, from 16.8° to 4.2° in double anchor group. There was significant difference in postoperative talar tilt angle between single and double anchor group. Conclusion. Significant differences in clinical and functional outcomes were not found between single and double suture anchor technique. On stress radiographs for evaluation of mechanical stability, modified-Brostrom procedure using double anchor showed less talar tilt angle than single anchor technique

In the Leiden University Medical Center (LUMC), the non-augmented direct repair method as described by Duquennoy for treatment of chronic lateral ankle instability, is used since the early eighties. To our knowledge, this procedure has not been described in English literature before. We performed a retrospective study, to assess the long-term outcome of non-augmented anatomical direct repair procedures, as originally described by Duquennoy. The procedure reassures ankle stability by retightening and reinsertion of the original talofibular and calcaneofibular ligament, without dissecting the ligamental tissue. The purpose of this study is to determine the long-term effects of the procedure in terms of postoperative quality of life, joint function and development of osteoarthritis. Twenty-three patients who were treated in our institution between 1985 and 2002 completed the Short Form-36 Health Survey (SF-36) for assessment of postoperative quality of life and the Olerud Molander Ankle Score (OMAS) for subjective symptom evaluation. Clinical reevaluation, including physical examination of the ankle and the completion of the Ankle Society ankle-hindfoot scale (AOFAS) questionnaire, was conducted for twenty-one patients after a mean follow-up of 13±7 (range 3–22.2 years) years. At final follow-up radiographs were taken to assess the development of osteoarthritis. The mean total postoperative SF-36 and OMAS scores were 79.6 (SD ±14.6) points and 81.7 points (N= 23 patients) respectively. The mean total postoperative AOFAS score was 89.7 points (N= 21 patients). We found a significant postoperative reduction in talar tilt and anterior drawer sign. According to the AOFAS, the long-term functional outcome of the procedure was excellent in 10 patients (48%), good in 7 patients (33%), fair in 4 patients (19%) and poor in none of the treated patients. The results in terms of ankle function and stability do not seem to deteriorate in time. The procedure is seldom causing restriction in range of motion, neither a higher chance of degenerative changes in the ankle joint on the long term. We conclude that the procedure as originally described by Duquennoy is simple and effective, with a very low complication rate and does not provoke restriction in range of motion of the ankle joint

The ‘gold standard’ for treatment of chronic ankle instability is Brostrom-Gould procedure, which is an ‘open’ surgery.

Most authors recommend this type of operation even after an arthroscopic inspection of the joint.

The arthroscopic methods, including thermal shrinkage, propose in the past didn’t received a widely spread support.

We present a method of arthroscopic lateral ligament ‘repair’ with an anchor placed in the fibula.

We used this technique on 31 consecutive patients (28 were available for follow-up).

21 patients were victims of work or traffic accidents and 3 had sport-related lesions.

The patients were evaluated after a 24,5 month follow-up.

The average post-op AOFAS score was 85,3 and average satisfaction was 3,77 (1 to 5)

We had two ‘relapses’ (another sprain without instability on the stress XR). On 3 patients we had some wound healing problems and we had 3 lesions of the superficial peroneal nerve, one of these is persistent. One patient developed a deep vein thrombosis post operatively.

With this method, we achieved good results with relatively few complications, even more considering that most of the patients were work-compensation cases. It’s a simple procedure, less ‘aggressive’ then the traditional one’s, producing an anatomical and functional repair of the lateral ligament.

We have treated 45 patients (47 ankles) for chronic lateral instability by a new reconstructive procedure. The operation includes lateral shift of the entire lateral capsule-ligament complex and proximal advancement of the talocalcaneal ligament and the inferior extensor retinaculum. We reviewed 39 patients (39 ankles) at a mean of 4.6 years (2 to 7) after operation. There were 29 men and 10 women with an average age of 27 years (19 to 43); 11 of them were competitive college-level athletes and 28 were recreational athletes. The functional rating was excellent in 26 patients, good in 8, fair in 3 and poor in 2. Thirty-six patients (92%) were satisfied with the result and 34 (9 of 11 college-level athletes and 25 of 28 recreational athletes) have been able to return to their preinjury level of sport. At the last review, there had been only three episodes of recurrent ankle instability, all in recreational athletes; none had required further surgery. The unsatisfactory results were associated with pre-existing degenerative changes in the ankle.

Background: Stress radiography and more recently magnetic resonance imaging have been used to study the integrity of lateral ankle ligaments in chronic symptomatic instability after injury.

Aim: Our aim was to see if magnetic resonance imaging was as good as examination under anaesthesia and stress radiography, for diagnosing injury to the lateral ankle ligaments.

Study Design: Cross-over study.

Methods: Fifty eight patients, 47 men and 11 women, were included in the study. These were athletes or military personnel with symptomatic instability of the ankle after injury. This cohort of patients had MRI scans, stress radiographs and arthroscopic treatment of their ankle. Integrity of the calcaneo-fibular ligament (CFL) was recorded arthroscopically. The sensitivity, specificity, positive and negative predictive value of MRI and stress views, in assessing integrity of the CFL, were compared against the arthroscopic findings which was considered to be the gold standard.

Results: Stress radiography under anaesthesia and MRI has sensitivities of 94% and 47% and specificities of 98% and 83% for diagnosing injury to the CFL, respectively. Stress radiography has a higher accuracy in diagnosing CFL injuries as compared to MRI.

Conclusion: The results of this study casts doubt on the efficacy of MRI in the diagnosis of serious ankle ligament injuries.

The December 2024 Foot & Ankle Roundup. 360. looks at: Tibiotalar sector and lateral ankle instability; Isolated subtalar fusion and correction of progressive collapsing foot deformity; Diabetic control and postoperative complications following ankle fracture fixation; Are insoles of any benefit for plantar fasciitis?; Postoperative foot shape and patient-reported outcome following surgery for progressing collapsing foot deformity; Calcaneo-stop procedure for symptomatic flexible flatfoot in children

Aim

The aim of this study was to compare the diagnostic accuracy of the Magnetic Resonance Imaging with that of Stress views of the ankle in testing the integrity of the lateral ankle ligaments. Arthroscopic diagnosis was used as the gold standard.

Background. Lateral ankle instability is a common problem, but the precise role of the lateral ankle structures has not been accurately investigated. This study aimed to accurately investigate lateral ankle complex stability for the first time using a novel robotic testing platform. Method. A six degrees of freedom robot manipulator and a universal force/torque sensor were used to test 10 foot and ankle specimens. The system automatically defined the path of unloaded plantar/dorsi flexion. At four flexion angles: 20° dorsiflexion, neutral flexion, 20° and 40° of plantarflexion; anterior-posterior (90N), internal-external (5Nm) and inversion-eversion (8Nm) laxity were tested. The motion of the intact ankle was recorded first and then replayed following transection of the lateral retinaculum, Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL). The decrease in force/torque reflected the contribution of the structure to restraining laxity. Data were analysed using repeated measures of variance and paired t-tests. Results. The ATFL was the primary restraint to anterior drawer (P< 0.01) and the CFL the primary restraint to inversion throughout range (P< 0.04), but with increased plantarflexion the ATFL's contribution increased. The ATFL had a significant role in resisting tibial external rotation, particularly at higher levels of plantarflexion, contributing 63% at 40° (P< 0.01). The CFL provided the greatest resistance to external tibial rotation, 22% at 40° plantarflexion (P< 0.01). The extensor retinaculum and skin did not offer significant restraint in any direction tested. Conclusion. This study shows accurately for the first time the significant role the ATFL and CFL have in rotational ankle stability. This significant loss in rotational stability may have implications in the aetiology of osteophyte formation and early degenerative changes in patients with chronic ankle instability. This is the first time the role of the lateral ankle complex has been quantified using a robotic testing platform

Limited information is published regarding the activity level after gracilis autograft reconstruction, and usually a knee-injury based score is used rather than a specific ankle PROM. The purpose of this study was to investigate the activity level and functional results after lateral ankle gracilis autograft reconstruction in patients with severe lateral ankle instability. The hypothesis was that patients would regain their pre-injury Tegner activity level or one level below and secondary to compare a specific ankle activity score, instability and function score. Finally, donor site and graft complications, clinical stability and range of motion were measured. All 69 patients (50 women, 19 men) recorded at the hospital with severe instability who underwent reconstruction of the anterior talofibular and the calcaneofibular ligament with a gracilis autograft and were minimum 6 months post-operative, were invited to participate in the study. Outcomes measures included the Tegner Activity level (1–10), Ankle Activity Score (0–10) recorded as pre-injury and at follow up. The Karlsson Petterson Ankle Function Score (0–100) and Visual Analog Score (VAS)(0–10) recorded pre-operatively and at follow up. All pre-injury and pre-operative data were recalled retrospectively from memory. Identification of functional ankle instability (IDFAI)(0–37) was recorded at follow up. The clinical tests, Anterior drawer test (0–4), Talar tilt test (0–4) and Range of motion (ROM)(degrees) were compared to the unaffected side at follow up. A difference of 1 in the activity scores was chosen as a clinical relevant difference. Data was tested for normal distribution and for statistical significant difference with a students t-test. study design: Cross sectional clinical study with a retrospective questionnaire. A total of 33 patients (27 women, 6 men), with a mean age on 45 years (range 19–68), were included in this study. Mean follow up was 3.7 years. Mean pre-operative Tegner score was 5.8 vs 5.6 at follow up (p. On average, the patients returned to their pre-injury activity level, with similar specific ankle activity scores to the Tegner. The majority had good functional results and few residual symptoms of functional instability. The response rate was low with few men responding; hence a prospective study is called for to establish the true effect of the surgical technique

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

Aims

This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur.

Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity, gastrocnemius-soleus dysfunction, age, gender, body weight and height, pes cavus, and lateral ankle instability are considered common intrinsic factors. The essence of Achilles tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and disruption of collagen fibres, and subsequent increase in non-collagenous matrix. Tendinopathic tendons have an increased rate of matrix remodelling, leading to a mechanically less stable tendon which is more susceptible to damage. The diagnosis of Achilles tendinopathy is mainly based on a careful history and detailed clinical examination. The latter remains the best diagnostic tool. Over the past few years, various new therapeutic options have been proposed for the management of Achilles tendinopathy. Despite the morbidity associated with Achilles tendinopathy, many of the therapeutic options described and in common use are far from scientifically based. New minimally invasive techniques of stripping of neovessels from the Kager's triangle of the tendo Achillis have been described, and seem to allow faster recovery and accelerated return to sports, rather than open surgery. A genetic component has been implicated in tendinopathies of the Achilles tendon, but these studies are still at their infancy

We describe the surgical treatment of 13 cases of chronic lateral ankle instability and concomitant anterior tibiotalor bony impingement of the ankle in servicemen, professional and recreational athletes. All patients had symptoms and signs of lateral instability and a painful block to dorsiflexion. Two patients presented with recurrence of impingement after a previous debridement alone without an ankle stabilisation. The anterior osteophytes were debrided arthroscopically and a Brostrom-Gould open stabilisation performed. After a mean follow up period of 12 months (range 4–23 months), all 13 patients had mechanically and functionally stable ankles. The mean improvement in range of dorsiflexion was 9 degrees and all but 1 had improvement with respect to a subjective and functional outcome assessment. There have been no recurrences of impingement to date. Our results suggest that ankle stabilisation performed in conjunction with debridement of osteophytes may reduce the recurrence of exostoses as well as improving the outcome

We reviewed 32 ankles in 30 patients at an average of five years after a Watson-Jones tenodesis. All but one patient had had ankle pain before operation and 19 had had clicking, catching, or locking of the ankle. Eleven of these had an ankle arthrotomy at the time of ligament reconstruction for intraarticular pathology. At review seven of 23 ankles had a significant decrease in ankle motion, and five in subtalar motion, but only two were unstable on examination. Twenty-one ankles, however, caused some pain on activity and nine were tender on palpation. These findings indicate intra-articular degeneration or injury rather than simple instability. Radiographs of 16 ankles showed good varus and anterior-drawer stability. Seven had talocrural osteoarthritis, but only four showed grade-1 subtalar osteoarthritis. We found no correlation between follow-up time and long-term results. The Watson-Jones tenodesis provides good rotational and lateral ankle instability and does not appear to lead to subtalar degeneration