The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis

Introduction. Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review is to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature. Methods. Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947-1/28/2020). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 3 weeks of surgery). Functional outcome scores (AOFAS, Karlsson scores), radiographic measurements (anterior drawer, talar tilt) and complications evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models. Results. After our search, we found 12 out of 1,574 studies that met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group; 28.0 (5.5) vs. 26.3 (0.0) respectively, p < 0.001; although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high. Conclusions. While there were some conflicting results, findings suggest that EM post-operative protocols for patients undergoing lateral ankle ligament reconstruction may not compromise functional outcomes or post-operative stability. Because heterogeneity was high, future studies are still needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.

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Biomechanics of Ankle Ligament Reconstruction: A Cadaveric Study to Compare Stability of Reconstruction Techniques Using 1 or 2 Fibular Tunnels

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120959284 ◽

2020 ◽

Vol 8 (10) ◽

pp. 232596712095928

Author(s):

Martina Gautschi ◽

Elias Bachmann ◽

Camila Shirota ◽

Tobias Götschi ◽

Niklas Renner ◽

...

Keyword(s):

Ligament Reconstruction ◽

Ankle Instability ◽

Intraoperative Complications ◽

Lateral Ankle ◽

Ankle Stability ◽

Ankle Ligament ◽

Significant Difference ◽

Tunnel Technique ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction

Background: Anatomic lateral ankle ligament reconstruction has been proposed for patients with chronic ankle instability. A reliable approach is a reconstruction technique using an allograft and 2 fibular tunnels. A recently introduced approach that entails 1–fibular tunnel reconstruction might reduce the risk of intraoperative complications and ultimately improve patient outcome. Hypothesis: We hypothesized that both reconstruction techniques show similar ankle stability (joint laxity and stiffness) and are similar to the intact joint condition. Study Design: Controlled laboratory study. Methods: A total of 10 Thiel-conserved cadaveric ankles were divided into 2 groups and tested in 3 stages—intact, transected, and reconstructed lateral ankle ligaments—using either the 1– or the 2–fibular tunnel technique. To quantify stability in each stage, anterior drawer and talar tilt tests were performed in 0°, 10°, and 20° of plantarflexion (anterior drawer test) or dorsiflexion (talar tilt test). Bone displacements were measured using motion capture, from which laxity and stiffness were calculated together with applied forces. Finally, reconstructed ligaments were tested to failure in neutral position with a maximal applicable torque in inversion. A mixed linear model was used to describe and compare the outcomes. Results: When ankle stability of intact and reconstructed ligaments was compared, no significant difference was found between reconstruction techniques for any flexion angle. Also, no significant difference was found when the maximal applicable torque of the 1-tunnel technique (9.1 ± 4.4 N·m) was compared with the 2-tunnel technique (8.9 ± 4.8 N·m). Conclusion: Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach. Clinical Relevance: Demonstrating similar stability in a cadaveric study and given the potential to reduce intraoperative complications, the 1–fibular tunnel approach should be considered a viable option for the surgical therapy of chronic ankle instability. Clinical randomized prospective trials are needed to determine the clinical outcome of the 1-tunnel approach.

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Magnetic Resonance Imaging Findings of the Lateral Ankle Instability after Anatomical Ligament Reconstruction Using a Semitendinosus Allograft Tendon with Biotenodesis Screws

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00274 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0027

Author(s):

Hong-Geun Jung ◽

Hwa-Jun Kang ◽

Mao-Yuan Sun ◽

Juan Agustin Coruna

Keyword(s):

Ligament Reconstruction ◽

Ankle Instability ◽

High Signal ◽

Mri Findings ◽

Lateral Ankle ◽

Postoperative Mri ◽

Ankle Ligament ◽

Lateral Ankle Instability ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction

Category: Ankle Introduction/Purpose: Surgery for lateral ankle instability is indicated in patients who have repetitive inversion ankle sprains despite conservative therapy. There have been many reconstruction procedures performed for the lateral ankle ligament instability. However, there has not been any report of postoperative MRI findings of lateral ankle instability after ligament reconstruction using a free tendon and biotenodesis screws. Therefore, this study was to analysis the MRI finding of the postoperative lateral ankle reconstruction using semitendinosus allograft tendon and the correlation with clinical outcome. Methods: The study is based on 34 ankles (33 patients) of chronic lateral ankle instability which underwent anatomical lateral ankle ligament reconstruction using a semitendinosus allograft tendon with bio-tendosis screws from July 2009 to April 2017 with at least 6 month postoperative ankle MRI checked (mean follow-up 16.5mo). In addition, clinical outcomes were evaluated using VAS pain score, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Karlsson-Peterson score, ankle stress views and subjective patient satisfaction. Results: Six ankles (17.6%) showed normal signal intensity(SI) while 28 ankles (82.4%) showed high SI on reconstructed allograft tendon area. High signal was shown around the biotenodesis screws. Eleven ankles showed synovitis (39.3%), partial tear of reconstructed allograft tendon 6 ankles (21.4), 5 osteolysis of the bone tunnel (17.9%), 4 screw pulled-outs (14.3%), 2 tendon complete tear (7.1%), 2 mucoid changes (7.1%), 2 cystic changes (7.1%). One ankle showed post-op MRI findings of reconstructed tendon infection (3.6%). The mean VAS pain score significantly decreased from 5.7 to 1.5. The mean AOFAS score improved from 72.0 to 89.1, while the Karlsson-Peterson score significantly improved from 54.7 to 85.7 (p<0.01) with 88% patient satisfaction. Stress talar tilt angle improved from 15.7o to 5.4 o. Conclusion: In the current study, various postoperative MRI findings were found after lateral ankle ligament reconstruction using allograft tendon and biotenodesis screws including high signal change of tendon, synovitis, tunnel osteolysis, screw pull-outs, tendon tears and etc. However, these MRI findings did not present as clinical complications and did not correlate with poor clinical outcomes.

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