Fair evidence consistently supports open surgical treatment for chronic ankle instability: a systematic review

2019 ◽  
Vol 4 (5) ◽  
pp. 254-269
Author(s):  
Chad Alexander Purcell ◽  
James Calder ◽  
Kentaro Matsui ◽  
Pontus Andersson ◽  
Jón Karlsson ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Systematic Evaluation ◽  
Anatomical Reconstruction ◽  
Lateral Ligament ◽  
Anterior Talofibular Ligament ◽  
Reconstruction Technique ◽  
Operative Techniques ◽  
Level Of Evidence

ImportancePatients with chronic ankle instability (CAI) who have failed non-operative treatments are most commonly treated with open ankle repair or reconstruction of the anterior talofibular ligament and/or calcaneofibular ligament. Over 50 operative techniques have been described for the treatment of CAI. However, there is no current systematic evaluation of currently used open operative techniques for the treatment of CAI.Aim/ObjectiveThe primary objective of this study is to provide evidence-based treatment recommendations for CAI in adults based on a comprehensive systematic review of the literature.Evidence reviewThe literature review of PubMed, EMBASE, Cochrane and Web of Science databases was completed on 22 February 2017. Search terms included two concepts: lateral ligament of the ankle (patients) and open reconstructive or repair procedures (intervention). All published clinical studies with English translation were included. Biomechanical, cadaveric, review articles, minimally invasive procedures and arthroscopic procedures were excluded. Open operative procedures from included articles were classified as anatomical or non-anatomical and repair or reconstructive. Articles were then assigned a level of evidence (I-V) to denote quality of the research methods. Articles were reviewed collectively to provide a grade of recommendation (A-C or I) in support for or against the operative intervention in treatment of CAI.FindingsSeventy one of 1635 identified articles were included for review. There is fair evidence (Grade B) in support of anatomical repair, anatomical reconstruction and non-anatomical reconstruction procedures. There was insufficient evidence available to grade internal brace and non-anatomical repair procedures.Conclusions and relevanceAlthough only fair-quality evidence exists in support of open operative treatment of CAI, this systematic review helps reassure clinicians of their current practices. The literature reaffirms support for open anatomical repair and anatomical reconstruction technique for CAI.Level of evidenceLevel II, systematic review.

scholarly journals Clinical Outcomes of Anatomical Reconstruction of the Lateral Ankle Ligament Complex: A Systematic Review

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0036
Author(s):  
Conor Mulvin ◽  
James P. Toale ◽  
Kevin Rosas ◽  
Eoghan T. Hurley ◽  
John G. Kennedy
Keyword(s):  
Systematic Review ◽  
Complication Rate ◽  
Ankle Instability ◽  
Return To Sport ◽  
Chronic Ankle Instability ◽  
Anatomical Reconstruction ◽  
Cochrane Library ◽  
Lateral Ligament ◽  
Level Of Evidence ◽  
Vas Scores

Category: Ankle; Sports Introduction/Purpose: Anatomical reconstruction has gained increased attention in recent years and is indicated for patients with poor-quality ligaments, previously failed lateral ligament repair, generalized ligamentous laxity, or in patients with a high BMI. The purpose of this systematic review was to evaluate the current literature on anatomical reconstruction of the lateral ligaments in the treatment of chronic ankle instability. Methods: A systematic search of Pubmed, EMBASE and Cochrane Library databases was performed during October 2019. The studies included were carefully evaluated with regard to level of evidence (LOE) and quality of evidence (QOE), clinical and radiological outcomes, complications, revision rates and return to sport. Results: Thirteen studies including a total of 296 ankles were included; 92% of studies were LOE III or IV and the QOE in all studies was of poor or fair quality. Within the autograft group, the AOFAS improved from 66.9 to 95.9, KPSSAF scores improved from 48 to 92.2, VAS scores improved from 6.8 to 0.2 at a follow up of 33.5 months, and the complication rate was 7.7%. Within the allograft group the AOFAS improved from 53.7 to 89.3, KPSSAF scores improved from 42.8 to 90.4, VAS scores improved from 7.3 to 1.9, and the complication rate was 7%. The overall rate of return to sport was 89%. Conclusion: The current systematic review demonstrated favorable results for both autograft and allograft reconstruction techniques in the treatment of chronic ankle instability. On comparing autograft and allograft techniques, minor differences were found both clinically and radiologically, with no overall evidence supporting one technique over the other

Quantitative Analysis of Deltoid Ligament Degradation in Patients With Chronic Ankle Instability Using Computed Tomographic Images

2021 ◽  
pp. 107110072199707
Author(s):  
Yasunari Ikuta ◽  
Tomoyuki Nakasa ◽  
Junichi Sumii ◽  
Akinori Nekomoto ◽  
Nobuo Adachi
Keyword(s):  
Ankle Instability ◽  
Ct Images ◽  
Chronic Ankle Instability ◽  
Control Group ◽  
Deltoid Ligament ◽  
Anterior Talofibular Ligament ◽  
Mri Findings ◽  
Calcaneofibular Ligament ◽  
Level Of Evidence ◽  
Strong Negative Correlation

Background: Rotational ankle instability (RAI) is associated with the faster onset of severe ankle osteoarthritis via dysfunction of the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. No specific clinical examination is available for RAI, and diagnostic imaging has limitations in evaluating ligament degradation. This study investigated the deltoid ligament degeneration using Hounsfield unit (HU) values on computed tomography (CT) images. Methods: Patients were enrolled in this retrospective analysis if they had undergone magnetic resonance imaging (MRI) and CT scans of the ankle. The chronic ankle instability (CAI) group comprised 20 ankles with CAI (9 men, 11 women; mean age, 28.7 years) and the control group comprised 28 ankles (16 men, 12 women, mean age, 41.3 years). The average HU values of the deep posterior tibiotalar ligament (dPTL) that constitutes the deltoid ligament were measured on coronal CT images, and MRI results were used as a reference. All patients were subdivided based on the MRI findings of dPTL injury such as fascicular disruption, irregularity, and the loss of striation. Results: A strong negative correlation was identified between age and HU values for all patients (Spearman ρ = −0.63; P < .001). The mean HU values of the dPTL for participants aged <60 years were 81.0 HU for the control group (21 ankles) and 69.5 HU for the CAI group ( P = .0075). No significant differences in the HU values were observed for the dPTL among the MRI subgroups. Conclusion: In addition to the conventional imaging examination such as stress radiographs and MRI, HU measurements of CT images could be useful for quantitatively and noninvasively evaluating degenerative changes in the deltoid ligament for CAI patients to assist the diagnosis of RAI. Level of Evidence: Level III. case-control study.

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary

2021 ◽  
pp. 036354652110080
Author(s):  
Sung Hyun Lee ◽  
Hyung Gyu Cho ◽  
Je Heon Yang
Keyword(s):  
Clinical Outcomes ◽  
Ankle Instability ◽  
Surgical Techniques ◽  
Chronic Ankle Instability ◽  
Anterior Talofibular Ligament ◽  
Extensor Retinaculum ◽  
Level Of Evidence ◽  
Group A ◽  
The Mean ◽  
Inferior Extensor Retinaculum

Background: Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear. Purpose: To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI). Results: Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups ( P < .001). However, there were no significant differences in the clinical results and radiologic findings between the groups. Conclusion: The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes.

Arthroscopic Findings in Patients with Chronic Ankle Instability

2002 ◽  
Vol 30 (3) ◽  
pp. 402-409 ◽  
Author(s):  
Beat Hintermann ◽  
Andreas Boss ◽  
Dirk Schäfer
Keyword(s):  
Structural Changes ◽  
Ankle Instability ◽  
Cartilage Damage ◽  
Case Series ◽  
Chronic Ankle Instability ◽  
Ankle Arthroscopy ◽  
Lateral Ligament ◽  
Deltoid Ligament ◽  
Anterior Talofibular Ligament ◽  
Ligament Injuries

Background There are little objective data on structural changes of the chronically unstable ankle. Such knowledge could help with preoperative planning. Hypothesis Preoperative ankle arthroscopy provides important insights into the causes and mechanisms of ankle instability and the resulting disability. Study Design Case series. Methods From 1993 to 1999, arthroscopic examination was performed in the ankles of 148 patients with symptomatic chronic ankle instability that had lasted 6 months or more. All structural changes were recorded and compared with the clinical diagnosis. Results A rupture or elongation of the anterior talofibular ligament was noted in 86% of ankles, of the calcaneofibular ligament in 64%, and of the deltoid ligament in 40%. Cartilage damage was noted in 66% of ankles with lateral ligament injuries, whereas 98% of the ankles with deltoid ligament injuries had cartilage damage. Although lateral instability could be verified arthroscopically in 127 patients, medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically. Conclusion Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected. For instance, the ligaments showed typical abnormalities corresponding to different entities of ankle instability and different intra-articular pathologic conditions.

scholarly journals Sonographically Guided Anchor Placement in Anterior Talofibular Ligament Repair Is Anatomic and Accurate

2020 ◽  
Vol 8 (12) ◽  
pp. 232596712096732
Author(s):  
Soichi Hattori ◽  
Kentaro Onishi ◽  
Yuji Yano ◽  
Yuki Kato ◽  
Hiroshi Ohuchi ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Open Repair ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Arthroscopic Repair ◽  
Anterior Talofibular Ligament ◽  
Lower Margin ◽  
Level Of Evidence ◽  
The Mean ◽  
Noninferiority Margin

Background: Arthroscopic repair is a widely accepted surgical treatment for chronic ankle instability; however, recent studies have shown that arthroscopic repair is nonanatomic in its anchor placement and resultant biomechanics. Ultrasound may improve the accuracy of the anchor placement. Hypothesis: Our hypothesis was that the accuracy of anchor placement in sonographically guided anterior talofibular ligament (ATFL) repair will be comparable with that in open ATFL repair. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 26 patients who received surgical treatment between April 2012 and October 2019 for chronic ankle instability. Fifteen patients underwent open modified Broström repair and 11 underwent sonographically guided ATFL repair. The distance between the anchor hole and the fibular obscure tubercle was measured using 3-dimensional computed tomography and was compared between the operative procedures. For comparison, a noninferiority trial was employed, with open modified Broström repair as the reference surgery. The noninferiority margin was defined as 5 mm. Results: The mean ± SD distance between the anchor and fibular obscure tubercle was 6.0 ± 2.7 mm in open repair and 5.6 ± 3.3 mm in sonographically guided repair. The mean difference in distance between the techniques ( open repair – sonographically guided repair) was 0.37 mm (95% CI, –2.1 to 2.9 mm). The lower margin of the confidence interval was within the noninferiority margin (–5 to 5 mm). Conclusion: Anchor placement under sonographically guided ATFL repair was equivalent to that of open ATFL repair and can be considered anatomic and accurate.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review

2018 ◽  
Vol 24 (1) ◽  
pp. 11-18 ◽  
Author(s):  
Matteo Guelfi ◽  
Marco Zamperetti ◽  
Andrea Pantalone ◽  
Federico G. Usuelli ◽  
Vincenzo Salini ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Lateral Ligament ◽  
Ligament Repair

scholarly journals Localizer-Assisted Arthroscopic Anterior Talofibular Ligament and Calcaneus Fibula Ligament Reconstruction for the Treatment of Chronic Lateral Ankle Instability

2021 ◽  
Author(s):  
Liangjun Zhao ◽  
Fang Xu ◽  
Shan Lao ◽  
Jingmin Zhao ◽  
Qingjun Wei
Keyword(s):  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Anatomical Reconstruction ◽  
Tilt Test ◽  
Anterior Talofibular Ligament ◽  
Adjacent Area ◽  
Test Results ◽  
Arthroscopic Reconstruction ◽  
Lateral Ankle ◽  
Lateral Ankle Instability

Abstract Background Anatomic reconstruction has become one of the standard techniques used for the treatment of chronic ankle instability. Although arthroscopic treatment of chronic ankle instability has made remarkable progress in recent years, no comprehensive description of arthroscopic reconstruction of the ankle ligament is available. The purpose of this study is to describe the surgical technique of localizer-assisted arthroscopic anatomical reconstruction of the anterior talofibular ligament and the calcaneus fibular ligament and to evaluate the clinical effect in patients. Method In total, 36 young adults with simple lateral ankle instability were treated with arthroscopic anatomical reconstruction of the anterior talofibular ligament and the calcaneus fibula ligament, including 20 males and 16 females with an average age of 27 years (17-35 years). All patients had more than three ankle sprains in the past two years. Physical examination revealed positive anterior drawer test results of the ankle and/or talus tilt test results. The operation was performed in two steps. First, we found the adjacent area center of the peroneal lateral stop of the talofibular ligament and the calcaneus fibular ligament on the surface of distal fibula, and the skin mark was made. The localizer guided the surgeon to the location, and then the fibula bone canal was created. Next, the residual end of the talofibular side stop of the anterior fibula ligament was located under the arthroscope, and the talofibular end bone canal was made after the localizer was accurately positioned. Then, the calcaneus lateral stop of calcaneus fibula ligament was located on the calcaneus body surface, and the skin mark was made. Furthermore, the calcaneus end bone canal was generated under guidance of the localizer. Finally, anatomical reconstruction of the anterior talofibular ligament and/or calcaneus fibula ligament was completed in a step-by-step manner. The clinical characteristics, preoperative and postoperative the American Orthopaedic Foot and Ankle Society (AOFAS) and Karlsson scores were recorded. Results The AOFAS score increased from 60 (45-70) to 92 (80-98), and the Karlsson score increased from 62 (40-72) to 95 (75-96) after the operation. During the follow-up period, no patients experienced postoperative complications, such as infection at the incision, nerve injury, skin necrosis and ankle stiffness. No cases of recurrence of ankle instability were found. Conclusion Arthroscopic reconstruction of the talofibular and calcaneus fibular ligaments can achieve satisfactory clinical results in the treatment of chronic ankle instability with lower recurrence rates and reduced complications compared with open surgery. Meanwhile, localizer-assisted reconstruction is a reliable and simple operation technology with high clinical success rates. In addition, increased understanding of anatomic markers is very important to avoid operation failure.

scholarly journals All-arthroscopic reconstruction of the anterior talofibular ligament is comparable to open reconstruction: a systematic review

2022 ◽  
Vol 7 (1) ◽  
pp. 3-12
Author(s):  
Ulrike Wittig ◽  
Gloria Hohenberger ◽  
Martin Ornig ◽  
Reinhard Schuh ◽  
Andreas Leithner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Outcomes ◽  
Ankle Instability ◽  
Search Algorithm ◽  
Case Reports ◽  
Anterior Talofibular Ligament ◽  
List Type ◽  
Complication Rates ◽  
Level Of Evidence ◽  
Return To Activity

The aim of this study was to determine whether all-arthroscopic repair would lead to improved clinical outcomes, lower complication rates, shorter postoperative immobilization and earlier return to activity compared to open Broström repair in the surgical treatment of chronic lateral ankle instability (CLAI). A systematic literature search was conducted using Pubmed and Embase to identify studies dealing with a comparison of outcomes between all-arthroscopic and open Broström repair for CLAI. The search algorithm was ‘ankle instability’ AND ‘Brostrom’ AND ‘arthroscopic’ AND ‘open’. The study had to be written in English language, include a direct comparison of all-arthroscopic and open Broström repair to treat CLAI and have full text available. Exclusion criteria were former systematic reviews, biomechanical studies and case reports. Overall, eight studies met the inclusion criteria and were included in the analysis. Clinical outcomes did not differ substantially between patients treated with either arthroscopic or open Broström repair. Studies that reported on return to activity and sports following surgery suggested that patients that had all-arthroscopic Broström repair returned at a quicker rate. Overall complication rate tended to be lower after arthroscopic Broström repair. Similar to open repair, all-arthroscopic ligament repair for CLAI is a safe treatment option that yields excellent clinical outcomes. Level of Evidence: Level III evidence (systematic review of level I, II and III studies).

scholarly journals Peroneus brevis tendon injury in chronic ankle instability.

2021 ◽  
Vol 15 (1) ◽  
pp. 37-42
Author(s):  
Rhavi Soares Daniel ◽  
Joaquim Maluf Neto ◽  
Auro Mitsuo Okamoto ◽  
Carlos Andrade
Keyword(s):  
Ankle Instability ◽  
Epidemiological Data ◽  
Tendon Injury ◽  
Chronic Ankle Instability ◽  
Ligament Injury ◽  
Lateral Ligament ◽  
Aofas Score ◽  
Level Of Evidence ◽  
Lateral Ligament Injury ◽  
Peroneus Brevis

Objective: To compare the surgical outcome of patients with chronic lateral ligament injury of the ankle, with and without an associated peroneus brevis tendon injury. Methods: This retrospective comparative study was based on epidemiological analysis and the American Orthopedic Foot and Ankle Society (AOFAS) scores of patients diagnosed with chronic ankle instability who were treated surgically with the Broström-Gould technique. The medical records of 50 patients treated in an orthopedics service between January 2012 and January 2020 were analyzed. The patients were divided into two groups: those with and without a peroneus brevis tendon injury. The following data were also collected: sex, age, comorbidities, and AOFAS score in the pre- and postoperative period (between 90-120 days), as well as other epidemiological data. Results: Sixteen patients (32%), whose mean age was 43 years and 76% of whom were female, presented with a peroneus brevis tendon injury. The right side (54%) was more commonly affected. The main comorbidities were obesity (14%), slight pes cavus (12%), diabetes mellitus (4%) and depression (4%). The mean improvement in AOFAS score was 41 points. There was a marginal difference in final AOFAS score (p=0.03) between the groups. Conclusion: The Broström-Gould Technique proved effective for treating chronic lateral ligament injury regardless of an associated peroneus brevis tendon injury. However, the final postoperative results were significantly worse in patients with a peroneus brevis tendon injury than in those without one. Level of Evidence III; Therapeutic Studies; Comparative Retrospective Study.

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