Lateral Ligament Reconstruction With Hamstring Graft for Ankle Instability: Outcomes for Primary and Revision Cases

Background: Optimal treatment for patients with severe ankle instability or failed previous ankle stabilization is not well defined, and newer techniques have limited presence in the literature. Purpose/Hypothesis: The purpose of this study was to evaluate clinical and radiographic outcomes after modified anatomic lateral ligament reconstruction using hamstring auto- or allograft in primary cases versus revision cases. We hypothesized that patients undergoing a revision procedure would demonstrate inferior patient-reported and radiographic outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent modified anatomic lateral ligament reconstruction by a single surgeon between 2010 and 2017 were identified. Indications included failure of previous ankle stabilization or severe ankle laxity. Patients completed preoperative and minimum 1-year postoperative Foot and Ankle Outcome Score (FAOS) surveys. They also underwent pre- and postoperative stress radiographs using the Telos Stress Device. Results: A total of 41 patients (42 ankles) were identified. The mean age was 32.1 years, and 36 patients (88%) were women. There were 25 primary procedures and 17 revision procedures. Hamstring autograft was utilized in 35 ankles and hamstring allograft in 7 ankles. A total of 34 patients (83%) provided postoperative patient-reported outcome scores at a mean of 26 months (range, 12-65 months). When comparing primary versus revision procedures, revision patients had significantly lower FAOS Pain (77.14 vs 90.66; P = .009), Sports (63.46 vs 82.16; P = .008), and Quality of Life (53.53 vs 76.70; P = .002) scores. In total, 34 patients (83%) had stress radiographs at a mean of 14 months (range, 3-62 months) postoperatively. Revision patients also had lower, though statistically insignificant, postoperative talar tilt measurements on average (5.73° vs 7.10°; P = .252), and pre- to postoperative change in talar tilt was not significantly different between groups (−4.94° vs −7.03°; P = .415). Conclusion: Revision procedures had significantly lower postoperative patient-reported outcome scores and lower talar tilt compared with patients undergoing a primary procedure, although the pre- to postoperative change in the talar tilt was not significantly different between groups.

Consistency and Reliability of Ankle Stress Radiography in Patients With Chronic Lateral Ankle Instability

Background: Ankle stress radiographs are important tools for evaluating chronic lateral ankle instability. The consistency of a patient’s ankle condition as it affects the reliability of ankle stress radiographs has never been evaluated. Purpose: To investigate the consistency and reliability of ankle stress radiographs in patients with chronic lateral ankle instability without an ankle injury during the study period. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Included were patients with chronic lateral ankle instability who underwent 2 repeated ankle stress radiographs between January 2014 and July 2019; those with an ankle injury during the study period were excluded. The tibiotalar tilt angle on varus stress radiographs and anterior translation of the talus on anterior drawer stress radiographs were measured at initial presentation and final follow-up examination. Interobserver reliability and consistency of ankle stress radiographs were analyzed using the intraclass correlation coefficient (ICC). Results: A total of 45 patients (mean ± standard deviation age, 36.4 ± 13.4 years; 18 men and 27 women; follow-up duration, 9.1 ± 3.2 months) were included. The mean ± standard deviation tibiotalar tilt angle and anterior talar translation at initial presentation were 10.8° ± 5.2° and 6.9 ± 2.7 mm, respectively. The interobserver reliabilities of the tibiotalar tilt angle and anterior talar translation were excellent (ICC = 0.926 [95% CI, 0.874-0.959] and 0.911 [95% CI, 0.766-0.961], respectively). The consistency between the initial and final radiographs was good for tibiotalar tilt angle (ICC = 0.763 [95% CI, 0.607-0.862]) and poor for anterior talar translation (ICC = 0.456 [95% CI, 0.187-0.660]). Conclusion: Although the interobserver reliability of the radiographic measurements was excellent, the consistency of the ankle stress radiographs was not as acceptable. Surgeons need to be cautious when deciding whether to operate on a patient with chronic lateral ankle instability based on a single ankle stress radiograph.

The Value of Additional Gravity Stress Radiographs for Decision Making in the Treatment of Isolated Type B Distal Fibular Fractures

Background: Prior to treatment decisions concerning isolated Weber type B ankle fractures, assessment of the stability of the ankle joint is mandatory. The gravity stress (GS) radiograph is a radiographic tool to determine stability. We hypothesized that this additional GS radiograph would lead to fewer operative treatments by applying the criterion of operative treatment when medial clear space (MCS) > superior clear space (SCS) + 2 mm on the GS radiograph, compared with the nonstressed mortise view criteria of advising operative treatment in case of MCS > SCS + 1 mm. Methods: This retrospective comparative cohort study analyzed 343 patients aged between 18 and 70 years with an isolated Weber type B ankle fracture diagnosed at the emergency department between January 2014 and December 2019. The cohort was divided into 2 groups based on whether an additional GS radiograph was performed. Group I consisted of 151 patients in whom a regular mortise and lateral radiograph were performed. Group II comprised 192 patients, with an additional GS radiograph. Primary outcome was type of treatment (conservative vs operative). Secondary outcomes were patient-reported functional outcomes and pain. Results: Baseline characteristics of both groups did not differ. In group I, surgery was performed in 60 patients (39.7%) compared with 108 patients (56.3%) in group II ( P = .002). In the operatively treated patients, the mean MCS on regular mortise view was significantly smaller in patients in whom an additional GS radiograph was performed compared to patients without an additional GS radiograph (4.1 mm vs 5.2 mm, P < .001). Mean Olerud-Molander Ankle Score and mean visual analog scale (VAS) for pain did not differ significantly between groups I and II. Conclusions: Contrary to what was hypothesized, the introduction of an additional gravity stress radiograph, by which operative treatment was indicated if the MCS was wider than the SCS + 2 mm, did not result in reduced operative treatment of Weber type B ankle fractures when operative treatment was indicated for MCS > SCS + 1 mm on non-gravity stress radiographs. Level of Evidence: Level III: retrospective comparative study.