Purpose: Quantitative assessment of lateral ankle ligament after allograft or autograft reconstruction surgery was conducted using ultrashort echo time (UTE) MRI technique to evaluate the maturity levels of the reconstructed anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL).

 Study design: Cohort study; Level of evidence, 3.

Methods: From June 2007 to September 2014, 26 patients who have been diagnosed as chronical ankle instability and treated with anatomic reconstruction of lateral ankle ligament were recruited for investigation including clinical evaluation using the rating scale of the American Orthopedic Foot and Ankle Society (AOFAS) and Karlsson score and radiological evaluation using MRI ultrashort echo time (UTE) scanning. The comparative analysis of the UTE-T2* value on reconstructed ligaments and clinical outcomes were performed between the patients using autografts and allografts. 

Results: The average AOFAS score of all participants improved from 69.3±11.9 preoperatively to 94.8±5.2 postoperatively. The average Karlsson score of all participants improved from 68.0±13.1 preoperatively to 94.2±5.6. The average UTE-T2* value of the econstructed ATFL was 8.3±1.0ms in allograft group and 7.6±1.1ms in autograft group (p=0.027). The average UTE-T2* value of the graft in the fibula tunnel was 7.8±0.6ms in allograft group and 7.2±0.8ms in autograft group (p=0.047). In L group (follow-up time longer than 3 years), the average UTE-T2* value of the reconstructed ATFL was 8.2±0.7ms on allograft (n=9) and 7.1±0.6ms on autograft (n=3) (p=0.036). In S group (follow-up time shorter than 3 years), the average UTE-T2* value of the reconstructed ATFL was 8.5±1.4ms on allograft (n=7) and 7.8±1.3ms on autograft (n=7) (p=0.259). In the patients who have received ATFL and CFL reconstructed together, the average UTE-T2* of reconstructed ATFL was 7.7±0.8ms, the average UTE-T2* of reconstructed CFL was 6.9±0.7ms (p=0.002).

Conclusion: This study shows that the average UTE-T2* value of ATFL and intra-tunnel graft is higher in allograft group compared to autograft group after lateral ankle ligament reconstruction treating chronical ankle instability. This indicates that the maturity level of the graft is better in autograft group during the ligamentization process, especially up to 3 years after reconstruction. As for patients receiving ATFL and CFL reconstruction together, the UTE-T2* value of ATFL is higher than that of CFL due to some anatomical and radiological factors.

Abstract

Objectives: Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion.

Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

Results: We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13–0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46-23.41, P<0.00001), and longer length of stay  (MD 1.60,95% CI 1.10-2.10, P<0.00001) compared to arthroscopic ankle fusion; however, there was no significant difference between two groups in terms of infection rate (OR 2.41, 95% CI 0.76-7.64, P = 0.14), overall complication rate (OR: 1.54, 95% CI 0.80–2.96, P = 0.20), and operation time (MD 4.09, 95% CI -2.49-10.66, P = 0.22). The between-study heterogeneity was high for tourniquet time but low or moderate for other outcomes. The direction of the effect sizes remains unchanged throughout sensitivity analyses.

Conclusions: The best available evidence demonstrates that arthroscopic ankle fusion may be associated with a higher fusion rate, shorter tourniquet time, and shorter length of stay compared to open ankle fusion. We found no significant difference between two groups in terms of infection rate, overall complication rate, and operation time. The best available evidence is not adequately robust to make definitive conclusions. Long-term results of the comparative efficacy of arthroscopic ankle fusion over open ankle fusion are not currently available. Further high quality randomised controlled trials that are adequately powered are required.

Background: in the extensive literature reviewed, acute ankle ligament lesion treatment method are variable, without agreement about what is ideal, and final results vary between papers, showing the absence of consensus. There are few papers that focus late results in terms of long term complaints and recurrence incidence.

Hypothesis/Purpose: The objective of this study is to investigate functional results, long term complaints and incidence of recurrence, following conservative treatment, of the first episode, involving severe lateral ankle ligament lesions (with articular instability). This common lesion, most often, affects young, professional and physically active patients, causing serious personal and economic consequences, but the long term follow up is net well discussed in the literature.

Study design: In this prospective, randomized study including 186 patients with severe lateral ankle ligament lesions were included in this study authors discuss long term complaints, recurrence rates and functional results.

Method: In group A, patients were treated with  walking boot (Robofoot®), comfortable weight bearing allowed, pain management, ice and elevation with restricted joint mobilization for three weeks.  After this, they were placed in a short, functional brace (Aircast® sport) for an additional three week period, with rehabilitation program commencing.

In group B, patients were initially immobilized using a functional brace  and followed the above mentioned sequences for patients in group A.

Long term results focusing recurrence rates, functional status and complaints were analised.

Background: Over time many variables with potential prognostic value on the progression from a lateral ankle sprain (LAS) to chronic ankle instability (CAI) have been studied. Some of these concern variations in bone and joint geometry, which are not resolved by conservative treatment and may therefore be predictive for failed conservative treatment c.q. the need for surgery.

Objective: To assess the inter- and intra-observer reliability of the most relevant radiographic measurements proposed in literature. Once determined to be reliable, their predictive value will be assessed.

Methods: Based on a sample size calculation an expected agreement of 80% and a relative error of 20%, 39 subsequent patients visiting the emergency department after a lateral ankle sprain were included. They received a standard anteroposterior and lateral radiograph. These radiographs were scored for 5 different measurements extracted from literature as potential prognostic factors: the medial distal tibial angle (MDTA) for varus/valgus alignment, the fibular position (FP) in relation to the tibia, tibiotalar contact ratio (α), the medial malleolar height angle (MMHA) and the talar curvature angle (TCA). Reliability was assessed by calculating the intraclass correlation coefficient (ICC) and objectified by drawing a Bland-Altman plot and calculating the standard error of measurement (SEM), minimal detectable change (MDC) and minimal clinical important difference (MCID).

Results: The inter- and intra-observer reliability of all measurements were significant with acceptable SEM, MDC and MCID. The inter-observer reliability of the MDTA (ICC 0.795), FP (ICC 0.951), MMHA (ICC 0.926) and TCA (ICC 0.889) ranged from substantial to excellent, apart from α (0.708) showing moderate reliability between observers. The intra-observer reliability of the MDTA (ICC 0.805), FP (ICC 0.976), α (ICC 0.801), MMHA (ICC 0.820) and TCA (ICC 0.774) ranged from substantial to excellent.

Conclusion: Apart from the tibiotalar contact ratio all measurements can be measured with at least substantial reliability. To avoid the risk of bias by inconsistent measurements, the tibiotalar contact ratio should not be included in future research on the prognostic value of these measurements on the progression from a LAS to CAI.

Background: Despite extensive research on the risk factors predicting the onset of chronic ankle instability (CAI), not much is known whether ankle bone shape of patients experiencing CAI differ from those of controls and whether specific ankle bone shapes make individuals more prone to develop CAI. In a recent study¹, shape differences in talus have been observed between healthy controls and patients with a talar osteochondral defect, a pathology seen in conjunction with ankle instability. This suggests that bone shape differences may exist between patients with CAI and controls.

Objective: Find differences in bone shapes between subjects with CAI and control subjects. 

Methods: A three-dimensional statistical shape model (SSM) of talus, which describes the mean talus shape and the shape variations from the mean within a studied population,  was built as described by Tumer et al.¹. The SSM was generated with CT scans of a population (i.e. 64 subjects) divided in three groups, with 32 tali from ankles that have a confirmed CAI and their contralateral side and 32 tali of healthy controls without reported ankle joint pathology.

With the help of the SSM, quantitative shape values were obtained, which describe how each bone shape varies (i.e. shape modes). These values were compared between three groups for the first five shape modes using an ANOVA test. The significance level (P = 0.05) was adjusted for multiple comparisons using the Bonferroni correction, resulting in a significance threshold of P = 0.003.  

Results: No significant (P > 0.003) shape differences were found between CAI group and contralateral controls. One of the shape modes describing the combination of changes in the lateral aspect of talus and the talar neck showed a significant (P < 0.0001) difference in CAI group vs. healthy control and contralateral vs. healthy controls.

Conclusion: A certain specific talus shape that does not show difference within the individual that had sustained a CAI, but significantly be distinguished from those of healthy controls may be indicative for an increased risk of developing CAI. Variations observed in the lateral aspect of talus and talar neck may be related to the attachment site and size of the anterior talo-fibular ligament, which contributes to the stability of the ankle joint and is the first ligament to rupture in ankle injuries.

References:

N. Tümer et al. "Bone shape difference between control and osteochondral defect groups of the ankle joint," Osteoarthritis and cartilage, 24(12), pp.2108-2115, (2016).

Background: It is not rare to see an ossicle located under the fibular tip (os subfibulare) in X-ray of juvenile patients. It involves accessory bone but most of them are avulsion fracture of lateral malleolus. The purpose of this study was to investigate the incidence of os subfibulare in juvenile patients.

Methods: Under 15 years old patients who visited our clinic for ankle pain from January 2016 to March 2016 were included in this study. Patients who had a history of ankle surgery was excluded.140 ankle X-rays from 100 patients (male: 61 female: 39, mean age 12.1) were evaluated. The presence of os subfibulare was examined by A-P and lateral X-rays. Os subfibulare were divided to small linear fragment (acute avulsion fracture of lateral malleolus) and round shaped fragment (chronic avulsion fracture of lateral malleolus).   

Results: There were os subfibulare in 25 ankles (17.9%). Small linear fragment was seen in 7 ankles (6 years old: 1 ankle, 8 years old: 1 ankle, 9 years old: 2 ankles, 11 years old: 2 ankles, 15 years old: 1ankle). Round shaped fragment was seen in 18 ankles (8 years old: 2 ankles, 9 years old: 2 ankles, 11 years old: 3 ankles, 12 years old: 1 ankle, 13 years old: 2 ankles, 14 years old: 7 ankles, 15 years old: 1 ankle).

Discussions: There are many studies which revealed the effectiveness of prevention program for ankle sprain. However none of them mentioned about which age group is most effective to start the program. It is said that 40% of ankle sprain result in chronic ankle instability and be a cause of osteoarthritis. It is important to prevent first ankle sprain. This study shows that acute avulsion fracture of lateral malleolus occurs mainly in age group under 11. The youngest patient was 6 years old. Every cases except one, bone fragment in over 12 years old patients were round shaped which is thought about chronic avulsion fracture of lateral malleolus. It means it is too late to start prevention program at age of 12. This study suggests that first ankle sprain injury occur younger than age of 11 and the best timing to start prevention program for ankle sprain is around the age of 6.

Background:

Ankle sprains are among the most common sports-related injuries and most injuries involve the lateral ankle ligament complex. There is controversy about the accuracy of the assessment tools which have been used to evaluate calcaneofibular ligament (CFL) injury. A recent systematic review showed that ultrasound was a valuable diagnostic tool for anterior talofibular ligament (ATFL) injury. However, only one study has revealed a sensitivity and specificity of ultrasound for detecting CFL injury.

Purpose:

The purpose of this study was to assess the effectiveness and reproducibility of ultrasound in the evaluation of the CFL when the ankle was placed in maximum dorsiflexion and inversion (DI) position.

Methods: 

A total of 27 ankles in 17 healthy individuals without recent history of ankle sprain or remote ankle surgeries were included in this study. A long axis view of the CFL was assessed with the ankle in DI position, followed by maximal plantarflexion and inversion (PI) position for comparison. Two examiners evaluated the CFL in order to check the intraobserver reliability. Ultrasound findings of the CFL were classified into three types: only calcaneal side was visible as a fibrillar pattern (type 1), both fibular and calcaneal sides were visible but there was anisotropy in fibular side (type 2) and both fibular and calcaneal sides were visualized as a fibrillar pattern (type 3). The results of ultrasound between two different ankle positions were compared using Man-Whitney’s U test. The level of concordance between two examiners was evaluated with the kappa index.

Results:

All 27 ankles in PI group was type 1. In contrast, there were five ankles of type 1, 16 of type 2 and four of type 3 in DI group. There was a significant difference between two groups (P < 0.001). The Kappa index between the evaluations of the two examiners in visualization of the CFL was 0.86.

Conclusions:

The results suggest that the both fibular and calcaneal sides of the long axis of the CFL was visualized by ultrasound with the ankle in maximum dorsiflexion and inversion position in a high concordance level.

The aim of this study was to determine the reliability and validity of preoperative magnetic resonance imaging (MRI) scans for the detection of additional pathologies in patients with chronic ankle instability (CAI) compared to arthroscopic findings.

METHODS: 

Preoperative MRI images of 30 patients were evaluated regarding articular and periarticular comorbidities and compared to intraoperative findings. The reliability of MRI was determined by calculating specificity, sensitivity, as well as positive and negative predictive values. The accuracy of the classification of cartilage lesions by Outerbridge and Berndt and Harty rating scales was determined by calculating the area under the receiver operating curve (AUC).

RESULTS: 

In total, 72 additional pathologies were found arthroscopically compared to 73 lesions gathered from MRI images. Sensitivity ranged from 89% for peroneal tendinopathy to 28% for additional ligamentous lesions. Specificity ranged from 100% for anterolateral impingement, loose bodies and peroneal tendinopathy to 38% for additional ligamentous lesions. For cartilage lesions, sensitivity was at 91% and specificity was at 55% for the Outerbridge grading scale. For the Berndt and Harty classification system, sensitivity was at 91% and specificity was at 28%. Correlation of additional pathologies ranged from weak (r s = 0.48; p = 0.02) to moderate results (r s = 0.67; p < 0.001).

CONCLUSION: 

CAI is associated with a high incidence of additional pathologies. In some cases, MRI delivers insufficient results, which may lead to misinterpretation of present comorbidities. MRI is a helpful tool for preoperative evaluation, but arthroscopy remains gold standard in the diagnosis of associated lesions in patients with CAI.

OBJECTIVE:

Restore lateral ankle stability and correct the underlying inframalleolar varus deformity.

INDICATIONS:

Patients with severe chronic ankle instability associated with post-traumatic and idiopathic cavovarus deformity on patients on whom conservative and orthopedic treatment failed to show results.

CONTRAINDICATIONS:

Irreducible hindfoot instability, deep or superficial infections, osteoarthritis of the subtalar joint, neurovascular impairment of the lower extremity, Charcot arthropathy, severe osteoporosis, elderly patients, diabetes mellitus and smokers.

SURGICAL TECHNIQUE:

Anterior ankle arthroscopy was performed using two classic anteromedial and anterolateral portals. The scope was localized in the lateral gutter and the remnant of the anterior talofibular ligament was repaired using a 4.5mm knotless anchor. The lateral calcaneous cortex was exposed through a lateral incision. The osteotomy was made initially with an oscillating saw and finished with a bone chisel. A 4mm laterally based wedge was used in all cases. The posterior osteotomy fragment was manually mobilized and shifted laterally, changing the angle of the calcaneous cortex. The osteotomy was stabilized with a blocked staple plate followed by wound closure.

POST-SURGICAL TREATMENT:

A stabilizing walking boot was indicated for 6 weeks. Thromboprophylaxis was used in patients who were over 30 years old. Following with clinical and radiographic follow-up at 6 weeks, partial weight bearing was initiated at 3 weeks P.S.

RESULTS:

Between February 2013 and November 2015, a lateral sliding osteotomy with a lateral based wedge was performed in 11 patients with a mean age of 38.7 ± 14.6 years (range 21.5-63.4 years). All patients had a history of severe lateral ankle instability associated with a severe inframalleolar cavovarus deformity. Significant pain relief was observed from 7.1 ± 1.8 (range 5-10) to 1.4 ± 1.2 (range 0-4) using the visual analogue scale. The American Orthopedic Foot and Ankle Society’s score improved significantly from 36.9 ± 12.9 (range 10-60) to 85.0 ± 10.5 (range 55-95).

CONCLUSIONS:

Endoscopic ankle ligament repair associated with calcaneal sliding osteotomy and a lateral based wedge may be an effective surgical option for severe chronic ankle instability associated with calcaneous varus deformity. Correcting alignment, restoring stability and reducing pain allows patients to walk and run properly resulting in higher quality of life.

LEVEL OF EVIDENCE:

Level IV, series of retrospective cases.