It has a simple surgical approach and does not affect the talocrural and subtalar motion. The ankle twist, rollover, or sprain may be the most overlooked athletic injury, and for that reason may also be amongst the worst. The results of the current study are encouraging, but LB repair and reconstruction is very complex, and surgeons need to have substantial experience to successfully treat such injuries. There are few reports of LB injury in the literature, and reports of diagnosis and treatment of LB injury are extremely rare. There is an agreement that the anterior structures are the first to be disrupted and that the damage extends posteriorly as severity increases. Modified arthroscopic Brostrom procedure. B: An uncommon mechanism of fracture, consisting of dorsiflexion and eversion, causing a compression-type lesion. A 5-year follow-up study of the modified Evans procedure. Your message has been successfully sent to your colleague. Bookshelf About 30% of patients may develop chronic ankle instability (CAI), which significantly limits their professional or recreational activities. Purpose: Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. Objectives: 2022 Nov;108(7):103159. doi: 10.1016/j.otsr.2021.103159. Regardless, examination under anesthesia remains impractical since it can only be performed in the operating room before arthroscopy. There were obvious tenderness at the ATFL insertion and the calcaneal fibular ligament insertion. Disclosure Dr E. Ferkel discloses that he is a consultant and instructor for Arthrex and Ferring Pharmaceuticals. Do not disregard or avoid professional medical advice due to content published within Cureus. For LB reconstruction, the tendon was fixed to the calcaneus, the cuboid, and the navicular bones in turn at the LB attachment area with 5.0-mm resorbing screws (Depuy Mitek, MA) (Fig. Among them, 3 patients (4.5%) got temporary superficial peroneal nerve palsy and skin numbness at ankle joint after surgery, which gradually recovered within 2 weeks. . Conversely, we postulated that the CFL was the primary restraint for lateral ankle instability and that reconstruction of the lateral capsuloligamentous complex should be offered only to CFL-deficient patients. 1 the display of certain parts of an article in other eReaders. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The chi-square test was used to compare dichotomous variables. Its integrity is compromised when excessive stress is applied while the ankle is inverted and dorsiflexed. Clipboard, Search History, and several other advanced features are temporarily unavailable. In these cases, if instability is still present after a comprehensive nonoperative treatment, a surgical stabilization is required [5], [6], [7]. 8600 Rockville Pike Feng SM, Sun QQ, Wang AG, Chang BQ, Cheng J. Orthop Surg. With myriad procedures described for chronic lateral ankle instability, there is little consensus on optimal treatment outcome or a truly "ideal" operation. Moreover, the ATFL was incised, pulled distally, and attached with the CFL using the same anchor sutures. Over 80 surgical procedures have been described for chronic lateral ankle instability, and the procedures can be . Overall, no postoperative ankle instability or relapsing ankle sprain was documented. Superior results are seen with physical therapy and exercise. Chronic ankle instability. Keyword Highlighting A P-value of <.05 was considered to indicate a statistically significant difference. Of the LB reconstruction patients, the surgical result was rated as excellent by 6/7 (85.7%) patients, and poor by 1/7 (14.3%) patients. When needed, we also performed osteophyte resection, loose body excision, scar tissue removal, and synovectomy. Chronic ankle instability is associated with the following clinical conditions 1-6: pathologic ligament laxity tibiotalar joint pathologies chondral or osteochondral injury synovial inflammation and/or ankle impingement positional errors of the fibula, restricted dorsiflexion degenerative changes e.g. Doherty C, Delahunt E, Caulfield B, et al. Both groups demonstrated significant improvement in their Tegner (p = 0.009) and AOFAS scores (p = 0.001) during their 24 months follow-up. Surgical excision for anterior-process fractures of the calcaneus. [3-5]. doi: 10.1016/j.otsr.2016.06.026. Epub 2021 Nov 29. Epub 2011 Jul 29. MRI is most useful for chronic ankle instability. All analyses were carried out using SPSS Version 21 (IBM Corp., Armonk, NY, USA). In such cases, if we only repair the ankle joint and ignore the LB lesions, patients will still experience postoperative tenderness and swelling in the region of the LB. J Orthop Surg Res. Anatomical repair of the outside (lateral) ankle ligaments is one common means of surgically stabilizing the ankle operatively. Bethesda, MD 20894, Web Policies Of the patients with concurrent LB injury, 82.1% (92/112) returned for final evaluation. Chronic ankle instability is truly a complex of three possible issues including ligament tear and laxity, peroneal tendon tear, and possible cartilage damage. Strength of the kappa coefficients was interpreted in the following manner: 0.01 to 0.20: slight; 0.21 to 0.40: fair; 0.41 to 0.60: moderate; 0.61 to 0.80: substantial; 0.81 to 1.00: near perfect. Synovitis and scar tissue were more common in group A (p = 0.01) compared to group B. White WJ, Mccollum GA, Calder JD. Epub 2014 Dec 15. The site is secure. Learn more about chronic ankle instability courtesy of Brace Direct. Normally with ankle sprain rehab, especially initially in your earlier rehab process, you'd be concerned with restoring mobility, particularly restoring end ranges of motion. Simultaneous Treatment of Osteochondral Lesion Does Not Affect the Mid- to Long-Term Outcomes of Ligament Repair for Acute Ankle Sprain: A Retrospective Comparative Study with a 3-11-Year Follow-up. Lindner HO, Kaufner HK. Approval for this study was obtained from the Institutional Review Board of the hospital where the study was conducted. Please enable it to take advantage of the complete set of features! The ATFL is the primary stabilizer against excessive ankle inversion. Preoperative and final follow-up values of the assessed variables (n = 98). As the calcaneocuboid joint is part of Chopart joint line, we also performed dorsoplantar, lateral, and stress radiographs with about 20 kp varus stress at the level of the calcaneocuboid joint to measure the calcaneocuboid angle.[1315]. DVT (deep vein thrombosis) prophylaxis was prescribed until the cast was removed. Clinical and radiographic findings after ten to eighteen years of follow-up. Three patients from group B complained of skin irritation. However, several factors may lead to chronic ankle instability with recurring ankle sprains: Inadequate primary treatment Incomplete healing of the ligaments Repetitive trauma with deteriorated tissue quality The right side was affected in 39 (39/67; 58.2%) cases and the left side in 28 (23/67; 41.8%) cases. . Data were expressed as mean SD for quantitative variables and as frequencies and percentages for qualitative variables. Zhongguo Gu Shang. By continuing to use this website you are giving consent to cookies being used. Weng PW, Chen CY, Tsuang YH, Sun JS, Lee CH, Cheng CK. Reconstruction of lateral ligaments of the ankle with allogeneic tendon grafts. Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Arthroscopic Anatomical Repair of Anterior Talofibular Ligament for Chronic Lateral Instability of the Ankle: Medium- and Long-Term Functional Follow-Up. 7). Long-term results of surgical reconstruction for chronic lateral instability of the ankle: comparison of Watson-Jones and Evans techniques. If there were discoloration, local tenderness, or swelling at this area, the supplementary imaging will be ordered, including stress x-rays and oblique views of the midfoot. Foot Ankle Int. Standing X-ray examination indicated normal joint space without stenosis, and the internal fixation was in good position. The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients. Kennedy JG, Smyth NA, Fansa AM, Murawski CD. Minimally invasive treatment of chronic ankle instability: a comprehensive review[J]. We searched the Cochrane Library, MEDLINE, and EMBASE. Arthroscopic treatment for anterolateral impingement of the ankle: Systematic review and exploration of evidence about role of ankle instability. Epub 2020 Mar 2. Philadelphia, PA: Mosby Elsevier; 2007. B: The calcaneocuboid angle is 10.8. Foot Ankle Int 1998;19:65360. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. In such cases, the objective of operative treatment is to restore stability and decrease the risk of posttraumatic osteoarthritis. The authors are grateful to K. Liu and L. Zhang of the Department of Orthopedics, and to X. Acta Chir Scand 1953;105:4606. Br J Sports Med, 2016, 50(24): 1493- 1495. One patient from group A developed superficial peroneal nerve intermediate branch entrapment. 23. Eils E, Demming C, Kollmeier C, Thorwesten L, Volker K, Rosenbaum D. Ankle taping and bracing for proprioception. 2022 Oct 20;17(1):459. doi: 10.1186/s13018-022-03354-4. Patients were given a comprehensive physiotherapy program and were discharged on the day of surgery with instructions to ambulate with partial weight-bearing. [6]. Edama M, Kageyama I, Kikumoto T, et al. Purpose Treatment of chronic lateral ankle instability (CLAI) with poor remnant quality is challenging. Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Lateral ankle sprains are the most common lower extremity injuries seen by healthcare providers [1]. The "giving way" usually happens while walking or doing other activities, but it can also happen while standing still. The anterior talo-fibular ligament reconstruction in surgical treatment of chronic lateral ankle instability. During this period, isometric and progressively active exercises commenced. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. This is because the LB plays a very important role in maintaining the stability of the lateral transverse tarsal joint. Accessibility Disclaimer, National Library of Medicine Br J Sports Med, 2018, 52(20): 1304- 1310. However, these are markedly rare complications that are more common during non-anatomic reconstruction. Physical therapy for lateral ankle sprains is effective in preventing ankle instability. Orthop Trauma Surg 1982;99:1837. The minimally invasive ATFL reconstruction with partial peroneus brevis tendon has advantages of small trauma, good reconstruction a nd excellent clinical outcomes, thus, is a safe and effective method for the treatment of chronic lateral ankle instability. Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Foot Ankle Int. Arthroscopic-assisted Brostrm-Gould for chronic ankle instability: a long-term follow-up. Tan DW, Teh DJW, Chee YH. Minor or occult ankle instability as a cause of anterolateral pain after ankle sprain. Copyright 2020 Elsevier Inc. All rights reserved. Cao S, Wang C, Ma X, Wang X, Huang J, Zhang C. Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: a comparative study with surgical findings and timings of scans. We conducted this retrospective study with 2 aims: to investigate the incidence rate and characteristics of LB injury, and to identify the method of diagnosis and treatment of LB injury. These are either anatomic or non-anatomic. Objectives: Anterior talofibular ligament (ATFL) injury is one of the most common injuries in sports medicine, resulting in chronic lateral ankle instability (CLAI). Pre- and postoperative evaluation included history taking and physical examination, including the talus tilt test and anterior drawer test. The ankle should be in neutral or slight plantar flexion to help align ATFL and CFL. Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture. It also helped identify synovitis and scar tissue that could not be viewed by MRI scans [6]. Get into a half-kneeling position on the floor with the ankle you are stretching in front Make sure your front foot flat on the floor and facing straight forward Shift your weight forward while keeping the heel firmly on the ground Keep the inner edge of the knee aligned with the big toe to prevent flaring in or outward Manual therapy is effective in promoting soft tissue repair. Recurrent inversion injuries caused pain, swelling, stiffness, and a feeling of giving way, thus preventing participants from participating in sports as well as the physical aspects of military training exercises. ment reconstruction in surgical treatment of chronic lateral ankle instability. Gerber JP, Williams GN, Scoville CR, et al. For chronic ankle instability, a combination of the following treatments is often successful at relieving symptoms and minimizing the risk of recurrent ankle sprains: . Recovery time after Lateral Ankle Instability Surgery Patients will remain non weight bearing for about two weeks in a cast. anatomical reconstruction; anterior talofibular ligament; arthroscopy; chronic ankle instability. Whole-body vibration (WBV) has the potential to address the neurophysiologic deficits accompanied by CAI and . Ankle arthroscopy was performed in all patients. Janssen KW, Kamper SJ. An official website of the United States government. doi: 10.11817/j.issn.1672-7347.2021.200807. Conservative versus surgical treatment. . Median follow-up duration was 28 (range, 2435) months. Chronic Lateral Ankle Instability - Everything You Need To Know - Dr. Nabil Ebraheim 218,176 views Dec 14, 2016 Dr. Ebraheims animated educational video describing the condition of. The patients' daily life may be seriously affected by ankle osteoarthritis and other irreversible damages, if the ATFL injury is not treated in time and drags on. You may be trying to access this site from a secured browser on the server. Further research is warranted to confirm the present findings. The stress upon it increases as the ankle moves into plantar-flexion and inversion, whereas the addition of internal rotation amplifies its risk for tear. . Numerous surgical procedures have been described for the treatment of chronic lateral ankle instability beginning with Elmslie, in 1934, who first reported using fascia lata graft to reconstruct the lateral ankle ligaments. Clinical rating scale for postoperative ankle reconstruction. Keywords: calcaneofibular ligament, chronic ankle instability, arthroscopy, athlete, brostrom-gould. Valderrabano V, Hintermann B, Horisberger M, Fung TS. Foot Ankle Int 2000;21:996-1003. Ankle sprains involve up to 30% of all sport injuries. The APC is seen on the lateral view, but is projected over the talus. Gellman M. Fracture of the anterior process of the calcaneus. Surgical Management of Lateral Ankle Instability in Athletes. Once it was ensured that ankle stability was reestablished, the wound was closed with absorbable sutures. Ankle traction was removed and a 4-cm incision was made, starting from the anterior margin of the fibula and ending downwards and posteriorly, approximately 1 cm distal from the tip of the lateral malleolus. Bachman S, Johnson SR. Torsion of the foot causing fracture of the anterior calcaneal process. and transmitted securely. Please enable it to take advantage of the complete set of features! The aim of the present study was to evaluate clinical results and complications of anatomic reconstruction of the lateral ligaments using allograft tendon and suspensory fixation in the treatment of such patients. Knowledge of regional anatomy is essential for investigating the severity of ankle sprains. Outpatient follow-up was conducted at 3, 6, 12, and 24 months postoperatively. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Strauss JE, Forsberg JA. Indeed, this modification resulted in reduced anterior talar displacement and a decreased talar internal rotation [25]. Guillo S, Bauer T, Lee JW, et al. LB = ligamentum bifurcatum. "Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Knupp M, Lang TH, Zwicky L, et al. Beumer A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM. Careers. Fractures, syndesmotic injuries, posttraumatic arthritis, loose bodies, bony avulsions, and osteophytes were identified using plain radiographs. Search for Similar Articles All of the above are associated with poor postoperative outcome and higher risk for ankle arthritis. Chronic ankle instability (medial and lateral). [11]. J Bone Joint Surg Am 1982;64:51924. Thus, the absence of scar tissue could be indicative of a lower healing potential in patients with CFL tears and may justify the need for further ligament reconstruction. The posterior talofibular ligament was intact in both groups. The calcaneonavicular part of the LB is thicker (average diameter 3 mm) and longer (average length 15 mm) than the calcaneocuboidal part (2 mm in diameter and 9 mm in length)[8] (Fig. Sun, Yaning MDa; Wang, Huijuan MDb; Tang, Yuchao MDa; Qin, Shiji MDa; Zhao, Mingming MDc; Zhang, Fengqi MDa,*, aDepartment of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University, bDepartment of Histology and Embryology, Hebei Medical University. In contrast, patients who underwent LB repair or LB reconstruction showed significant improvements in VAS pain score and AOFAS score at the last follow-up. The calcaneocuboid angle was significantly reduced and the Chopart joint stability was significantly improved at final follow-up compared with preoperatively (Table 2). Baumbach SF, Braunstein M, Herterich V, Bcker W, Waizy H, Polzer H. Oper Orthop Traumatol. Failure after strict rehabilitation may be an indication of surgery. Please try after some time. DEFINITION Lateral ligament injuries of the ankle are treated conservatively with good results in most cases. This study aims to examine the results of a treatment algorithm based on the integrity of the CFL and to investigate the significance of clinical examination, imaging modalities, arthroscopy, and anatomic reconstruction in highly active patients with chronic ankle instability. Li X, Lin TJ, Busconi BD. Lateral ankle sprains are the most common musculoskeletal injury. Mild syndesmotic attenuation was evident in three patients in group A and four patients in group B, whereas deltoid ligament injury was prevalent in three patients in group A and two patients in group B. Our treatment algorithm for chronic ankle instability highlighted the role of arthroscopy and lateral capsuloligamentous complex repair in high-demand groups. For the investigation of cartilage lesions, bone bruising, and peroneal tendon tears, ankle MRI without contrast was performed on all participants [12]. High-intensity training with a bi-directional bicycle pedal improves performance in mechanically unstable ankles--a prospective randomized study of 19 subjects. Foot Ankle Int 2000;21:37984. Both scores were calculated preoperatively and two years postoperatively. Weber B fracture of the lateral malleolus with concomitant anterior talofibular ligament injury following an ankle supination injury. This retrospective study included 218 consecutive patients with CLAI who underwent surgery from January 2012 to December 2015. Foot Ankle Int 2017;38:76978. Ankle sprain is often combined with LB damage. Proprioception is essential for neuromuscular control in relation to sport injury and performance. Ankle sprains are common injuries that may recur as chronic conditions. Disclaimer, National Library of Medicine 8600 Rockville Pike Would you like email updates of new search results? Before Postoperative follow-up was conducted for 12-24 (15.643.17) months. The timely introduction of physical therapy speeds up the healing process. The https:// ensures that you are connecting to the Horibe S, Shino K, Taga I, et al. . Int Orthop 34:991-996 30. Andermahr J, Helling HJ, Rehm KE, et al. Inter-rater reliability for CFL tears was very high for clinical examination under anesthesia in conjunction with arthroscopy (k = 0.909), moderate between clinical examination and ankle arthroscopy (k = 0.514), and fair between MRI and ankle arthroscopy (k = 0.357). Usually, the conservative treatment for acute injuries is successful, even if a chronic ankle instability persists in 5-20% of cases, defined by an instability lasting more than 6 months [3], [4]. Sports injuries were the cause for ankle instability in 44 (44/67; 65.7%) cases, whereas trauma suffered during military training was the cause in 23 (23/67; 34.3%) cases. LB = ligamentum bifurcatum. . These findings had a higher prevalence in group A (p = 0.011) and most likely stemmed from post-injury hematomas. Patients were reviewed at 3, 6, 12, and 24 months after surgery at the outpatient clinic. [Reconstruction of anterior talofibular ligament and calcaneofibular ligament with autologous peroneus brevis tendon in the treatment of chronic lateral ankle instability]. Orthop Traumatol Surg Res 96:417-423 218 Arch Orthop Trauma Surg (2012) 132:211-219 123. 4). The test was considered positive for angles greater than 10 degrees or when the tibiotalar angle difference was more than 6 degrees. You may switch to Article in classic view. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Furthermore, despite the markedly low post-injury Tegner score, all participants improved considerably and ultimately became fit to return to heavy labor and competitive sports (p = 0.009). Two Mitek G-II anchors (Mitek Products Inc., Norwood, MA, USA) were then inserted into the bare bone area accommodating the reattachment of the CFL to the lateral malleolus. Sports Med 2014;44:12340. The ePub format is best viewed in the iBooks reader. [1,2] Especially in the active population, where lateral ankle sprain accounts for up to 20% of all sports-related injuries. Postoperative stiffness developed in two patients in group A, with severe restriction of ankle dorsiflexion (greater than 15 degrees). Gribble PA, Bleakley CM, Caulfield BM, et al. Arthroscopic approach to lateral ankle ligament stabilization may provide good outcomes, with long-term data still limited. Epub 2018 Sep 20. In the long run, 20 30% of chronic ankle instability . The https:// ensures that you are connecting to the Conclusions: Treatment of chronic lateral ankle instability: a modified Brostrm technique using three suture anchors. Magnetic resonance imaging (MRI) also offers valuable information for the assessment of chronic ankle instability patients [7]. MeSH Our treatment algorithm for chronic ankle instability highlighted the role of arthroscopy and lateral capsuloligamentous complex repair in high-demand groups. Parkes J. Of the patients who underwent excision of the fracture fragment, the surgical result was rated as excellent by 1/32 (3.1%) patients, good by 11/32 (34.4%) patients, and fair by 20/32 (62.5%) patients. Its significance was twofold. The work cannot be changed in any way or used commercially without permission from the journal. Patients with ankle sprain may have concurrent LB injury; so after examination of the ankle joint, the LB should be examined in detail (clinical side differences were noticed). Ankle arthroscopy is a recommended to address intra-articular disorder before stabilization. The objective of this study was to compare the difference of plantar pressure distribution between surgical treatment and conservative treatment for CAI. Following a lateral ankle sprain, 40% of individuals develop chronic ankle instability (CAI), characterized by recurrent injury and sensations of giving way. A lateral ankle ligament sprain is one of the most common lower extremity injuries in activities and sports that consist of strenuous jumping and cutting maneuvers (Brown et al., 2004; Delahunt et al., 2006).Most (45% - 75%) individuals who have initially sprained their lateral ankle ligaments will be experience aggravation that progresses to chronic ankle instability (CAI), which is affected . The mean number of recurrent inversion injuries per patient was 1.0 2.1 (range: 1-10), whereas the median duration of symptoms (interval between first injury and surgery) was 23 months (range: 6-168 months). Stability of the fixation was evaluated with the anterior drawer and talar tilt tests. AOFAS scores measured during the 24-month follow-up demonstrated that most patients reported minor to no limitations regarding their fitness status (p < 0.001). Ferran NA, Maffulli N. Lateral ankle sprains. Of the 67 patients, 29 left ankles and 38 right ankles were included in this study. An official website of the United States government. Moreover, despite being originally designed for knee evaluation, Tegner Activity Level scoring system has also been used for the assessment of the ankle joint [15,16]. This can lead to persistent ankle instability in the lateral ankle ligaments. Chronic instability can lead to loose ankle ligaments, loss of joint cartilage, and tendon injury. Wolters Kluwer Health Get new journal Tables of Contents sent right to your email inbox, http://creativecommons.org/licenses/by-nc-nd/4.0, March 2018 - Volume 97 - Issue 9 - p e0028, Diagnosis and treatment of chronic lateral ankle instability with ligamentum bifurcatum injury: An observational study, Articles in Google Scholar by Yaning Sun, MD, Other articles in this journal by Yaning Sun, MD, C5 palsy after C5/6/7 posterior foraminal decompression: A case report. Ioannis K Triantafyllopoulos, Dimitrios G Economopoulos, [], and Louw van Niekerk. The lateral ligament repair is widely accepted as the primary operative treatment for chronic lateral ankle instability. Li X, Killie H, Guerrero P, Busconi BD. [1] Chronic instability refers to a feeling of apprehension in the ankle, "giving way" and recurrent ankle sprains, persisting for a minimum of six months after the initial sprain. Adler H. Ligamentous injuries of the foot arch. LB = ligamentum bifurcatum. Concomitant intra-articular pathology was addressed accordingly. Orthopaedics and Trauma Department, Ministry of Defence Hospital Unit (MDHU) Northallerton, Northallerton, GBR, AOFAS, American Orthopaedic Foot and Ankle Society, Chronic Lateral Ankle Instability in Highly Active Patients: A Treatment Algorithm Based on the Arthroscopic Assessment of the Calcaneofibular Ligament, Monitoring Editor: Alexander Muacevic and John R Adler. Generating an ePub file may take a long time, please be patient. Seven patients sought professional help for their instability elsewhere before our consultation. 2015 Sep;21(3):216-9. doi: 10.1016/j.fas.2015.01.008. They specialize in Orthopedic Surgery, has 36 years of experience, and is board certified in Orthopedic Surgery. The remaining 30 patients (30/67 [44.78%], group B) developed mechanical instability with combined ATFL and CFL rupture. Valderrabano V, Wiewiorski M, Frigg A, Hintermann B, Leumann A. Epidural anesthesia was administered, and the patient was placed in supine position with a thigh tourniquet. Sammarco GJ, DiRaimondo CV. 2. Funding support: This study was not supported by any funding. [2] However, the outcome was not ideal in those who underwent excision of the anterior process of the calcaneus; there were significant postoperative decreases in talar tilt (P < .05) and anterior drawer (P < .05), but there was no significant postoperative improvement in visual analog scale pain score and AOFAS score. Furthermore, ankle MRI offered valuable additional information about the severity of ligamentous and cartilaginous injuries [7]. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Foot Ankle Int 2007;28:10414. [8]. Diagnostic arthroscopy followed, where the integrity of the CFL was assessed. Under normal circumstances, the calcaneocuboid angle is <5. In routine examination of the foot, the avulsion of the APC can not be found, because on the lateral x-ray of the foot, the APC is projected on the talus. The Mann-Whitney test was used for unpaired samples. Plait AD. The difficulty in evaluation and treatment is due in part to the ankle complex is composed of three joints: talocrural, subtalar, and tibiofibular syndesmosis. Curr Pain Headache Rep, 2020, 24(3): 8. Some authors highlighted the role of the ATFL in rotational ankle microinstability and the need for its repair when a tear is present [18,19]. The mean age was 29.9 6.4 years (range: 13-50 years). Functional results of modified Mason-Allen suture versus horizontal mattress suture in the arthroscopic Brostrm-Gould procedure for chronic ankle instability. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. 2018 Jun 25;13(1):159. doi: 10.1186/s13018-018-0870-6. Introduction. [Arthroscopic repair of chronic lateral ankle instability]. The Brostrom-Gould procedure is the gold standard surgical treatment for patients with chronic ankle instability (CAI) whose symptoms are refractory to conservative treatment. Please try again soon. Rarely, operative management is indicated in the setting of syndesmosis injury with tibiofibular diastasis or chronic ankle instability with recurrent sprains. Nevertheless, its value in chronic ligament tears is debatable. Inter-rater reliability for CFL tears was moderate on clinical examination (k = 0.514) and fair on MRI, in conjunction with ankle arthroscopy (k = 0.357). 2022 Mar 28;23(1):294. doi: 10.1186/s12891-022-05260-6. All content published within Cureus is intended only for educational, research and reference purposes. The https:// ensures that you are connecting to the However, the LB is essential for the stability of the transverse tarsal joint (Chopart lateral joint line). Among the disadvantages of non-anatomic reconstruction techniques are altered kinematics, decreased subtalar and talocrural joint mobility, increased risk for adjacent cutaneous nerve injury, and the sacrifice of the peroneus brevis [20-22]. Rupture of calcaneocuboid ligament. Schneider W, Jurenitsch S. Sports activity level after surgical treatment for chronic anterolateral ankle instability: a multicenter study. J Bone Joint Surg Am 1951;33-A:3826. Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. These results indicate that simple excision of the fracture fragment is not an ideal way to treat LB injury; it is worth mentioning that we cannot just excise the APC, as the scar tissue connection cannot compensate for LB function. This was a consequence of bulky suture knots during lateral capsuloligamentous reconstruction. Background: Chr onic lateral ankle instability causes significant problems in physical activity and accelerates development of . Injections For Chronic Ankle Sprain Operative Treatment Options Potential Complications Post Operative Period & Recovery FAQs Symptom Checker Where is your pain? Toe-touch weight-bearing was allowed with the assistance of crutches. MeSH Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Preoperative Lymphocyte-to-Monocyte Ratio Can Indicate the Outcomes in Repair of I-III Degree Injury of Lateral Ankle Ligament. Brostrm reconstruction is associated with lower morbidity, quicker functional recovery, and no proprioception interference [23]. In the operating room, a specific surgeon performed provocative tests and standardized stress views. Chronic ankle instability can occur when acute sprains are not identified, treated, and allowed to heal. Before The ankle joint was fixed in neutral position by lower leg plaster casting. The American Orthopaedic Foot and Ankle Society (AOFAS) and Tegner scores were noted post-injury and during the 24-month follow-up. to maintaining your privacy and will not share your personal information without [19]. Conversely, in "mechanical" instability, provocative tests are positive. Yi G, Fu S, Yang J, Wang G, Liu Y, Guo X, Shi J, Zhang L. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Most patients had no pain or occasionally mild pain. Among them, one patient was elected to address chronic ankle instability with Karlsson anatomic reconstruction, whereas six patients underwent ankle arthroscopy. Lateral ankle sprains cause damage to the ligaments and other soft tissues of the foot. Chronic ankle instability is defined by the outer (lateral) side of the ankle "giving way" on a regular basis. Deafferentation due to mechanoreceptor damage postinjury is suggested to contribute to arthrogenic muscle inhibition (AMI). After clinical examination, they were all investigated further with MRI scans and stress views. The Ankle Hindfoot AOFAS rating system was preferred because the ankle and hindfoot were perceived as a single albeit complex system. [17]. [18]. Agnholt J, Nielsen S, Christensen H. Lesion of the ligamentum bifurcatum in ankle sprain. sharing sensitive information, make sure youre on a federal 6). She did not complete the rehabilitation training, which led to ankle stiffness and an inability to return to the previous level of sports activity. 8th Edition. 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains[J]. Postoperative routine nursing and standardized rehabilitation exercise were recommended. Therefore, the excellent postoperative outcome documented in both groups supports our hypothesis regarding the lower clinical significance of ATFL. Between the third and sixth postoperative weeks, instructions were given for a transition from partial to full weight-bearing. A: The calcaneocuboid angle is normal. Orthopaedics Department, Medical School, University of Patras, Patras, GRC, 4 China (e-mail: [emailprotected]). Patients with LB lesions experience substantially more pain in the region of the LB with radiation of pain to the forefoot compared with patients with only lesions in the region of the ankle joint. According to pathomechanics, chronic lateral ankle instability can be either "functional" or "mechanical". Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability. Postoperatively, most patients recovered very well. 3); the extruding base of the fifth metatarsal can be palpated with the middle finger of the examiner, and the external malleolus be hold with the thumb, the marked tender point of the LB injury can be felt upon by the crooked index finger, between these 2 bones. In contrast, the rationale for anatomic repair is to restore normal anatomy by imbrication of the lateral capsuloligamentous complex. eCollection 2022. Part I: Anatomy, biomechanics, diagnosis, and natural history. The CFL is the only ligament bridging the tibiotalar and subtalar joints. In patients with CFL tear, our algorithm mandated further treatment. CFL tears mandated that modified Brostrm-Gould reconstruction would follow. Patients achieved satisfactory results after treatment with LB repair and reconstruction with an allograft, and achieved mechanical stability without serious complications. The operative procedure chosen depended on the fracture type. Several methods of conservative treatment, such as peroneal muscle strengthening, ankle bracing that blocks subtalar joint inversion, and application of small lateral heel wedges, have been described. 2022 Apr 19;2022:6234561. doi: 10.1155/2022/6234561. Exclusion criteria: combined medial (deltoid ligament) and lateral ankle instability; local infection of the ankle joint; fracture of the tibia, fibula, talus, or calcaneus (except for the ankle avulsion of small bones). Patients with CLAI often have concurrent LB injury. [12] Contraindications to this surgery included congenital collagen deficiency, bodyweight >120 kg, severe heart disease, lesions affecting liver and kidney function, severe diabetes, central nervous system diseases, and other medical diseases. All tests were two-sided, with statistical significance set at p < 0.05. Federal government websites often end in .gov or .mil. official website and that any information you provide is encrypted We restricted ankle arthroscopy to 37 patients (37/67 [55.22%], group A). Finally, during weeks 9 to 12, patients were allowed to perform sports specific training. AITFL, anterior inferior tibiofibular ligament; ATFL, anterior talofibular ligament; PTFL, posterior talofibular ligament; CFL, calcaneofibular ligament. Chronic ankle instability is common after an acute lateral ankle sprain. 2018 Dec;104(8S):S207-S211. Results: Stress ultrasound provides an ideal and immediate evaluation of the ligament integrity in the office. Imaging diagnosis for chronic lateral ankle ligament injury: a systemic review with meta-analysis. Eversion strength and surface electromyography measures with and without chronic ankle instability measured in 2 positions. 2016;24(4 . may email you for journal alerts and information, but is committed Postoperatively, some patients still had clinically detectable signs (discoloration, tenderness, and swelling) at the point of the LB. Baumhauer JF, O'Brien T. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. government site. Careers. : (anterior talofibular ligamentATFL)3~6ATFLATFL: 201512018167422517~41(12.63.2)2938ATFLXATFLATFL361224(American Orthopaedic Foot and Ankle SocietyAOFAS)(Karlsson ankle functionalKAF)(the Japanese Society for Surgery of the FootJSSF): 6752(77.6%)12(17.9%)II~III23(34.3%)IV5(7.5%)3(4.5%)212~24(15.643.17)64(95.5%)XAOFAS(94.786.37)(64.1712.43P<0.01)KAFJSSF(KAF91.0411.36 vs 59.7413.63P<0.01JSSF95.3210.21 vs 66.9214.38P<0.01): ATFL. Would you like email updates of new search results? Krips R, van Dijk CN, Lehtonen H, Halasi T, Moyen B, Karlsson J. 2017 Apr;38(4):405-411. doi: 10.1177/1071100716683348. The scores used for evaluating the postoperative outcome and level of activity indicated that both groups improved significantly. It was used for recognizing those with CFL deficient ankles and for addressing associated intra-articular pathologies. Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Clinical examination under anesthesia proved to be highly sensitive and specific. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion. The anchors were in good position. In 51.4% (112/218) of these patients, CLAI was combined with LB injury. Repeated ankle sprains are a common cause of this syndrome. 2). Thus, while studying excessively active individuals, we frequently face the paradox of improved functional postoperative scores coexisting with low postoperative patient satisfaction. Yuan C, Wang Z, Zhu G, Wang C, Ma X, Wang X. Biomed Res Int. At 14 days postoperatively, the sutures were removed, and plaster fixation was applied for 4 weeks. Epub 2012 Aug 9. The posterior talofibular ligament (PTFL) is of less clinical significance. The calcaneocuboid angle at 20 kp varus stress. 2022 May 9;9:816669. doi: 10.3389/fsurg.2022.816669. However, as this is a retrospective study, the need for a superior level of evidence calls for the design of a prospective study with a higher number of participants and increased (more than 80%) statistical power. Failure after strict rehabilitation may be an indication for surgery. Sports Med 1999 Jan;27(1):61-71. Clinicians should closely examine the LB in cases of CLAI, and should surgically repair or reconstruct the LB when necessary. Of the 112 cases of CLAI plus concurrent LB injury, 62 patients (55.4%) were men, and 50 (44.6%) were women. The treatment options of immobilization and functional management are discussed. In patients with ankle sprain, anterior talofibular ligament injury may cause avulsion fracture. This procedure, called . The left foot was involved in 69 cases (61.6%), and the right in 43 cases (38.4%). Anat Anzeiger Off Organ Anat Gesellschaft, 2018, 216: 69- 74. In preoperative assessment, a detailed history was taken and a thorough clinical examination was performed. This test was performed with the ankle held at 15 degrees of plantar-flexion, the talus in extreme varus, and the tibia rotated internally at 10 degrees. Finally, as reports of LB injury are extremely rare, we cannot compare our method with methods used by other organizations. Am J Sports Med. English, Also, patients were encouraged to start proprioception and manual resistance exercises, to focus on intrinsic muscle strengthening, and begin swimming. Methods One hundred and eight patients with CLAI, who were treated surgically . Two years after surgery, it improved to 96.6 6.84 in group A and 96.9 6.53 in group B, whereas the overall mean score was 96.9 6.54 (p < 0.001) (Table (Table11). Synovitis and scar tissue formation were more common in group A (p = 0.011). Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. [10]. Southern California Orthopedic Institute Sports Medicine and Arthroscopy Fellowship receives institutional support from Depuy Mitek and Smith & Nephew. Ankle arthroscopy provided useful information about the pattern of the injury and decision-making regarding the necessity for LLC reconstruction. Hermans JJ, Wentink N, Beumer A, Hop WC, Heijboer MP, Moonen AF, Ginai AZ. [16] When the anterior talofibular ligament and the calcaneofibular ligament were successfully reconstructed, the LB was checked for relaxation or complete rupture due to avulsion fracture. Anatomic repair using a modification of the Brostrm procedure is the preferred technique for initial surgery. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. The purpose of this study is to investigate the relationship between preoperative radiographic alignment, intraoperative stress testing, concomitant pathology, and . Cohen's kappa coefficient was used to determine the inter-rater reliability between clinical examination and arthroscopy, as well as MRI and arthroscopy. This retrospective study included 218 consecutive patients with CLAI who underwent surgery from January 2012 to December 2015. Return to play after modified Brostrm operation for chronic ankle instability in elite athletes. For chronic lateral ankle instability, we also need to look for other conditions such as peroneal tendon pathology, fractures, joint lesions . Would you like email updates of new search results? Bookshelf [7]. So we summarize the following experience for reference: in type I and type II injuries the fracture fragment should be removed and reconstructed with a wire anchor; cannulated screws were used to fix the fracture in type III patients, and the LB reconstruction was performed with autograft or allograft tendons. Chronic ankle instability is initially treated nonoperatively, with surgical management reserved for those who have failed to improve after 3 to 6 months of bracing and functional rehabilitation. [13]. However, even in cases where PTFL is ruptured, reconstruction is not necessary [9]. cOrthopedics, Hebei Provincial People's Hospital, Shijiazhuang, Hebei, P.R. Keywords: This study aims to investigate the effect of double-bands anatomical reconstruction of the ATFL's fibular enthesis for the treatment of CLAI. The LB is a double ligament with a common origin on the lateral aspect of the anterior process of the calcaneus (APC). Skeletal Radiol 1987;16:1146. J Orthop Surg Res. In cases where the CFL was intact (group A) (Figure (Figure1),1), no further treatment was performed. your express consent. It also prevents the ankle ligaments from weakening. A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle. Over the next two weeks, patients were allowed to perform proprioception, resistance, and closed chain training exercises. Statistical analyses were performed with statistical software (SPSS version16.0; SPSS, Inc, Chicago, IL). J Bone Joint Surg Br 1991;73:8025. Feng SM, Shao CQ, Sun QQ, Oliva F, Maffulli N. J Orthop Surg Res. We aim to describe a treatment algorithm for chronic lateral ankle instability based on the arthroscopic findings of the calcaneofibular ligament (CFL). Asia Pac J Sports Med Arthrosc Rehabil Technol. AJR Am J Roentgenol 2009;193:66271. Data is temporarily unavailable. Difference of Plantar Pressure Distribution Between Surgical Treatment and Conservative Treatment for Chronic Ankle Instability Sponsors: Lead Sponsor: Peking University Third Hospital It also permitted the management of associated intra-articular injuries that were responsible for the majority of symptoms seen in patients with functional chronic ankle instability [13]. Finally, the lateral portion of the inferior extensor retinaculum was tagged to the periosteum of the fibula with absorbable sutures (Figures (Figures2,2, ,3).3). 2022 Feb 25;35(2):172-7. doi: 10.12200/j.issn.1003-0034.2022.02.016. An official website of the United States government. Chronic ankle instability (CAI) has been defined as "repetitive bouts of lateral ankle instability resulting in numerous ankle sprains.". Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Tourne Y, Besse JL, Mabit C (2010) Sofcot chronic ankle . In "functional" ankle instability, patients report a subjective feeling of "giving way" with provocative tests being negative. More than half of these injuries occur after excessive ankle plantar-flexion and inversion during athletic activities or military training. The integrity of the ATFL was assessed with the anterior drawer test. All participants were recreational athletes or active service military personnel. Treatment for chronic ankle instability is based on the results of the examination and tests, as well as on the patient's level of activity. Individuals who participate in activities that involve the ankle, such as ballet and gymnastics or . The average age at the time of surgery was 31.9 (range, 1843) years. In particular, the mean post-injury Tegner score was 3.48 1.49 in group A and 3.61 1.29 in group B, whereas at two years post-surgery it increased to 6.12 2.03 (p = 0.008) and 6.2 2.15 (p = 0.009), respectively. Outcome of the modified Brostrom procedure for chronic lateral ankle instability using suture anchors. Chinese]. Case Rep Orthop 2016;2016:15. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Melo L, Canella C, Weber M, et al. The complication was addressed with surgical excision of the knots. 1-3 For many individuals, ankle sprains lead to functional or mechanical impairments, resulting in the sensation of giving way and repeated bouts of instability.4 This clinical phenomena is known as chronic ankle instability (CAI). Symptoms Pain, usually on the outer side of the ankle, may be so intense that you have difficulty walking or participating in sports. Bookshelf This study is limited by its retrospective nature. A: Inversion-adduction is the common mechanism causing the anterior talofibular ligament and the LB injury. [14]. The follow-up period was two years. Knee Surg Sports Traumatol Arthrosc. [20] The LB also provides the main static stability of the lateral and medial columns, stabilizing the linking between the midfoot and the hindfoot.[15]. With someone who has had several ankle sprains, like Virginie, you . Sci Rep. 2022 Oct 5;12(1):16650. doi: 10.1038/s41598-022-21115-5. government site. Preoperative color Doppler ultrasonography and magnetic resonance examination were performed to observe ATFL injury. 19 Younes C, Fowles JV, Fallaha M, et al. The site is secure. 2017 Feb;103(1S):S171-S181. It was, therefore, a valuable tool in determining whether ligament reconstruction was required, and if this proved not to be the case, it was used as a standalone treatment option [13,14]. Prospective observational study of midtarsal joint sprain: epidemiological and ultrasonographic analysis. 2022. Preoperative and final follow-up values of the assessed variables of excision of the fracture fragment (n = 32). Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence Authors Song Ho Chang 1 , Brandon L Morris , Jirawat Saengsin , Yves Tourn , Stephane Guillo , Daniel Guss , Christopher W DiGiovanni Affiliation The postoperative results in group A indicated that arthroscopic treatment alone sufficed for the management of patients with functional instability. Ankle function and motion were restored without re-instability. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. Modification of the Brstrom repair with suture anchors has been used to address chronic lateral ankle instability. Failure after strict rehabilitation may be an indication for surgery. Our proposed algorithm offered a reliable pathway for accurate evaluation and successful treatment of chronic lateral ankle instability in high-demand groups. PMC If the injury does not improve with bracing and therapy over time, the best treatment is surgical ligament repair. The diagnosis of LB injury can be missed or delayed. Knee Surg Sports Traumatol Arthrosc. All identified randomized and quasi-randomized controlled trials of operative treatment for . Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Kaikkonen A, Lehtonen H, Kannus P, Jrvinen M. Long-term results of Watson-Jones tenodesis of the ankle. Federal government websites often end in .gov or .mil. The pattern of lateral ankle ligamentous injury is well understood. Both the anterior ankle drawer test and the varus stress test were positive. Kennedy JG, Smyth NA, Fansa AM, et al. Int Orthop, 34 (7) (2010), pp. Chronic lateral ankle instability: Results of two-staged approach, correlation with magnetic resonance imaging findings, and incidence of associated pathologies - A 4-year follow-up study Shaival Dalal 1, Geralt Morgan 1 1 Department of Trauma and Orthopaedics, Princess of Wales Hospital, Glamorgan, United Kingdom Sixty-eight of the 112 patients underwent LB repair, and 8 underwent LB reconstruction using allogeneic tendon grafts. Abbreviations: AOFAS = American Orthopaedic Foot and Ankle Society, APC = anterior process of the calcaneus, CLAI = chronic lateral ankle instability, LB = ligamentum bifurcatum, VAS = visual analog scale pain scores. Treatment The majority of ankle sprains will heal with time and are treated with rest, and physical therapy including peroneal muscle strengthening with proprioception and range of motion of the ankle. These three issues need to all be considered as part of a triad of chronic ankle instability issues. Foot Ankle Clin. Early and late repair of lateral ligament of the ankle. Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. They were recreational athletes or active military personnel. 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