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Objective To compare three surgical techniques for lateral ankle ligament reconstruction using finite element (FE) models. Methods A three-dimensional FE model of the left foot of a healthy volunteer and lateral collateral ligament injury models were developed. Three tendons [one-half of the autologous peroneus longus tendon (PLT), one-half of the peroneus brevis tendon (PBT), and an allogeneic tendon] were used for lateral collateral ligament reconstruction. The ankle varus stress and anterior drawer tests were performed to compare the three surgical techniques. Results The ankle varus stress test showed that the equivalent stresses of the anterior talofibular ligament (ATFL) (84.00 MPa) and calcaneofibular ligament (CFL) (27.01 MPa) were lower in allogeneic tendon reconstruction than in the other two techniques but similar to those of normal individuals (138.48 and 25.90 MPa, respectively). The anterior drawer test showed that the equivalent stresses of the ATFL and CFL in autologous PLT reconstruction (31.31 and 28.60 MPa, respectively) and PBT reconstruction (31.47 and 29.07 MPa, respectively) were lower than those in allogeneic tendon reconstruction (57.32 and 52.20 MPa, respectively). Conclusions The allogeneic tendon reconstruction outcome was similar to normal individuals. Allogeneic tendon reconstruction may be superior for lateral ankle ligament reconstruction without considering its complications.

Background: Studies regarding magnetic resonance imaging (MRI) findings of the lateral ankle ligaments in chronic lateral ankle instability and their clinical relevance for surgery are lacking. This study classified the lateral ankle ligament MRI findings of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in chronic lateral ankle instability (CLAI) and correlated these findings with ankle stress radiographs. Methods: We included 132 ankles with CLAI that underwent ligament reconstructions from 2006 to 2013. The distributions of the ATFL and CFL morphologies were evaluated using the following categories: (1) the amount of thickness: normal/thickened/attenuated/non-visualized, (2) the presence of discontinuity, (3) wavy or irregular contour, and (4) increased signal intensity on T2-weighted images. The relationships between the ligament morphologies and stress radiographs were analyzed. Results: The ATFL was normal in 5 (4%) ankles, thickened in 35 (27%), attenuated in 76 (58%), and non-visualized in 16 (12%), while the CFL was normal in 39 (30%) ankles, thickened in 42 (32%), attenuated in 44 (33%), and non-visualized in 7 (5%). Discontinuity of the ATFL or CFL was observed in 46 (35%) ankles. Wavy or irregular contours were observed in 55 (42%) ATFLs and 37 (28%) CFLs, and signal intensity of both ligaments was increased in 19 (14%) ankles. ATFL ( P < .001) and CFL thickness ( P = .007) correlated with the talar tilt angle. Conclusions: The MRI findings of CLAI showed several morphologies and specific incidences for each morphology. Attenuated, wavy appearance was the most frequent MRI pattern. Thickness was related to the degree of instability. Level of Evidence: Level IV, retrospective case series.

Category: Arthroscopy; Ankle; Sports Introduction/Purpose: The Broström-Gould is the gold standard in repair of the lateral ankle ligaments for chronic instability and arthroscopic Broström repairs have become increasingly popular with outcomes comparable to the open procedure. Despite demonstrated success, the arthroscopic Broström, like the open procedure, does not achieve the same mechanical strength as the intact native ankle ligaments and is therefore not appropriate for early aggressive rehabilitation. Suture tape augmentation of an open Broström procedure has been shown to further strengthen the repair and produce favorable outcomes in preventing recurrent instability. Studies reporting long-term clinical outcomes of patients who undergo this procedure are lacking. This study reports clinical and functional outcomes after an arthroscopic repair with arthroscopically applied suture tape augmentation and an accelerated post-operative rehabilitation protocol. Methods: Ninety-three patients with chronic recurrent ankle instability who had failed non-operative treatment (bracing, taping, physical therapy) underwent arthroscopic lateral ligament repair augmented by a suture tape applied in a novel all-arthroscopic fashion (double stranded polyethylene tape fixed to talus and fibula with interference screws). Postoperatively patients were placed in a CAM walker and allowed to bear weight immediately. On postoperative day 8 patients were placed in a functional brace and began physical therapy to include motion, strength, and proprioceptive activities. At week 4 patients began sports specific activities and were allowed to return to unrestricted activity at week 8. Foot and Ankle Ability Measure (FAAM), Visual Analog Score (VAS), Tegner Score, and range of motion measurements were performed. Statistical analysis was done to determine averages, ranges, and standard deviations of scores. Paired t-test was utilized to find statistically significant differences in scores. Results: Eighty-five patients (42 males, 43 females; average age 30.42 years) were available at a minimum of 24 months post- operatively (range 24-68). Postoperatively, average VAS scores fell to 0.85 from 4.67, (pConclusion: The results indicate that acclerated rehabilitation after arthroscopic lateral ligament repair augmented with arthroscopically applied suture tape is a safe and effective procedure that produces favorable outcomes for patients with chronic recurrent ankle instability.

Background: Lateral ankle instability is one of the most common musculoskeletal disorders and can result in ankle damage. This study reports on the results of the anatomical reconstruction of ligaments using semitendinosus tendon allograft and bioabsorbable tenodesis screws for chronic lateral ankle instability, as well as the functional and radiological results of this procedure. Methods: From February 2007 to January 2013, 70 patients (72 ankles) underwent this procedure. Six patients were lost to follow-up, and ultimately 64 patients (66 ankles) were evaluated. Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, Karlsson-Peterson ankle scores, and patient satisfaction were evaluated at a mean of 22.1 months (range, 12-68 months) postoperatively. The talar tilt angle and anterior translation were assessed radiographically in pre- and postoperative ankle stress views. The mean patient age at surgery was 30.1 years (range, 16-59 years). Results: The mean VAS pain score decreased from 5.5 to 1.3 ( P < .05), and the mean AOFAS improved from 71.0 to 90.9 ( P < .05). The mean Karlsson-Peterson score improved from 55.1 to 90.3, whereas talar tilt decreased from 14.8 degrees to 3.9 degrees. There was no significant difference in clinical outcomes between the pretensioned and nonpretensioned groups. Conclusion: This procedure yielded successful results, including satisfactory ankle stability and clinical outcomes, in ankles with poor lateral ligament tissues. Level of Evidence: Level IV, case series.

BackgroundThe sensorimotor influence of the lateral ankle ligaments in muscle activation is unclear.HypothesisThe lateral ankle ligaments have significant sensorimotor influence on muscle activation.Study DesignControlled laboratory study.MethodsMuscle-firing characteristics in response to a high-speed inversion perturbation and during gait were assessed in 13 normal subjects. Solutions (1.5% lidocaine or a placebo of saline) were injected bilaterally into the anterior talofibular and calcaneofibular ligaments (1.5 ml per ligament) to alter peripheral afferent influence. Subjects were again tested with the same protocol.ResultsThe protective response of the anterior tibialis and peroneal muscles during inversion perturbation and mean muscle activation amplitude decreased during running after both injections. After injection, no significant differences were seen for muscle reflex latencies, maximum amplitude, time to maximum amplitude during inversion perturbation, or mean amplitude during walking.ConclusionThe lateral ankle ligaments have a sensorimotor influence on muscle activation.Clinical RelevanceInduced edema from the injected solutions may have altered the sensorimotor influence of the lateral ankle ligaments, thereby inhibiting the dynamic ankle stabilizers. This finding suggests that dynamic stability may be compromised because of swelling after joint injury.

BackgroundUnsatisfactory long-term results have been reported after use of a Broström repair for patients with chronic ankle ligament insufficiency.HypothesisRepair or reconstruction of both the anterior talofibular and calcaneofibular ligaments is essential for normal kinematics of the ankle-hindfoot.Study DesignCase series.MethodsThirteen patients with chronic instability of the ankle were found at operation to have injuries of both the anterior talofibular and calcaneofibular ligaments, with a lack of healthy ligament margins suitable for suturing. Reconstruction of the ligaments was performed with bone-patellar tendon graft. The score devised by Good et al. was used to assess the patients’ clinical condition before the operation and at final follow-up.ResultsBefore the operation, six patients had a grade 3 clinical condition and seven had a grade 4 condition. At a mean follow-up of 26.5 months, all patients had a grade 1 condition. The average talar tilt of the patients was improved from 18.4° ± 5.5° to 4.9° ± 2.6°, and the average anterior drawer sign was improved from 9.1 ± 2.6 mm to 5.8 ± 1.6 mm.ConclusionIn cases of combined injuries, short-term results of reconstruction of the anterior talofibular and calcaneofibular ligaments using bone-split patellar tendon graft were good, with a low frequency of complications.

Thirty-one consecutive ankles in 30 patients with chronic lateral ankle instability were reconstructed using a split peroneus brevis tendon graft. All patients had pain and instability despite adequate treatment and a rehabilitation program. Six patients had clinical and radiographic evidence of associated subtalar laxity. Four patients (four ankles) had prior Brostrom ligament reconstructions. The average time from the initial injury or treatment to surgery was 23 months. At a mean follow-up of 44 months (range, 24–64 months), the functional results included excellent in 20 ankles, good in 9, fair in 1, and poor in 1. Ankle stability, which did not deteriorate with time, was achieved in 30 of 31 ankles. This procedure is simple, safe, and reliable with a 94% good to excellent clinical result and 97% mechanical stability. It is an excellent reconstruction choice for those individuals with high demand ankles, with a longstanding ankle instability with or without subtalar instability, and for failed primary reconstruction.

The aim of this study was to assess the results of 32 cases of chronic ankle instability. These were treated by ligament shortening and reinforced with an inferior extensor retinaculum flap. All patients complained of persistent functional instability unrelieved with proprioceptive exercises. Results were assessed clinically (pain, instability, recovery of sports activity, mobility) and radiologically (correction of laxity on stress x-rays). This enabled us to draw up a revision score on a scale of 100 points. We obtained a mean score of 86.7 points (45–100 points), and subjective results showed that 88% of the patients were satisfied with the surgery.

The contributions of the lateral ankle ligaments to resisting anterior-posterior displacement of the talus were evaluated in eight unembalmed cadaveric ankles. While holding the distal tibia fixed, loads of 150 N were applied to the talus in the anterior and posterior directions in the neutral, dorsiflexed, and plantarflexed positions using an hydraulic test system. Tests were performed on the intact specimens then after sequential sectioning of the lateral ligaments of the ankle. Under strictly anteroposterior loading and without an axial (weight-bearing) load applied, no single ligament could be isolated as having a dominant stabilizing function.

Fifty-two of 86 repaired lateral ankle ligaments were reevaluated 3 to 53 months after surgery. Ninety-eight percent were functionally stable. Mechanical stability was determined by talar tilt measurement on "stress roentgenographs". This was found to be a reliable predictor of degree of injury and postoperative symp tomatology. Surgical repair in selected cases is rec ommended to assure mechanical and functional sta bility.

The problem of chronic instability of lateral ankle ligaments has been approached with both conservative and surgical measures. Many operative procedures have been devised to correct this problem, and of these the Watson-Jones, modified Elmslie and Evans procedures are the most commonly used in our community. This paper was designed to: 1) compare the results of the three procedures; 2) investigate subtalar motion in a population of uninjured ankles; and 3) compare these results to subtalar motion in ankles after lateral ligament reconstruction. We found that each of the three procedures had a surprisingly high incidence of postoperative pain. All procedures had a high rate of return to preinjury activity level, and the majority of the patients were satisfied with the results of the operation. Postoperatively, the Watson-Jones repair exhibited the highest percentage of subjective instability. Twenty-four per cent of the Watson-Jones repairs had a postoperative talar tilt greater than 5°. It was determined that subtalar motion was affected by the type of reconstructive procedure, and although this fact had been theorized in the literature, it had not been documented by objective data.

Twenty of 26 original athletes with injuries to the lateral ligaments of the ankle were reexamined 2 to 5 years following treatment. The functional quality of their an terior talofibular (TF) and calcaneofibular (CF) ligaments was tested by stress examination, using a commercially available stress device, and was compared with the results of stress examination, arthrography, and sur gery at the time of injury. Surgically treated patients showed a 70% to 100% recovery of the functional properties of the lateral ankle ligaments on comparison with the contralateral, unin jured ankle. Of the six patients treated conservatively With elastic bandages and rest, only one had regained normal function, whereas the others showed minimal or no improvement. Isolated lesions of the anterior TF ligaments, when treated conservatively, may have only a slightly better prognosis than a combined lesion of both anterior TF and CF ligaments in the athletic pop ulation.