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The knee is a joint that is often injured in sport, with a large and increasing number of ligament tears and repairs; postoperative complications can lead to poor outcome, such as stiffness. Beyond the well-known and well-described intra- and extra-articular causes of postoperative stiffness, the present study introduces the concept of a central reflex motor inhibition mechanism called arthrogenic muscle inhibition (AMI). AMI occurs after trauma and can be defined as active knee extension deficit due to central impairment of Vastus Medialis Obliquus (VMO) contraction, often associated with spinal reflex hamstring contracture. This explains the post-traumatic flexion contracture that is so common after knee sprain. The clinical presentation of AMI is easy to detect in consultation, in 4 grades from simple VMO inhibition to fixed flexion contracture by posterior capsule retraction in chronic cases. After recent anterior cruciate ligament (ACL) tear, more than 55% of patients show AMI, reducible in 80% of cases by simple targeted exercises initiated in consultation. Practically, in patients who have sustained knee sprain, it is essential to screen for this reflex mechanism and assess reducibility, as AMI greatly aggravates the risk of postoperative stiffness. In case of hemarthrosis, we recommend joint aspiration, which provides immediate benefit in terms of pain and motor inhibition. In case of persistent AMI, classical electrostimulation and "cushion crush", as used by all physiotherapists, are ineffective. To reduce the risk of postoperative stiffness, no surgery should be considered until AMI has resolved. LEVEL OF EVIDENCE: expert opinion., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

The Double Bundle U-DOS Reverse Technique for posterior cruciate ligament (PCL) tears is a novel arthroscopic technique that combines two well-known procedures: the mono-tunnel approach and the medial-portal approach, provides better posterior stability, improved functional outcomes, and a reduced risk of posterior tibial subluxation. This technique allows for the simultaneous treatment of anterolateral and posteromedial bundles and has been successfully performed on 16 patients, with follow-up showing sufficient support and resistance to posterior tibial subluxation or excessive displacement, resulting in a stable knee joint., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Traumatic injuries of the ankle are the most common injuries in sports. Up to 40% of patients who have undergone inversion ankle sprain report residual symptoms. The primary purpose of the study is to evaluate the incidence of SPN entrapment as consequence of acute severe inversion ankle sprain in children and adolescents; the secondary is to report the diagnostic pathway and the results after surgical treatment. From 2000 to 2015 were reviewed to summarize patients under the age of 15 years treated for a first episode of severe inversion ankle sprain. Cases with persistent symptoms (more than 3 months) indicative for SPN neuropathy were then identified. Instrumental investigations were recovered and a pre-operative assessment of pain (VAS) was recorded. Patients were evaluated at minimum of 1-year post-operative follow-up. 981 acute ankle sprains have been evaluated. 122 were considered severe according to van Dijk criteria. 5 patients were considered affected by neuropathy of the SPN. All patients underwent surgery consisting in neurolysis and capsular retention and ligament reconstruction. At 25 months of follow-up AOFAS moved from 57.6 to 98.6. The study highlights a previously unreported condition of perineural fibrosis of the superficial peroneal nerve at the level of the ankle following first acute severe inversion ankle sprain in children., (© 2021. The Author(s).)

Competing Interests: The author certifies that neither he, nor any members of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Background: Unexplained pain in the medial proximal tibia frequently leads to revision after unicondylar knee arthroplasty (UKA). As one of the most important factors for osteogenic adaptive response, increased bone strain following UKA has been suggested as a possible cause., Questions/purposes: In this study we: (1) performed a cadaver-based kinematic analysis on paired cadaveric specimens before and after mobile-bearing and fixed-bearing UKA; and (2) simultaneously characterized the strain distribution in the anterior and posterior proximal tibia during squatting., Methods: Five pairs of fresh, frozen full-leg cadaver specimens (four male, one female, 64 years to 87 years) were subjected to a dynamic squatting motion on a kinematic rig to simulate joint loading for a large ROM. Forces were applied to the quadriceps and hamstrings during the simulation while an infrared camera system tracked the location of reflective markers attached to the tibia and femur. Tibial cortical bone strain was measured with stacked strain gauge rosettes attached at predefined anterior and posterior positions on the medial cortex. Pairwise implantation of mobile-bearing (UKAMB) and fixed-bearing implants (UKAFB) allowed a direct comparison of right and left knees from the same donor through a linear mixed model., Results: UKAMB more closely replicated native kinematics in terms of tibial rotation and in AP and mediolateral translation. Maximum principal bone strain values were consistently increased compared with native (anteromedial, mean [± SD] peak strain: 311 µε ± 190 and posterior, mean peak strain: 321 µε ± 147) with both designs in the anteromedial (UKAFB, mean peak strain: 551 µε ± 381, Cohen's d effect size 1.3 and UKAMB, mean peak strain: 596 µε ± 564, Cohen's d effect size 1.5) and posterior (UKAFB, mean peak strain: 505 µε ± 511, Cohen's d effect size 1.3 and UKAMB, mean peak strain: 633 µε ± 424, Cohen's d effect size 2.1) region. However, in the anterolateral region of the medial tibial bone, UKAFB demonstrated the overall largest increase in strain (mean peak strain: 1010 µε ± 787, Cohen's d effect size 1.9), while UKAMB (613 µε ± 395, Cohen's d effect size 0.2) closely replicated values of the native knee (563 µε ± 234)., Conclusion: In this in vitro cadaver study both UKAMB and UKAFB led to an increase in bone strain in comparison with the native knee. However, in the anterolateral region of the medial tibial plateau, proximal tibial bone strain was lower after UKAMB and UKAFB. Both UKAMB and UKAFB lead to comparable increases in anteromedial and posterior tibial strain in comparison with the native knee. In the anterolateral region of the medial tibial plateau UKA, proximal tibial bone strain was closer to the native knee after UKAMB than after UKAFB. In an attempt to link kinematics and strain behavior of these designs there seemed to be no obvious relation., Clinical Relevance: Further clinical research may be able to discern whether the observed differences in cortical strain after UKA is associated with unexplained pain in patients and whether the observed differences in cortical bone strain between mobile-bearing and fixed unicondylar designs results in a further difference in unexplained pain.

Background: Pectoralis major (PM) injuries are rare, primarily occurring in males during athletic activity. In the current literature, these injuries have not been well described in National Football League (NFL) athletes., Hypothesis: The incidence of PM injuries will be low in NFL athletes, with athletes missing significantly more time after injuries requiring operative management., Study Design: Cohort study., Level of Evidence: Level 4., Methods: All documented PM injuries were retrospectively analyzed using the NFL Injury Surveillance System over a 15-season period. The data were analyzed by season, session, position, activity, and contact type at the time of injury. Additionally, the incidence, treatment, and days missed as a result of injury were assessed., Results: Over 15 consecutive seasons, there were a total of 211 PM injuries. Of these injuries, 132 were classified as strains and 79 as ruptures. The incidence of strains was 0.41 per 10,000 athlete-exposures, compared with 0.25 per 10,0000 athlete-exposures for ruptures ( P < 0.01). Players with PM ruptures treated operatively missed significantly more days than players treated nonoperatively (146.7 ± 55.0 vs 77.2 ± 72.9; P < 0.01)., Conclusion: NFL athletes miss significantly more time after operative compared with nonoperative management of PM ruptures., Clinical Relevance: PM injuries are rare, with the current literature lacking description of these injuries in NFL athletes. The paucity of data limits physicians from providing adequate counseling and expectations for athletes with this injury. This research represents the largest study assessing PM injuries in NFL athletes.

Background: The purpose of this study was to assess the frequency of superior labrum anterior posterior (SLAP) lesions, long head of biceps tendon (LHBT) pathologies, and superior rotator cuff tears accompanying subscapularis tears. We hypothesised that LHBT lesions, superior rotator cuff tears, and especially SLAP lesions were very frequent with subscapularis tears., Methods: The digital files of patients who underwent shoulder arthroscopy were reviewed retrospectively. One hundred and eleven patients with subscapularis tears evident on surgery videos were examined. Superior labrum, LHBT, and superior rotator cuff lesions were investigated by the authors of this study. The statistical analyses were made with SPSS statistics software, and significance was set at P < 0.05 value., Results: There were 111 patients with both subscapularis tears and surgery videos. The mean age was 58.09 ± 10.21, and 63.1% of the patients were female. 98.2% of the 111 patients had a SLAP lesion. 7.2% of those were SLAP I and 91% were SLAP II lesions while 1.8% were healthy. The 75.7% of the patients had a LHBT pathology, and 83.8% had superior cuff tear., Conclusions: Subscapularis tears were almost always accompanied by SLAP lesions. On the other hand, biceps tendon pathologies and superior rotator cuff tears were also very frequent with subscapularis tears., Level of Evidence: Prognostic study, Level IV (retrospective cohort study)., (Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

The complexity of the carpus explains the difficulty treating carpal injuries. Lesions are dominated by perilunate dislocation, scapholunate dislocation, and scaphoid fractures. The other injuries are trivial. Symptoms include pain and loss of wrist strength, reversible for an acute and well-treated lesion. Too often, these ligament injuries are diagnosed late. For delays longer than 6 weeks, ligament repair is ineffective. These old, complex lesions are potentially highly arthritic in the radiocarpal and mediocarpal joints. Improvements in wrist surgery have mitigated these chronic lesions. Various surgical techniques can preserve a functional wrist; wrist arthrodesis is no longer the only solution for these arthritic wrists. Over the past decade, arthroscopy has contributed to better understanding the injuries of the carpus as well as to better healing them. For acute or chronic ligament injuries without degenerative osteoarthritis, arthroscopy is the treatment of the future. This technique involves a long learning curve and the various arthroscopic techniques must be validated., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction: Chronic functional instability--characterized by repeated ankle inversion sprains and a subjective sensation of instability--is one of the most common residual disabilities after an inversion sprain. However, whether surgical reconstruction improves sensorimotor control has not been reported to date. The purpose of this study was to assess functional improvement of chronic ankle instability after surgical reconstruction using the remnant ligament., Materials and Methods: We performed 10 cases in the intervention group and 20 healthy individuals as the control group. Before and after surgical reconstruction, we evaluated joint position sense and functional ankle instability by means of a questionnaire., Results and Discussion: There was a statistically significant difference between the control and intervention groups before surgical reconstruction. Three months after surgery in the intervention group, the joint position sense was significantly different from those found preoperatively. Before surgery, the mean score of functional ankle instability in the intervention group was almost twice as low. Three months after surgery, however, the score significantly increased. The results showed that surgical reconstruction using the remnant ligament was effective not only for improving mechanical retensioning but also for ameliorating joint position sense and functional ankle instability.

Background: During the symposium held by the French Arthroscopy Society on rotator cuff tears in patients over 70 years of age, the absence of studies into potential specific pathological features in this age group was pointed out. Here, our main objective was to describe magnetic resonance imaging (MRI) findings in this patient population., Hypothesis: Tendons and muscles are smaller, lamellar dissection more prominent, and dystrophic changes more marked in patients over 70 years of age., Material and Method: We retrospectively studied 50 patients with isolated supraspinatus tears, including 25 younger than 50 and 25 older than 70 years of age. Tear size and retraction were evaluated according to Patte; tendon thickness, lamellar dissection, and fatty infiltration according to Goutallier; muscle size according to Thomazeau; and the tangent sign according to Zanetti., Results: In contradiction to our study hypothesis, lateral tendon thickness was similar in the two age groups. Medial thickness of the tendon-muscle junction, however, was greater in the younger group. Lamellar dissection was more marked and fatty infiltration more severe in the older group. As expected, marked muscle wasting and a positive tangent sign were noted in over two-thirds of patients in the older group., Conclusion: This preliminary study in a small number of patients identified specific MRI features of supraspinatus tears in patients older than 70 years compared to younger patients. A larger study would be useful to confirm these findings., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objective: To present the case of a bone lesion of the scapula in a collegiate basketball player., Background: A 19-year-old National Collegiate Athletic Association Division I male basketball player presented with pain in the posterior region of the right shoulder. During practice, he was performing a layup when his arm was forced into hyperflexion by a defender. Evaluation revealed a bone lesion involving the scapular spine and base of the acromion., Differential Diagnosis: Acromioclavicular joint sprain, subacromial bursitis, subscapular bursitis, humeral head contusion, acromial fracture., Treatment: The patient was treated for 2 months with therapeutic modalities and rehabilitation exercises. Because of persistent pain and the risk of a pathologic fracture, open surgical biopsy and bone grafting were then undertaken., Uniqueness: Most simple bone cysts affect the proximal humerus and femur, whereas our patient's lesion was in the acromial complex., Conclusions: Athletic trainers should be alert to the unusual possibility of bone cysts, which are usually identified incidentally when radiographs are obtained for other reasons. Most simple bone cysts are asymptomatic, but a pathologic fracture can occur with trauma.

Introduction: Wrist arthroscopy has evolved since its inception to become an essential diagnostic and therapeutic tool for the management of various wrist disorders. Our study aimed to examine the outcomes of arthroscopic debridement in the treatment of scapholunate (SL), lunotriquetral (LT) and triangular fibrocartilage complex (TFCC) tears., Methods: We conducted a retrospective review of 68 consecutive wrist arthroscopies performed at our institution between January 2000 and July 2005. All the patients complained of wrist pain, which often interfered with their daily activities, work or sports. A standard arthroscopic technique was employed in all. Any intercarpal ligament or TFCC tears found were debrided., Results: There were 42 patients with TFCC tears, 58 with SL tears and 49 with LT tears. At a mean follow-up time of 16.6 months, 85.3% of the patients reported an improvement in symptoms and 27.9% had improved range of motion. Grip strength improved by 11.8%. All except two patients returned to their original activities. Outcome following arthroscopic debridement was determined using the Mayo Modified Wrist Score. Based on the postoperative wrist scores of 47 patients, 24 were rated excellent, 17 good, four fair and two poor. By comparing the pre- and postoperative wrist scores of 31 patients, we were able to demonstrate significant improvement in patients who underwent wrist arthroscopies., Conclusion: Our study demonstrated that there is a definite role for arthroscopic debridement in the management of SL, LT and TFCC tears.

Purpose: In the treatment of chronic ankle instability, most non-anatomical reconstructions use the peroneus brevis tendon. This, however, sacrifices the natural ankle stabilising properties of the peroneus brevis muscle. The aim of this study was to evaluate the functional outcome of patients treated with a hemi-Castaing procedure, which uses only half the peroneus brevis tendon., Methods: We performed a retrospective cohort study of patients who underwent hemi-Castaing ligamentoplasty for chronic lateral ankle instability between 1993 and 2010, with a minimum of one year follow-up. Patients were sent a postal questionnaire comprising five validated outcome measures: Olerud-Molander Ankle Score (OMAS), Karlsson Ankle Functional Score (KAFS), Tegner Activity Level Score (pre-injury, prior to surgery, at follow-up), visual analog scale on pain (VAS) and the Short Form 36 (SF-36)., Results: Twenty patients completed the questionnaire on functional outcome. The OMAS showed good to excellent outcome in 80% and the KAFS in 65%, the Tegner Score improved from surgery but did not reach pre-injury levels, the VAS on pain was 1 of 10 and the SF-36 returned to normal compared with the average population., Conclusions: Even though most patients were satisfied with the results, outcome at long-term follow-up was less favourable compared with the literature on anatomical reconstructions. In accordance with the literature, we therefore conclude that the initial surgical treatment of chronic lateral ankle instability should be an anatomical repair with augmentation (i.e. the Broström-Gould technique) and the non-anatomical repair should be reserved for unsuccessful cases after anatomical repair or in cases where no adequate ligament remnants are available for reconstruction.

Background: Musculotendinous infraspinatus ruptures belong to the category of "muscle strain injuries". They differ from a classic rotator cuff tear by the following features: tendon attachment remains intact and the acute initial stage typically undergoes an intense muscular edema, replaced, 6 to 12 months later, by complete and permanent fatty infiltration of this muscle., Methods: Between 1993 and 2007, we prospectively identified 59 musculotendinous ruptures of the infraspinatus muscle tendon complex. Fifty-eight percent of these patients were females. The average age at presentation was 50 years old. Onset was non traumatic in 78% of these cases. Twenty-nine patients were seen at the acute lesion stage with pain and, on T2 fat saturated MRI sequences, muscular edema. A second group of 30 patients presented with a stage 4 fatty infiltration of the infraspinatus muscle associated with a musculotendinous disruption. Twenty-three patients underwent EMG testing which was normal in all cases. None of these patients had a full thickness tear of the rotator cuff tendons, 21% of the patients presenting in the acute phase had a partial thickness tear of the supraspinatus, which increased to 70% in patients presenting in the chronic phase suggesting a more degenerative etiology. Calcific tendonitis was seen in 61% of patients., Results: Twenty-four patients underwent surgery, while the remaining 35 were treated conservatively. The average follow-up, for all of them, was 46 months (12-125). The Constant score increased from 51.7 to 69.4 (p<0.001). There was no significant difference between the operated and the non-operated groups (p=0.325). All the patients seen at the acute painful edematous stage progressed to stage 4 complete fatty infiltrations, irrespective of selected treatment. None of the patients who underwent surgery had any regression of their fatty infiltration., Conclusions: Early diagnosis of this lesion can be made using T2 fat saturated MRI imaging. We hypothesize that early tendon repair which restores muscle tension in the infraspinatus may halt the progression of this entity and prevent complete functional loss of this muscle., Level of Evidence: Level IV: Therapeutic study., (2009 Published by Elsevier Masson SAS.)

Objectives: We examined the accuracy of the Ottawa Ankle Rule (OAR) to rule out ankle and mid-foot fractures in patients presenting with acute ankle sprain and differences of accuracy between surgeons and non-surgeons., Design: Prospective cohort study., Setting: Swiss urban secondary care centre., Participants: Between September 2001 and October 2002 359 patients presented with a case of ankle sprain. Of these, 251 patients both met recruitment criteria and provided data for this study. A group of surgeons and non-surgeons assessed the OAR and all patients underwent blinded radiographic assessment., Main Outcome Measures: Sensitivity, specificity of the OAR., Results: Of the 251 patients with ankle sprains 33 had an ankle fracture (13%) and none had a mid-foot fracture. All cases with a fracture had a positive OAR result (sensitivity 100% 95% CI; 89-100) and of 218 patients without a fracture, the OAR was negative in 45 cases (specificity 21%; 16-27). In the subgroup of patients assessed by surgeons, sensitivity was 100% (77-100) and specificity was 32% (20-46). In the non-surgical group, sensitivity was also 100% (82-100) but specificity was lower (17% (11-23)., Conclusions: This validation study of the OAR in a Swiss setting produced similar results than those published previously in various other settings. We found differences in the performance of the rule between surgical and non-surgical staff indicating that the OAR has its interpretation component which is more difficult to judge properly by well-instructed non-surgical assessors.

Background: Grade III syndesmosis sprains are usually treated with internal fixation. Limited information is available on early weightbearing and early return to activity after operative treatment for grade III syndesmosis sprains., Hypothesis: Treatment of grade III syndesmosis sprains in intercollegiate athletes with internal fixation, early range of motion, and early weightbearing can lead to rapid return to sport with minimal complications and no ankle problems in midterm follow-up., Study Design: Case series; Level of evidence, 4., Methods: We evaluated a consecutive series of intercollegiate athletes treated operatively with 4.5-mm cortical screw fixation for grade III syndesmosis sprains. At 1 week after surgery, patients were allowed to begin range of motion exercises, progressive weightbearing, and gradually return to full activity as tolerated. Outcome measures included time to return to full activity and, at final follow-up, the Sports Ankle Rating System scores., Results: Six male intercollegiate college athletes met the inclusion criteria for this study. The average time for return to full activity was 41 days (range, 32-48 days). There were no intraoperative complications or complications when resuming in-season sport activities with the screw in place. One screw broke during removal. At an average follow-up of 34.3 months, using the Sports Ankle Rating System, the average clinical rating score was 96.2, the average quality-of-life measure was 96.7, and the average single assessment numeric evaluation was 95.3. Radiographs at final follow-up showed no mortise widening or lateral talar subluxation. Two patients had mild degenerative changes on lateral radiographs with anterior tibial osteophytes., Conclusions: In selective cases, athletes can return to full activity as early as 6 weeks after internal fixation of grade III syndesmosis sprains.

Background: Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and use of an external support (e.g. ankle brace), and surgical repair or reconstruction., Objectives: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults., Search Strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006., Selection Criteria: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults., Data Collection and Analysis: At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings., Main Results: Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants. The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I(2) statistics showed the remaining trials to be more homogeneous. The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group., Authors' Conclusions: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomised controlled trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Background: Hamstring strains are among the most frequent injuries in sports, especially in events requiring sprinting and running. Distal tears of the hamstring muscles requiring surgical treatment are scarcely reported in the literature., Objective: To evaluate the results of surgical treatment for distal hamstring tears., Design: A case series of 18 operatively treated distal hamstring muscle tears combined with a review of previously published cases in the English literature. Retrospective study; level of evidence 4., Setting: Mehiläinen Sports Trauma Research Center, Mehiläinen Hospital and Sports Clinic, Turku, Finland., Patients: Between 1992 and 2005, a total of 18 athletes with a distal hamstring tear were operated at our centre., Main Outcome Measurements: At follow-up, the patients were asked about possible symptoms (pain, weakness, stiffness) and their return to the pre-injury level of sport., Results: The final results were rated excellent in 13 cases, good in 1 case, fair in 3 cases and poor in 1 case. 14 of the 18 patients were able to return to their former level of sport after an average of 4 months (range 2-6 months)., Conclusions: Surgical treatment seems to be beneficial in distal hamstring tears in selected cases.

Background: A search of the literature shows that the effect of surgery on ankle proprioception has been hardly investigated., Objective: To examine the effect of anatomical reconstruction of the anterolateral capsuloligamentous complex on ankle joint position sense., Methods: A prospective study using the "slope box" test. Ten consecutive patients were included in the study, and 10 healthy athletes represented the control group., Results: Similar test-retest reliability rates (overall reliability 0.92; p = 0.0013) were obtained to those of the original designers of the method. There were no significant differences with respect to side dominance (p = 0.9216). Investigation of the characteristics of mean absolute estimate errors showed that the controls tested became error prone in the range of slope altitudes 7.5-25 degrees in every direction, compared with the range 0-5 degrees (range of p values 0.00003-0.00072). The results of the intervention group showed that, for the two main directions of interest (anterior and lateral), preoperative differences in mean absolute estimate errors between injured (anterior 3.91 (2.81) degrees ; lateral 4.06 (2.85) degrees ) and healthy (anterior 2.94 (2.21) degrees , lateral 3.19 (2.64) degrees ) sides (anterior, p = 0.0124; lateral, p = 0.0250) had disappeared (postoperative differences: anterior, p = 0.6906; lateral, p = 0.4491). The afflicted ankle had improved significantly after surgery in both important directions (anterior, p<0.0001; lateral, p = 0.0023)., Conclusions: The study shows that differences in joint position sense between healthy and injured ankles disappeared as the result of surgery. Preoperative data show that proprioceptive malfunction is a cause of functional instability. If treatment is by means of surgery, the retensioning of the original anterolateral structures is inevitable, even if other grafting or surgical techniques are used.

Background: Inversion injuries, primarily sprains, of the ankle are one of the most commonly treated injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and the use of an external support (e.g. ankle brace or taping), and surgical repair or reconstruction., Objectives: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults., Search Strategy: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field., Selection Criteria: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute injuries to the lateral ligament complex of the ankle in adults., Data Collection and Analysis: At least two, usually three, reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled using fixed and random effects models and relative risks with 95% confidence intervals for dichotomous outcomes calculated. Heterogeneity between trials was tested using a standard chi-squared test. We undertook sensitivity analyses to explore the effects of inclusion of quasi-randomised trials and subgroup analyses by the two main methods of conservative treatment., Main Results: Seventeen studies, involving a total of 1950 mostly young active adult males, were included. All trials had methodological flaws. In particular, allocation was rated as effectively concealed in only one trial and there was no report of masking outcome assessors to the interventions in any trial. Outcome measures were variously defined and data for pooling for individual outcomes were only available for a maximum of 11 studies. While there were statistically significant differences for three primary outcomes (non-return to pre-injury level of sports; undefined pain or pain on activity; and subjective or functional instability) in favour of the surgical treatment group using the fixed effects model, these findings failed to demonstrate robustness in sensitivity analyses. Exclusion of the data from explicitly quasi-randomised trials or, given the highly statistically significant heterogeneity, analyses using the random effects model modified these findings to non-statistically significant differences. There was no statistically significant difference in ankle sprain recurrence, the other primary outcome measure. Though there was a statistically significantly higher incidence of objective instability in conservatively treated patients, the functional implications of this are uncertain. There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. Subgroup analyses by type of conservative treatment (plaster cast or functional treatment) revealed no statistically significant differences in effect for any of the six outcomes examined., Reviewer's Conclusions: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. Sufficiently powered, good quality and adequately reported randomised trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

We arthroscopically resected the impinged distal fascicle of the anterior inferior tibiofibular ligament (AIT-FL) in 21 patients (mean age 31 (11-68) years, 14 women) with chronic ankle pain after an ankle sprain. Clinical tests revealed moderate laxity in 2 and severe laxity in another 2, the remaining 17 ankles showing only mild laxity. During arthroscopy, an impinging distal fascicle of the AITFL was found in all cases. Following anterolateral synovectomy, the fascicle was excised. At the follow-up after mean 3 (2-4) years, good-to-excellent results were obtained in 17 patients. 19 patients were satisfied with the procedure and 17 patients returned to their previous level of activity. 2 patients who had mild laxity were graded as poor because of neuromas of the terminal branches of the superficial peroneal nerve. These patients became asymptomatic after an injection of steroids.

Recent reports on the outcome of sports injuries have pointed out that ankle sprains may cause long term discomfort, this occasionally being due to peroneal tendon dislocation which may become chronic. The present paper reports a method, which includes deepening of the retromalleolar groove and at the same time maintaining the cartilagenous gliding layer. Long term follow-up (2 to 10 years) is presented on four patients. One of the patients returned successfully to international track and road races. In each case, the clinical result after the operation was successful, the ankles showing normal biomechanical functions.

Eighteen athletes with symptoms of recurrent sprain and instability of the ankle during activity were treated by reconstructing the lateral ligament by the Evans technique. Before the operation 55 per cent had given up all athletic activities because of pain, swelling or instability, and 17 per cent had restricted their activities. The average age at operation was 24.6 years and the average follow-up period 3.1 years. Normal stability was achieved in 67 per cent and improved stability in 11 per cent, but only 33 per cent were still engaged in athletic activities without any complaints from the ankle. The results are similar to other methods of surgical repair.

Our approach to the problem of ankle sprains and instability is reviewed. After diagnostic evaluation (including stress roentgenography, arthrography, or tenography if necessary), most of our patients are treated either by taping if they have a grade 1 or 2 sprain or by casting if they have a grade 3 disruption. If the injury should progress to chronic instability despite this treatment regimen, which is an unusual occurrence, satisfactory reconstructive procedures are available. Indications for acute primary repair are limited.