Search

Category: Ankle; Sports Introduction/Purpose: Ankle sprains represent one of the most common injuries in the population (1). Most sprains resolve with conservative therapy, however, failure resulting in ligament laxity may require surgical intervention from pain and instability from injury to the anterior talofibular ligament (ATFL) (2). Surgical repair of the ATFL has relatively high success rates, however post-procedure chronic instability and pain remain a clinical challenge, with re-operation rates reported up to 14% (3). Artelon® FlexBand® matrix (Artelon, Sandy Springs, GA) is a copolymer of polyurethane urea and polycaprolactone (PUUR), a synthetic matrix designed to reinforce soft tissue repair during tendon/ligament reconstructive procedures. The goal of this study is to present patient reported outcomes (PROs) after modified Broström repair with PUUR augmentation device compared to historically reported ATFL repairs. Methods: This multi-center, IRB approved study is collecting data on patients that have undergone ATFL repair (isolated and non-isolated) with PUUR augmentation. These results represent an interim data analysis of an ongoing clinical study. A total of 47 patients diagnosed with chronic lateral ankle instability that had failed conservative therapy, and required surgical intervention to repair the lateral ligament complex were enrolled across two different research centers. Patient demographics, patient reported outcomes (PROs), safety, and complications were collected. PROs included Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), visual analog pain score (VAS), and Veterans Rand-12 (VR-12) at 2-, 6-, 12-weeks, 6-months and 1- and 2-year follow-up visits. Results: The average patient age was 40 years, and average BMI was 30.9. There is a statistical difference in VAS scores at all follow-up times after surgery (2 weeks to 2 years) compared to pre-surgery, with long term VAS scores at 1 and 2 years showing the greatest improvement (0.76 and 0.88, respectively, p< 001) compared to baseline. Similarly, FFI scores showed significant improvement at 12 weeks to 2 years. FAAM scores in PUUR augmented patients significantly improved at 6 months, 1 year and 2 year follow-up. Patient general health assessed by VR-12 showed significant improvement at longer term 1- and 2-year follow-up (Figure 1). There were no procedure or product related adverse events or complications necessitating a return to the OR for any patient. Conclusion: Our data shows a significant improvement in VAS as well as improvements in foot specific PROs, FFI and FAAM in patients who underwent the modified Brostrom procedure with augmentation. Future studies will address Flexband augmentation vs. modified Brostrom in parallel in a randomized, prospective study. [ABSTRACT FROM AUTHOR]

Abstract Background Measuring the strain patterns of ligaments at various joint positions informs our understanding of their function. However, few studies have examined the biomechanical properties of ankle ligaments; further, the tensile properties of each ligament, during motion, have not been described. This limitation exists because current biomechanical sensors are too big to insert within the ankle. The present study aimed to validate a novel miniaturized ligament performance probe (MLPP) system for measuring the strain patterns of the anterior talofibular ligament (ATFL) during ankle motion. Methods Six fresh-frozen, through-the-knee, lower extremity, cadaveric specimens were used to conduct this study. An MLPP system, comprising a commercially available strain gauge (force probe), amplifier unit, display unit, and logger, was sutured into the midsubstance of the ATFL fibers. To measure tensile forces, a round, metal disk (a “clock”, 150 mm in diameter) was affixed to the plantar aspect of each foot. With a 1.2-Nm load applied to the ankle and subtalar joint complex, the ankle was manually moved from 15° dorsiflexion to 30° plantar flexion. The clock was rotated in 30° increments to measure the ATFL strain detected at each endpoint by the miniature force probe. Individual strain data were aligned with the neutral (0) position value; the maximum value was 100. Results Throughout the motion required to shift from 15° dorsiflexion to 30° plantar flexion, the ATFL tensed near 20° (plantar flexion), and the strain increased as the plantar flexion angle increased. The ATFL was maximally tensioned at the 2 and 3 o’clock (inversion) positions (96.0 ± 5.8 and 96.3 ± 5.7) and declined sharply towards the 7 o’clock position (12.4 ± 16.8). Within the elastic range of the ATFL (the range within which it can return to its original shape and length), the tensile force was proportional to the strain, in all specimens. Conclusion The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns.

Introduction/Purpose: The modified Brostrom-Gould (MB) technique incorporates the inferior extensor retinaculum for added strength of anatomic Anterior Talo-Fibular Ligament (ATFL) repair. A major limitation of the MB technique is the inability to restore native ATFL biomechanics. Surgical augmentation methods have been introduced to address the MB insufficiency. The purpose of this study is to investigate the isolated biomechanical performance of common MB augmentation elements including suture tape, allograft, and copolymer compared to that of native ATFL. Methods: A total of 24 samples were tested in this study, n=6 in each group. An electromechanical testing system (Instron, Norwood, MA) was used to investigate the biomechanical performance of native ATFL, UHMW-PE suture tape (FiberTape™, Arthrex, Inc., Naples, FL), allograft (Semitendinosus Graft), and copolymer (FlexBand™, Artelon, Marietta, GA). Native ATFL ligaments were isolated from cadaver specimens (mean age: 63 years; range: 45-80), semitendinosus allografts were obtained from LifeNet Health (Jacksonville, FL). Samples measured 20 mm between rigid fixtures and oriented parallel with the long axis of the load cell to simulate worse-case loading. Samples were loaded to failure at 305 mm/min. Biomechanical outcomes included elongation, stiffness, and ultimate load to failure. One-way ANOVA was used to evaluate significant effects of all biomechanical variables. If significance was observed, post-hoc comparisons of augment element and native ATFL were performed with either Tukey or Holm-Sidak test (SigmaPlot, 14.0, Systat). Results: Stiffness was greatest for the suture tape group (246.4±52.1N/mm) and least for the copolymer (9.4±2.9N/mm). Significant differences were observed between all augment elements except when comparing ATFL to allograft (p=0.086). Ultimate load was greatest for the suture tape group (544.1±59.7N) and least for the copolymer (146.7±8.9N). Analysis revealed that suture tape ultimate load was statistically greater than copolymer (p < 0.001, Fig.1). Elongation at ultimate failure was greatest for the copolymer group (30.0±8.7mm) and least for suture tape (2.6±0.5mm). Significant interactions were detected for all ultimate load comparisons except for allograft and ATFL (p=0.691), allograft and suture tape (p=0.537), and ATFL and suture tape (p=0.436). See Figure 1 for all data and statistical outcomes. Conclusion: ATFL augmentation elements require thorough evaluation for clinical adoption. Copolymer was 79% weaker in ultimate load and elongated 131% more than the native ATFL. Conversely, suture tape group exhibited 47% greater ultimate load and 82% less elongation at failure compared to ATFL. Clinically, these results suggest the copolymer maintains elastic properties incapable of supporting ATFL ligament healing under load. ATFL augmentation with suture tape offers advantageous postoperative load-sharing support and may allow return to preinjury level activity sooner, as has been seen clinically.1 These results provide insight into how these augmentation elements perform in a static model. [ABSTRACT FROM AUTHOR]

BackgroundWe describe the topographic anatomy of the lateral ligament complex of the ankle using 3-dimensional (3D) computed tomography (CT) imaging.MethodsDissection of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) was performed on 8 unpaired fresh-frozen cadaver feet. Ligaments were sharply dissected from bone, and the footprint was outlined with radio-opaque paint. The specimen underwent a 0.625-mm slice CT scan of the ankle with 3D reconstructions. Software was used to determine the surface area of the ligament footprint as well as measure the distance from the peroneal tubercle to the center of the CFL footprint. Data are presented as mean ± standard error.ResultsSix specimens had a bifid ATFL. Seven ankles had a bifid ATFL footprint on the talus. All specimens had intact CFL fibers. The intact superior and inferior limbs of the ATFL measured 19.7 ± 1.2 mm and 16.7 ± 1.1 mm. The CFL measured 24.8 ± 2.4 mm. The area of the footprints of the superior ATFL and inferior ATFL on the talus measured 1.5 ± 0.26 cm(2) and 0.90 ± 0.07 cm(2). The CFL and ATFL origins on the fibula were continuous and measured 3.48 ± 0.39 cm(2). The CFL insertion on the calcaneus measured 2.68 ± 0.20 cm(2). The CFL was found 27.1 ± 1.0 mm posterior and superior from the peroneal tubercle.ConclusionsIn presumably uninjured specimens, both the ATFL and its footprint on the talus were bifid. The CFL and ATFL origins have a single confluent footprint on the anterior border of the distal fibula. The CFL footprint on the calcaneus is almost 3 cm posterior and superior to the peroneal tubercle.Clinical relevanceThis study may assist surgeons in anatomically reconstructing the lateral ligament complex of the ankle.

Background: Measuring the strain patterns of ligaments at various joint positions informs our understanding of their function. However, few studies have examined the biomechanical properties of ankle ligaments; further, the tensile properties of each ligament, during motion, have not been described. This limitation exists because current biomechanical sensors are too big to insert within the ankle. The present study aimed to validate a novel miniaturized ligament performance probe (MLPP) system for measuring the strain patterns of the anterior talofibular ligament (ATFL) during ankle motion.Methods: Six fresh-frozen, through-the-knee, lower extremity, cadaveric specimens were used to conduct this study. An MLPP system, comprising a commercially available strain gauge (force probe), amplifier unit, display unit, and logger, was sutured into the midsubstance of the ATFL fibers. To measure tensile forces, a round, metal disk (a "clock", 150 mm in diameter) was affixed to the plantar aspect of each foot. With a 1.2-Nm load applied to the ankle and subtalar joint complex, the ankle was manually moved from 15° dorsiflexion to 30° plantar flexion. The clock was rotated in 30° increments to measure the ATFL strain detected at each endpoint by the miniature force probe. Individual strain data were aligned with the neutral (0) position value; the maximum value was 100.Results: Throughout the motion required to shift from 15° dorsiflexion to 30° plantar flexion, the ATFL tensed near 20° (plantar flexion), and the strain increased as the plantar flexion angle increased. The ATFL was maximally tensioned at the 2 and 3 o'clock (inversion) positions (96.0 ± 5.8 and 96.3 ± 5.7) and declined sharply towards the 7 o'clock position (12.4 ± 16.8). Within the elastic range of the ATFL (the range within which it can return to its original shape and length), the tensile force was proportional to the strain, in all specimens.Conclusion: The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns. [ABSTRACT FROM AUTHOR]

Purpose of Review: Lateral ankle ligament sprains are one of the most commonly reported injuries in high-level athletes and the general population. Unfortunately, up to 40% of these can go on to develop chronic lateral ankle instability which in the right circumstances requires surgical intervention. The purpose of this review is to present the gold standard surgical treatment for chronic lateral instability with anatomic ligament repair and to highlight the techniques, outcomes, and importance of anatomy when considering surgical treatment. Recent Findings: Recent and remote literature agrees that the initial treatment for chronic ankle instability is non-operative rehabilitation. In the cases where this fails, the gold standard of surgical treatment is open anatomic repair using the Brostrom-Gould technique which stands out as having very good results over the course of time. Recent studies have shown equally good outcomes with arthroscopy as well as with internal brace devices, and both techniques show potential for earlier rehabilitation. In those with contraindications for anatomic repair including innate soft tissue laxity, high BMI, and in the revision setting, anatomic ligament reconstruction is an appropriate surgical option. Summary: Open modified Brostrom lateral ligament repair continues to be the preferred method of surgical treatment for chronic lateral ligament instability. In the setting of new modifications and techniques, long-term outcome studies are necessary to identify both their usefulness in long term and to compare them to the open surgery outcomes. It would be useful to standardize rehabilitation protocols as well as return to sport metrics in order to better evaluate outcomes moving forward. [ABSTRACT FROM AUTHOR]

Category: Ankle; Sports Introduction/Purpose: Ankle sprains represent one of the most common injuries among both athletes and the general public (1). While most sprains resolve with conservative therapy, failure resulting in ligament laxity may necessitate surgical intervention due to pain and instability from injury to the anterior talofibular ligament (ATFL), the weakest ligament in the lateral ligamentous complex (2). Surgical repair of ATFL has relatively high success rates, however post-procedure chronic instability and pain remain a clinical challenge, with re-operation rates reported as high as 14% (3). The Artelon® FlexBand® matrix is a biocompatible, synthetic matrix designed to reinforce soft tissue repair during tendon/ligament reconstructive procedures. The goal of this study is to compare the outcomes of ATFL reconstructive surgery with and without this synthetic graft augmentation. Methods: This multi-center, IRB approved study used a combination of retrospective medical chart review and prospective procedure satisfaction phone surveys in patients that had undergone ATFL repair (isolated and non-isolated) with or without synthetic graft augmentation. These results represent an interim data analysis of an ongoing clinical study. A total of 234 patients, (82 Control and 152 FlexBand augmented) diagnosed with chronic lateral ankle instability that had failed conservative therapy, and required surgical intervention to repair the lateral ligament complex were enrolled across four different research centers. Patient demographics, physician assessment of healing progression, safety, complications necessitating a return to OR, and post-op rehabilitation schedule were analyzed. Two study sites used Visual Analog Scale (VAS) to assess pain pre-surgically and at 2, 6, and 12 week follow-up visits. Phone survey questionnaires were given to patients that reached at least 1yr post-op to assess long-term patient satisfaction and function. Results: Average patient age was 42yrs in both groups and average follow-up time was 19.2mo (FlexBand) and 28.4mo (Control). There was no statistical difference in baseline VAS pain scores between groups. Augmented patients demonstrated significantly lower VAS scores at 2-,6-, and 12-week follow-up visits (p < 0.001, p< 0.0001and p< 0.0001, respectively) compared to controls (Fig 1). In addition, a significant acceleration in return to FWB status in augmented group compared to control patients was observed (9.04 ± 0.38wks, N=101 vs. 11.82 ± 1.67wks, N=45; p = 0.027). Both groups demonstrated equivalent AE safety profiles and complications were similar across groups with 3.7% (3/82) of control and 3.9% (6/152) augmented patients requiring a return to OR, however, no AEs or complication events were related to the Flexband Device. Conclusion: Our data shows a significant reduction in VAS pain scores in patients who underwent the modified Brostrom procedure with augmentation at all follow up time points. In addition, synthetic graft augmentation may lead to earlier return to function due to the significantly lower time to achieve FWB status. Further investigation on the potential clinical benefits of ATFL augmentation with Artelon Flexband is ongoing through a prospective, randomized, controlled study. Overall, long-term (>1yr) patient satisfaction was equivalent across groups and a trend toward potential earlier recovery times were better for the augmented group than the control group. [ABSTRACT FROM AUTHOR]

Abstract Background The aim of this study was to quantitatively evaluate and characterize the dimension and signal intensity of anterior talofibular ligament (ATFL) using 3.0 T MRI in the mechanical ankle instability group pre- and postoperatively. Methods A total of 97 participants were recruited retrospectively in this study, including 56 with mechanical chronic ankle instability (CAI group) and 41 without ankle instability (Control group). All the subjects accepted MRI preoperatively. Among the 56 CAI patients, 25 patients, who accepted modified Broström repair of ATFL, underwent a MRI scan at follow-up. The ATFL dimension (length and width) and signal/noise ratio (SNR) were measured based on MRI images. The results of the MRI studies were then compared between groups. Results The CAI group had a significantly higher ATFL length (p = 0.03) or ATFL width (p

Abstract Background The purpose was retrospectively to investigate functional and clinical outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) reconstruction using a single allograft. Methods Patients with severe chronic lateral instability of the ankle underwent surgery after conservative treatment failed. Ultrasounds of the ankle were performed, and if the AFTL and CFL were completely torn without enough soft tissue for repair, the ligaments were reconstructed using allograft tendon. Outcomes were assessed by clinical examination, stress radiography, ultrasound, the American Orthopaedic Foot and Ankle Society score (AOFAS), and Karlsson Ankle Functional score (KAFS) before surgery and at final follow-up. Results Nineteen patients, ten men and nine women with mean age of 27.9 years (range, 19–41 years), underwent reconstruction. Mean follow-up was 30 months (range, 24–40 months). At final follow-up, all patients had returned to activity without instability, pain, or limited range of motion. On stress radiography, mean talar tilt angle decreased from 17.32° ± 3.58° before surgery to 4.16° ± 1.12° at follow-up (p

Purpose of review: Ankle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques. Recent findings: Based on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option. Summary: Currently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures. [ABSTRACT FROM AUTHOR]

Injuries to the lateral ligaments of the ankle are among the most frequent sporting injuries. These injuries constitute a significant portion of all sports-related injuries. Nearly all cases involve damage to either the anterior talofibular ligament (ATFL) or the calcaneofibular ligament (CFL). While they are generally considered to be mild injuries, without adequate rehabilitation and treatment, these injuries often result in lingering symptoms for many patients for a period ranging from 6 weeks to 18 months. Subsequently, this analysis seeks to assess the non-surgical, conservative approaches currently employed in managing lateral ligament injuries of the ankle. Therefore, this assessment explores the variations and effectiveness of conservative treatment approaches based on the injury's severity and the mechanisms of trauma. The study conducted an analytical literature review that relied on diverse sources, including orthopedic books, e-books, articles, journals, and internet databases, to accomplish this. The main sources were obtained from reputable databases such as UpToDate, NCBI, and PubMed. Collectively, these sources provide definitions, outlines, evaluations, and discussions related to the topic. As such, they facilitated the formulation of an informed conclusion on the approach to treating lateral ligament injuries of the ankle complex. The reviewed literature shows that early and effective initial treatment involving pain management, prompt resumption of weight-bearing activities, limited immobilisation, and targeted physical therapy yields favorable outcomes for minor-grade sprains and is an effective preventive measure against recurrent injuries. Accordingly, athletes who experience regular ankle sprains should consider prophylactic bracing or taping to lower the risk of re-injury while enhancing their functionality. Notably, the existing functional and conservative management methods demonstrate and yield positive post-treatment outcomes. Nonetheless, the efficiency and effectiveness of these treatments depend on the specific nature of the injury and the unique traits of the individuals who sustain it. Consequently, these factors must be considered for when determining the appropriate treatment approach., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Maduka et al.)

Background Chronic lateral ankle instability (CLAI) is caused by lateral ankle ligament weakness or rupture secondary to recurrent sprains. The surgical management has traditionally involved a modified Broström-Gould (MBG) procedure with or without internal brace (IB) augmentation. This study aims to demonstrate the improved outcomes for patients undergoing an MBG procedure with IB augmentation for CLAI. Methodology A retrospective analysis was performed among 40 patients undergoing an MBG procedure with or without IB for CLAI at a large teaching hospital between January 2012 and June 2019. Functional outcomes were measured using the Manchester-Oxford Foot Questionnaire (MOxFQ). Clinic letters were reviewed to assess additional outcomes including postoperative complications, revision surgery rate, time in a plaster cast, and time to full weight-bearing. Results A total of 23 patients were included in the study, with seven undergoing both MBG and IB procedures and 16 undergoing MBG intervention alone. The average age was 37.1 years in the IB group and 35.7 years in the MBG group. The mean MOxFQ overall raw scores (10.9 vs. 33.6, p < 0.016), standing and walking MOxFQ subscale (4 vs. 15.2, p < 0.012), pain MOxFQ subscale (4.86 vs. 10.9, p < 0.042), and social interaction subscale (2 vs. 7.5 p < 0.023) all showed significantly better results for the IB group versus the MBG group. Patients in the IB group had significantly less number of weeks in plaster than the MBG group and were able to fully weight bear sooner (4.14 vs. 6, p < 0.01). The MBG group suffered a postoperative complication in seven patients compared to zero in the IB group (p < 0.057). There were three re-ruptures in the MBG group requiring further revision surgery compared to zero in the IB group (3 vs. 0, p < 0.53). Conclusions MBG surgery with IB augmentation for CLAI appears to have better outcomes in terms of overall function and may have fewer overall complications. The IB group displayed a lower recurrence of pain, less time in a plaster cast, and a quicker return to walking., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Flaherty et al.)

Introduction Chronic lateral ankle instability (CLAI) is a known complication of ankle sprains, most commonly involving injury to the anterior talofibular ligament (ATFL). Growing evidence has shown an association between anteromedial (AM) impingement and CLAI. The purpose of this paper is to compare magnetic resonance imaging (MRI) with arthroscopic findings for the incidence of AM impingement in CLAI. Methods A retrospective study was performed by analyzing the radiological and operative reports of all patients who underwent an arthroscopic Broström-Gould procedure for CLAI between 2021 and 2022 at Changi General Hospital, Singapore. All patients who had a pre-operative MRI ankle scan performed and mention of the presence or absence of AM impingement in the operative notes were included in this study. Patients with concomitant fractures or systemic conditions affecting the same ankle were excluded. Results Ninety-seven patients were included in this study, 65 males and 32 females; 6.2% (6 of 97) of patients had a suggestion of AM impingement based on MRI findings, and 77.3% (75 of 97) of patients were noted to have AM impingement based on arthroscopic findings. Conclusion There is a high incidence of AM impingement associated with CLAI. AM impingement is often missed based on MRI findings. Arthroscopic Broström should be considered to address both issues of AM impingement and CLAI in the same setting., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Koh et al.)

Introduction: Patients with lateral instability of the ankle have a much higher prevalence of an os subfibulare compared with the general population. In children and adolescents with known os subfibulare and chronic instability of the ankle, surgical resection of the os subfibulare and the Broström/Gould procedure to reattach the ATFL to the fibula has been described if conservative therapy fails., Case Report: Our case is about a 10-year-old girl with chronic instability of the ankle and a symptomatic os subfibulare, with additional cystic and edematous changes in the distal fibula in the MRI. Due to the reduced bone density, we assumed a higher risk of anchor pullout with the normal refixation at the distal fibula. Therefore, the surgical technique according to Broström/Gould was modified and the ATFL was refixed on the talar side., Conclusion: In cases of symptomatic os subfibulare with clinical instability of the ankle, a Broström/Gould operation and resection of the os subfibulare is recommended after failure of conservative therapy. Our case showed that a very satisfying post-operative result can be achieved with a modification of the Broström/Gould operation, with reattachment of the ATFL to the talus instead of the fibula., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)