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Background: Short-term results after arthroscopic/endoscopic lateral ligament repair for chronic lateral ankle instability have been satisfactory, although medium- to longer-term results are lacking. Purpose/Hypothesis: The purpose of this study was to report the medium-term results of an all-inside endoscopic classic Bröstrom-Gould procedure where both the both lateral ligaments and the inferior extensor retinaculum can be approached directly, interchanging between arthroscopy for intracapsular structures and endoscopy for extracapsular structures. It was hypothesized that the all-inside endoscopic classic Bröstrom-Gould procedure would produce sustainable good outcomes at a medium term of 5 years. Study Design: Case series; Level of evidence, 4 Methods: A prospective database for 43 patients who underwent an all-inside endoscopic classic Bröstrom-Gould repair of the anterior talofibular ligament and calcaneofibular ligament with inferior extensor retinaculum augmentation was reviewed. Patient details, American Orthopaedic Foot & Ankle Society score, Karlsson score, ankle activity score (AAS), and patient satisfaction were collected and analyzed. Results: The study cohort of 43 patients with a mean age of 29.4 years (SD, 11.9 years) were reviewed at a mean follow-up of 63.1 months (SD, 8.5 months). The American Orthopaedic Foot & Ankle Society scores showed significant improvement from a mean of 69.6 (SD, 13.9) to 93.7 (SD, 10.7), while the Karlsson score improved from 59.7 (SD, 14.5) to 91.5 (SD, 14.5) at the final follow-up. The AAS showed that 32 (74.4%) patients maintained or had improvement in the AAS, from a mean of 5.38 (SD, 2.8) to 5.41 (SD, 2.8), with a mean satisfaction rate of 9.1 (SD, 1.3). Although the remaining 11 patients had a reduced AAS, at a mean of 4.6 (SD, 2.6), they reported a mean satisfaction rate of 7.4 (SD, 2.9). There were no surgical complications or reoperations reported in this cohort, although there were 3 patients with recurrent instability at their last follow-up, resulting in a failure rate of 7%. Conclusion: The current study is the first to report the medium-term outcomes of an all-inside endoscopic classic Bröstrom-Gould procedure. Overall, 93% of the patients had good functional outcomes, but approximately 25% of patients had decreased ankle activity levels at a mean of 5 years postoperatively, albeit with good satisfaction rates. [ABSTRACT FROM AUTHOR]

Purpose: Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair. Materials and Methods: Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed. Results: The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05). Conclusions: Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients. Level of evidence: 4. [ABSTRACT FROM AUTHOR]

Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy. A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included. 180 studies were identified of which 3 (164 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy. The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. [ABSTRACT FROM AUTHOR]

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]

The gold standard diagnostic method for acute lateral ankle ligament sprain is magnetic resonance imaging (MRI). However, it is hardly accessible and is time-consuming. Therefore, additional diagnostic methods are warranted. Point-of-care ultrasound, on the other hand, is inexpensive, widely available, time-efficient testing method. Therefore, the aim of this meta-analysis is to determine the diagnostic accuracy of ultrasound for acute ankle ligament injuries compared to MRI. In our systematic review and meta-analysis, we followed the recommendations of the Cochrane Handbook. We searched the following databases from inception to March 31, 2022: Medline (PubMed), EMBASE, and Cochrane Library. Eligible studies investigated the diagnostic accuracy of US compared to MRI for diagnosing acute lateral ankle ligament injuries. Finally, we calculated pooled sensitivity and specificity with a 95 % confidence interval (CI). Eight studies met our eligibility criteria, involving 434 patients. For anterior tibiofibular ligament (ATFL) injury, the summary sensitivity and specificity were Se = 0.97 (CI: 0.89–0.99) and Sp = 0.93 (CI: 0.84–0.97). For calcaneofibular ligament (CFL) injury, the summary sensitivity and specificity were Se.: Se = 0.81 (CI: 0.58–0.93) and Sp = 0.92 [0,81;0,97]. In addition, subgroup analysis based on US performed by different types of investigators was comparable between each other (radiologist group Se = 0.98, CI: 0.24–1, and Sp = 0.91, CI: 0.74–0.97, and the orthopedic/ emergency department group Se = 0.96, CI: 0–1, and Sp = 0.97, CI: 0–1). Ultrasound showed high diagnostic accuracy for acute lateral ankle ligament injury, irrespective of the investigator. Therefore, based on the current available data, it could be used in primary diagnostics of acute lateral ankle ligament injury. [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: Our aim in this study was to identify the fibular footprint of the Anterior Inferior Tibiofibular Ligament (AITFL) and its relation to Wagstaffe fracture fragment size.Methods: We examined 25 cadaveric lower limbs which were carefully dissected to identify the lateral ankle ligaments. The AITFL anatomy was compared to 40 Wagstaffe fractures identified from our ankle fracture database.Results: The AITFL origin was from the anterior fibular tubercle with an average length of 21.61 mm (95% CI 20.22, 22.99). The average distance of the distal aspect of the AITFL footprint to the distal fibula margin was 11.60 mm (95% CI 10.49, 12.71). In the ankle fractures analyzed, the average length of the Wagstaffe fragment was 17.88 mm (95% CI 16.21, 19.54). The average distance from the distal tip of the fibula to the Wagstaffe fracture fragment was 21.40 mm (95% CI 19.78, 23.01). In total there were 22 syndesmosis injuries. There was no statistical difference in Wagstaffe fragment size between stable and unstable groups.Conclusion: The AITFL fibular origin was both larger and more distal than the Wagstaffe fracture fragments seen in our institution. Therefore, this suggests that a ligamentous failure will also have to occur to result in syndesmotic instability. The size of fracture fragment also did not confer to syndesmotic instability on testing. Level of Evidence - 3. [ABSTRACT FROM AUTHOR]

Background: There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.Methods: A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.Results: 78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.Conclusion: Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.Prospero Registry: CRD42020169876.Level Of Evidence: II. [ABSTRACT FROM AUTHOR]

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: To compare clinical function after knot anchor versus knotless anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability. Methods: All patients who underwent arthroscopic surgical ATFL repair using knot or knotless suture anchors were included in this study. Functional scores (American Orthopedic Foot and Ankle Society (AOFAS), Karlsson score and Tegner activity scores) and magnetic resonance imaging (MRI) were used to evaluate the ankle with a follow-up of at least 2 years. Results: A total of 52 patients with chronic ankle instability were included in this study. Among these patients, 23 patients underwent one knot anchor repair procedure (Group A), and the other 29 patients underwent one knotless anchor repair procedure (Group B). At the final follow-up, there were no significant differences between Group A and Group B regarding the AOFAS score (89 ± 9 vs 84 ± 11; ns), Karlsson score (82 ± 14 vs 75 ± 18; ns), or Tegner activity score (4 ± 1 vs 4 ± 2; ns). There also were no significant differences in the mean ATFL signal–noise ratio (SNR) value (7.5 ± 4.4 vs 7.3 ± 2.9; ns) or ATFL angle (82° ± 7° vs 84° ± 9°; ns) between the groups. Conclusion: When compared with knot repair, knotless repair of the lateral ankle ligament produced similar functional outcomes. Level of evidence: III. [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]

Purpose: The aim of this study was to compare long-term outcomes after anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) repair and reconstruction at 5–10 years after surgery. Methods: Forty-five patients who underwent surgical repair or reconstruction of both ATFL and CFL were retrospectively investigated in this study. American Orthopedic Foot and Ankle Society (AOFAS), Karlsson Score, and Tegner activity scale were used to evaluate the ankle function at a follow-up of 5–10 years. Ultrasound examination was used to evaluate the ATFL and CFL, and MRI was used to evaluate the cartilage. Results: At final follow-up, no patient had recurrent ankle instability. There were no significant differences in AOFAS (92.6 ± 6.5 vs 89.6 ± 3.4; n.s.) or Karlsson Score (93 ± 8.2 vs 90.6 ± 5.0; n.s.) between the reconstruction group (twenty patients) and the repair group (twenty-five patients) postoperatively. There were also no significant differences in activity level as measured by the Tegner activity score (6 (range 4 to 8) vs 6 (range 5 to 7); n.s.). Five patients in the reconstruction group complained of some tightness of the ankles. Ultrasound showed the reconstructed ligaments maintained good continuity and were thicker than the repaired ligaments. Conclusion: Patients in both the repair and the reconstruction cohort had high patient satisfaction with the outcomes and high function and activity levels that indicated recreational sports participation over a long period. Level of evidence: III. [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: To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model.Methods: Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three-dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL-only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF).Results: The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL-only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively.Conclusions: There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL-only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair.Level Of Evidence: III, case-control therapeutic study. [ABSTRACT FROM AUTHOR]

Purpose: To compare the function and activity level after one-anchor repair versus two-anchor repair of the anterior talofibular ligament (ATFL) in patients with chronic lateral ankle instability.Methods: All patients who underwent arthroscopic surgical ATFL repair using suture anchors were included in this study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score) and Tegner activity score were used to evaluate ankle function at a follow-up of a minimum of 2 years. A magnetic resonance imaging (MRI) scan was performed to evaluate the repaired ATFL.Results: A total of 51 patients with chronic ankle instability were included in this study. Among them, 20 patients accepted a one-anchor repair procedure (one-anchor group), and the other 31 patients accepted a two-anchor repair procedure (two-anchor group). At the final follow-up, there was no significant difference in the AOFAS score between the one-anchor group and the two-anchor group (90 ± 9 vs 91 ± 10; ns). However, the mean Karlsson score of the two-anchor group (88 ± 12) was significantly higher than that of the one-anchor group (80 ± 14) (p = 0.04). There was a significant difference in activity level as measured by the Tegner activity score (5 ± 1 vs 4 ± 1; p < 0.001) between the two-anchor group and the one-anchor group after surgery. Patients in the two-anchor group (68%) had a significantly higher percentage of sport participation compared to those in the one-anchor group (30%) (p = 0.01).Conclusion: Compared with a one-anchor repair, a two-anchor repair of the lateral ankle ligament produced better functional outcomes. Arthroscopic ATFL repair with two anchors provided a minimally invasive technique with a higher rate of return to sports than repair with one anchor. The present study showed its clinical relevance by maintaining the advantage of ATFL repair using two anchors regarding the clinical function.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

The purpose of this study was to systematically review the current evidence in the literature to ascertain whether the anatomic ankle ligament reconstruction procedure with allograft resulted in improved patient outcomes after ≥2 years of follow-up. A literature search of Medline, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Clinical studies investigating anatomic lateral ankle ligament reconstruction procedures for chronic ankle instability with a mean of >2 years' follow-up were included. Means were calculated for population size, age, follow-up duration, and postoperative Tegner scores. Pooled estimates were calculated for postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion, return to sports, risk of postoperative instability, and complications. Six clinical trials with 153 patients were included. The pooled estimated mean for the postoperative AOFAS score was 89.4 points (95% confidence interval [CI], 86.0 to 92.9; I 2 = 88.7%). The pooled proportion of patients who returned to sports after surgery was 80% (95% CI 57.0% to 100%; I 2 = 88.7%). The pooled total risk of recurrent instability after surgery was 6% (95% CI 1% to 12%; I 2 = 0%). No rejection was reported. Anatomic lateral ankle ligament reconstruction procedure results in significant improvements in patient function and outcome scores, with low rates of recurrent instability. [ABSTRACT FROM AUTHOR]

Background: Acute inversion ankle sprains are among the most common musculoskeletal injuries. Higher grade sprains, including anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injury, can be particularly challenging. The precise effect of CFL injury on ankle instability is unclear. Hypothesis: CFL injury will result in decreased stiffness, decreased peak torque, and increased talar and calcaneal motion and will alter ankle contact mechanics when compared with the uninjured ankle and the ATFL-only injured ankle in a cadaveric model. Study Design: Descriptive laboratory study. Methods: Ten matched pairs of cadaver specimens with a pressure sensor in the ankle joint and motion trackers on the fibula, talus, and calcaneus were mounted on a material testing system with 20° of ankle plantarflexion and 15° of internal rotation. Intact specimens were axially loaded to body weight and then underwent inversion along the anatomic axis of the ankle from 0° to 20°. The ATFL and CFL were sequentially sectioned and underwent inversion testing for each condition. Linear mixed models were used to determine significance for stiffness, peak torque, peak pressure, contact area, and inversion angles of the talus and calcaneus relative to the fibula across the 3 conditions. Results: Stiffness and peak torque did not significantly decrease after sectioning of the ATFL but decreased significantly after sectioning of the CFL. Peak pressures in the tibiotalar joint decreased and mean contact area increased significantly after CFL release. Significantly more inversion of the talus and calcaneus as well as calcaneal medial displacement was seen with weightbearing inversion after sectioning of the CFL. Conclusion: The CFL contributes considerably to lateral ankle instability. Higher grade sprains that include CFL injury result in significant decreases in rotation stiffness and peak torque, substantial alteration of contact mechanics at the ankle joint, increased inversion of the talus and calcaneus, and increased medial displacement of the calcaneus. Clinical Relevance: Repair of an injured CFL should be considered during lateral ligament reconstruction, and there may be a role for early repair in high-grade injuries to avoid intermediate and long-term consequences of a loose or incompetent CFL. [ABSTRACT FROM AUTHOR]

Background: The open modified Broström anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. Despite recent increases in publications regarding arthroscopic repair of the anterior talofibular ligament (ATFL) for treatment of chronic ankle instability, research is lacking that compares the functional outcomes between arthroscopic repair and open repair procedures for chronic ankle instability. Purpose: To compare function and activity level after arthroscopic repair versus open repair of the ATFL in patients with lateral ankle instability. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent arthroscopic or open surgical Broström repair of the ATFL between January 2012 and August 2014 were invited to participate in this study. All of the patients had consented for arthroscopic repair if feasible. In cases in which arthroscopic repair was impossible, the open modified Broström procedure was performed after arthroscopy. Patients accepted a systematic rehabilitation program postoperatively. American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score were used to evaluate ankle function preoperatively and at a minimum follow-up of 2 years. Magnetic resonance imaging (MRI) was performed to evaluate the signal to noise ratio (SNR) of the repaired ATFL. Results: A total of 60 patients were included in this study. They were assigned to 1 of 2 groups according to their surgical procedure: 23 patients underwent arthroscopic repair (arthroscopic group) and 37 patients underwent open repair (open group). No patient in either group had ankle instability at follow-up postoperatively. After surgery, the AOFAS score (P < .001), KAFS (P < .001), and Tegner activity score (P < .001) increased significantly in both groups. However, no significant difference was found in AOFAS score (93.3 ± 8.9 vs 92.4 ± 8.6; P = .7), KAFS (90.3 ± 12.5 vs 89.4 ± 10.6; P = .75), and Tegner score (5 ± 2 vs 5 ± 2; P = .61) between the arthroscopic group and the open group, respectively. As well, no significant difference was found in the mean SNR value of ATFL between the arthroscopic group and the open group (9.1 ± 2.7 vs 8.8 ± 2.3; P = .39, respectively). Conclusion: When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. Arthroscopic ATFL repair, as a minimally invasive technique, provided favorable outcomes. [ABSTRACT FROM AUTHOR]

Background: Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging.Objective: Our aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane.Methods: Magnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted.Results: By MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%.Conclusions: PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL. [ABSTRACT FROM AUTHOR]

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.)

Lateral ankle ligament complex injuries are most commonly managed nonoperatively. If no improvements have been made following conservative management, surgical intervention is warranted. Concerns have been raised regarding complication rates following open and traditional arthroscopic anatomical repair. In-office needle arthroscopic anterior talo-fibular ligament repair provides a minimally invasive arthroscopic approach to the diagnosis and treatment of chronic lateral ankle instability. The limited soft tissue trauma facilitates rapid return to daily and sporting activities making this an attractive alternative approach to lateral ankle ligament complex injuries., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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.)

Purpose: To determine the accuracy of a three-dimensional (3D) T2-weighted fast spin-echo (FSE) magnetic resonance (MR) sequence compared with two-dimensional (2D) sequence for diagnosing anterior talofibular ligament (ATFL) tears, chondral lesion of the talus (CLT) and os subfibulare/avulsion fracture of the distal fibula (OSF).Materials and Methods: Thirty-five patients were included, who had undergone ankle MRI with 3D T2-weighted FSE and 2D T2-weighted FSE sequences, as well as subsequent ankle arthroscopy, between November 2013 and July 2014. Each MR imaging sequence was independently scored by two readers retrospectively for the presence of ATFL tears, CLT and OSF. The area under the receiver operating curve (AUC) was compared to determine the discriminatory power of the two image sequences. Interobserver agreement was expressed as unweighted kappa value.Results: Arthroscopic findings confirmed 21 complete tears of the ATFL, 14 partial tears of the ATFL, 17 CLTs and 7 OSFs. There were no significant differences in the diagnoses of ATFL tears (p = 0.074-0.501), CLT (p = 0.090-0.450) and OSF (p = 0.317) obtained from the 2D and 3D sequences by either reader. The interobserver agreement rates between two readers using the 3D T2-weighted FSE sequence versus those obtained with the 2D sequence were substantial (κ = 0.659) versus moderate (κ = 0.553) for ATFL tears, moderate (κ = 0.499) versus substantial (κ = 0.676) for CLT and substantial (κ = 0.621) versus substantial (κ = 0.689) for OSF.Conclusion: Three-dimensional isotropic T2-weighted FSE MRI of the ankle resulted in no statistically significant difference in diagnostic performance compared to two-dimensional T2-weighted FSE MRI in the evaluation of ATFL tears, CLTs and OSFs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Ankle inversion injuries are common and most patients will have complete resolution of symptoms with nonoperative treatment. Some patients will develop chronic ankle instability and may develop associated pathology such as peroneal tendonitis, osteochondral lesions, ankle synovitis, and ankle impingement. A careful physical examination is imperative to evaluate for ankle instability as well as concomitant pathology. Imaging begins with standard radiographs and advanced imaging is used to evaluate for osteochondral lesions, ligament integrity, tendinitis, and other soft tissue lesions. Nonoperative treatment consists of immobilization, bracing, and physical therapy. Surgical treatment is reserved for patients who have symptoms despite nonoperative treatment and often involves imbrication of the lateral ankle ligament complex. Outcomes are typically favorable and most patients can expect to return to athletic activity. [ABSTRACT FROM AUTHOR]

Ankle taping is convenient fixation for ankle instability after lateral ligament injury. There are many reports on ankle taping regarding stability or limitation of plantar/ dorsiflexion or inversion/ eversion. However, no studies have been conducted on the effect of rotatory instability. The biomechanical effect of ankle taping on rotatory instability was examined for lateral ligament injury. Using 8 fresh frozen legs, we made a ligament injury model by sequential cut of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). Each injury model was applied to 39.2N of anterior traction for dorsiflexion and 19.6Nm of torque for internal rotation in the condition of "unfixed", "taping" and "plaster cast". Three dimensional measurements were performed by a magnetic tracking system (3space, Polhemus). Both in the ATFL and ATFL+CFL injury model, the dorsiflexion angle of taping (17.1±4.2° and 17.4±3.5°) was significantly larger than that of plaster cast (9.6±3.2° and 11.9±3.2°) (p<0.05). On the other hand, the internal rotation angle of taping was significantly smaller (7.0±1.6° and 7.7±2.4°) than that of unfixed (17.1± 4.2°and 17.4±3.5°), and there was no significant difference between taping and plaster cast fixation. These results indicate that the limitation of dorsiflexion by taping is less than that by plaster cast and is a good stabilizer for internal rotation instability in the same way as that by plaster cast. [ABSTRACT FROM AUTHOR]

We examined the induction of the catalase gene (cttl+) of fission yeast Schixosaccharomyces pombe in response to several stresses by using mutants of transcription factors (Atfl and Papl) and a series of deletion mutants of the ctt1+ promoter region. A tran-scription factor, Atfl, and its binding site are necessary for the induction of ctt1+ by osmotic stress, UV irradiation, and heat shock. Induction by menadione treatment, which produces superoxide anion, required element A, the region from -111 to -90 (numbered with the transcription start site as +1). The factor responsible for the induction of the gene by oxidative stress via element A was identified as the transcription factor Papl. We also found that Atfl is activated by menadione treatment in papl mutant cells, although it is not activated by menadione treatment in pap1+ cells. The activity of cata-lase is not increased in pap1 cells by several stresses, despite mRNA induction, suggesting that Papl plays some role in the expression of catalase activity. [ABSTRACT FROM AUTHOR]

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated., Competing Interests: Disclosure All authors have no financial disclosures to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)