Ankle Instability and Arthroscopy: Ligament Reconstruction or Not.

Chronic ankle instability often develops when acute lateral ankle ligament injuries, like ankle sprains, are left untreated or are poorly managed. Typically, conservative treatment is preferred for these injuries, reserving surgical intervention for specific cases. Surgery may become necessary if rigorous rehabilitation does not yield satisfactory results. Several surgical options exist, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair is feasible when the ligaments are in good condition. However, if the ligaments are severely damaged, anatomic reconstruction using either autografts or allografts is recommended. Additionally, ankle arthroscopy can be performed alongside ligament repair to address any intra-articular issues contributing to chronic instability. While tenodesis techniques have been used, they are generally discouraged due to their less favourable long-term outcomes, particularly because they can alter the biomechanics of the ankle and hind foot. Ultimately, surgical treatment for chronic lateral ankle ligament instability is beneficial for patients who have not responded to non-operative approaches, with open anatomic reconstruction being a reliable method for stabilizing the ankle. This article presents a unique case where the anterior tibiofibular ligament reconstruction was done in a polio foot along with which additional procedures were carried out to correct the deformities of the foot and to make the ankle stable.

Chronic ankle instability has been described as presenting with complete tears of both the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in 20% of cases. Arthroscopic techniques to treat chronic ankle instability are increasingly being reported and in some instances they can be technically demanding. The aim of this study was to describe an arthroscopic all-inside repair of both the ATFL and CFL, and to report the outcomes of a group of patients with chronic ankle instability that underwent the technique. Twenty-four patients [22 male and 2 female, median age 41 (range 22-56) years] with chronic ankle instability and torn ATFL and CFL were treated arthroscopically after failing non-operative management. Median follow-up was 35 (mean 34.7, and range 18-55) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, both fascicles of the ATFL and the CFL were repaired. Arthroscopic examination demonstrated ATFL and CFL injuries in all patients. Subjective improvement in their ankle instability was observed postoperatively. The anterior drawer and the talar tilt tests were negative at follow-up. The median AOFAS score increased from 65 (mean 65, range 52-85) preoperatively to 97 (mean 97, range 85-100) at final follow-up. Chronic ankle instability with concomitant injury of both the ATFL and CFL, can be successfully treated by an arthroscopic all-inside repair. The clinical relevance of the study is the description of the first arthroscopic all-inside ATFL and CFL anatomic repair technique, which offers excellent clinical results and the inherent benefits from minimally invasive surgery. IV, retrospective case series.

Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and non-anatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability. V.

Background: Ankle sprain is the most frequent sports trauma. After repeated sprains, Chronic Instability (CAI) occurs and usually requires a surgical procedure. New surgical strategies to treat symptomatic CAI are evolving. In this article we describe a fully arthroscopic technique for CAI treatment. Methods: January 2017 to January 2020, we arthroscopically treated 26 patients for CAI, 21 of these were included in the study. The patient’s average age was 33, 43 years. Median Follow-Up (FU) was 22, 38 months. Using a suture passer or a grasper and knotless anchors, the ligaments were repaired with an arthroscopic technique and reinforced with arthroscopic plication technique. Results: At FU the AOFAS mean was 96, 29; FADI mean was 131, 38; VAS mean was 1, 00. All patients reported subjective improvement in their ankle instability after the arthroscopic repair. Conclusion: Chronic ankle instability can be successfully treated by an arthroscopic repair reinforced with arthroscopic plication technique. It is possible obtain significant functional outcomes with high patient satisfaction.

BackgroundApproximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI) requiring surgical intervention. There has been growing interest among surgeons regarding whether arthroscopic techniques can replace open Brostrom-Gould surgery in treating CLAI. The purpose of this study was to pool the results of multiple studies comparing the treatment effects of these two fixation approaches.MethodsOur study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on CLAI that were repaired using the arthroscopic or open Broström-Gould technique. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, complications, and time efficiency.ResultA total of 686 patients from 11 studies were included in the analysis. Among them, 351 patients underwent open repair, and 335 underwent arthroscopic Brostrom-Gould surgery. The present study revealed that arthroscopic and open Brostrom-Gould techniques demonstrated no significant differences in talar tilt, talar anterior translation, complication rate, and time to return to previous level of activity. Furthermore, no significant differences were observed in AOFAS, K–P, VAS, and Tegner scores at the 2-year follow-up. However, significant differences were noted between the two surgical approaches in terms of early weight-bearing (WMD = − 1.33 weeks, 95% CI = [− 1.91, − 0.76], P = 0.17, I2 = 40%), as well as AOFAS scores (WMD = 1.00, 95% CI = [0.05, 1.95], P = 0.73, I2 = 0%), K–P scores (WMD = 1.57, 95% CI = [0.49, 2.64], P = 0.15, I2 = 47%), and VAS scores (WMD = − 0.15, 95% CI = [− 0.60, 0.29], P < 0.08, I2 = 61%) within the first postoperative year.ConclusionsOur findings support that arthroscopic repair yields comparable outcomes to open surgery. Consequently, we advocate for adopting arthroscopic repair as a preferred alternative to the conventional open Broström-Gould procedure for treating chronic lateral ankle instability.

Background Recurrent defects after open and arthroscopic rotator cuff repair are common. Double-row repair techniques may improve initial fixation and quality of rotator cuff repair. Purpose To evaluate the load to failure, cyclic displacement, and anatomical footprint of 4 arthroscopic rotator cuff repair techniques. Hypothesis Double-row suture anchor repair would have superior structural properties and would create a larger footprint compared to single-row repair. Study Design Controlled laboratory study. Methods Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. Results There were no differences in load to failure and displacement with cyclic loading between the single-row repair and each double-row repair. All repair groups demonstrated load to failure greater than 250 N. A significantly greater supraspinatus footprint width was seen with double-row techniques compared to single-row repair. Conclusions The single-row repair technique was similar to the double-row techniques in load to failure, cyclic displacement, and gap formation. The double-row anchor repairs consistently restored a larger footprint than did the single-row method. Clinical Relevance The arthroscopic techniques studied have strong structural properties that approached the reported performance of open repair techniques. Double-row techniques provide a larger footprint width; although not addressed by this study, such a factor may improve the biological quality of repair.

Ankle sprains are one of the most common injuries in both athletes and the general population. A major problem accompanying ankle injury is the high rate of recurrence, with about 20% of acute ankle sprain patients developing chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability usually needs surgical intervention. Various anatomic reconstruction techniques using the ruptured ends of the ligaments to restore stability have gained popularity. The purpose of this study was to evaluate the functional results of the treatment of chronic lateral ankle instability with anatomic repair of the injured ligaments and reinforcement with polyester tape. A prospective study of 30 consecutive patients who underwent anatomic reconstruction of the lateral ligaments using transosseous suturing and augmentation using a polyester tape done at a single centre by a single surgeon from 2016 to 2017. All patients were assessed preoperatively and postoperatively at 6 weeks, 3, 6 and 12 months. The American Orthopaedic Foot and Ankle Score (AOFAS) and Free Online Foot and Ankle Ability Measure (FAAM) were recorded and used for results analysis. At 12 months' follow-up, the AOFAS had improved from mean 52.47 ± 2.06 to 91.0 ± 6.03 (p&lt; 0.001) .The FAAM mean score had improved from mean 55.21± 1.9 to 90.43 ± 4.02 Conclusion. The ankle ligament reconstruction with additional polyester tape augmentation is an effective technique in treating chronic ankle instability with a satisfactory surgical outcome.

Enhanced anatomical accuracy in arthroscopic all-inside lateral ligament repair using ultrasound-guided anchor placement.

Category: Ankle, Hindfoot, Imaging, Ankle Instability Introduction/Purpose: Varus hindfoot deformity may increase the risk of chronic ankle instability (CAI).Weightbearing CT (WBCT) semi-automated measurements and built-in databases may contribute to investigate the relationship between clinical and radiographic data. The objective of this study was to analyze hindfoot alignment (HA) in relation with CAI in a series of patients using these new tools. We hypothesized that there would be a positive correlation between a varus morphotype and a history of CAI. Methods: This is a Level 3 retrospective comparative study of a continuous series of 124 feet (63 patients) referred from July to December 2016. and subsequently assessed by WBCT (PedCAT®, CurveBeam LLC). The measurement software (Talas®, Curvebeam LLC), gave HA as a value of Foot and Ankle Offset (FAO). This measures the offset between the center of the ankle joint and the median line of the foot joining the centers of the calcaneus and forefoot weight bearing surfaces. Data was prospectively saved in a database (CubeView®, CurveBeam, PA, USA). The definition of CAI was a history of at least 3 ankle sprains during a 6 months period. Exclusion criteria were medial instability and syndesmotic injuries (2 cases).A univariate analysis was conducted to study CAI against the following variables: gender (Fisher), BMI and FAO (Kurskal-Wallis). The significant variables were subsequently included in a multivariate logistic model. Results: Nineteen feet had CAI, in 12 patients. Gender (p=0.0467 –the proportion of women for patients with CAI was 72.3%, compared to 33.3% without CAI) and FAO (p=0 .0002) were significant in the univariate analysis. The mean FAO was respectively -1.40 (SD: 5.50) and 3.56 (SD: 5.31) with and without a history of CAI. No significant difference of age or BMI was shown. After verification of log-linearity between odds of CAI and FAO, the multivariate logistic regression adjusted for gender demonstrated a 15% increase of odds of CAI per unit increase of varus (adjusted Odds Ratio (CI95%): 0.858 (0.771-0.943) p=0.003), and no more significant effect of gender after adjustment on FAO (Odds ratio (CI95%) Female versus Male: 0.548 (0.185 -1.669) p=0.277). Conclusion: A positive linear relationship was found between Varus Hindfoot Alignment measured using a semi-automatic tool in WBCT and the odds ratio for Chronic Ankle Instability, thus confirming and quantifying previous findings. The recent development of semi-automatic measurements and prospective databases opens future perspectives for big data and multivariate analysis in foot and ankle pathology.

Ankle sprains are very common injuries and are usually managed non-operatively. With poor rehabilitation, 20% of ankle sprains may develop chronic instability, which often necessitates surgical intervention. Rehabilitation after such procedures is focused on regaining the function of the ankle while keeping a stable joint. Post-operative rehabilitation and weight-bearing status varies greatly among surgeons. Our aim is to review the existing most recent literature that investigates post-operative outcomes following different rehabilitation protocols in patients with Chronic Lateral Ankle Instability (CLAI). We performed a literature search from 2002 to 2022, through Medline/Pubmed databases using the terms ‘ankle lateral ligament’, ‘repair’, ‘reconstruction’ and ‘post-operative rehabilitation’. A gray literature search was also performed using the Google Scholar search engine. Studies that described post-operative rehabilitation protocols following CLAI surgery were included. 25 studies with 1045 patients describing rehabilitation protocols following repair/reconstruction of CLAI were included. Most studies used the Broström procedure or modification of it. In 82% of cases patients were immobilised in a cast from day 1 post-operatively for two weeks and were kept non-weight-bearing in 64% during the same time. A boot or brace was kept up to 6 weeks in 82%. Full weight-bearing was recommended either at the very start following surgery (32%), or after four weeks from surgery (36%). Early range of movement exercises started after week 2, with muscle strengthening, proprioception, and balance between week 2 and 6. Return to sports is usually between 2-4 months. In conclusion, post-operative rehabilitation protocols following CLAI surgery vary considerably. We attempted to quantify the studies that provide enough information on this subject and create a post-operative rehabilitation protocol following anatomic repair/reconstruction for CLAI.

We have read the article published by Toyooka et al., titled “Talus Position Correlates With Dorsiflexion Range of Motion Following a Lateral Ankle Sprain: A Cross-Sectional Study” (Health Science Reports, 2025) [1]. In this study, the authors ideally highlighted the correlation between anterior talus deviation and dorsiflexion range of motion (DFROM) followed by lateral ankle sprain. There are some limitations that we want to emphasize to further magnify this novel topic; Firstly, the sample size of the study is only 36 patients, principally consisting of young age, which limits the findings to other age groups with varying physical activity, and also does not clarify the grading of sprain. The Wisthoff et al. cross-sectional study, which has a sample size of over 36, offers important information about this relationship. Acute lateral ankle sprains occurred in 55 of the 108 participants in the Wisthoff et al. study. DFROM was found to have increased over time, suggesting a trend toward recovery. The study discovered that following an acute lateral ankle sprain, mechanical laxity and DFROM change over time, with significant variations in DFROM between sprain grades. In contrast to those with grade I sprains, participants with grade III sprains showed less DFROM, indicating that more severe sprains may result in more dorsiflexion restrictions because of altered talus positioning [2]. Secondly, this study keenly concentrates on the correlation between the anterior talofibular ligament (ATFL) and DFROM through an MRI assessment; it did not give ideas about other ligaments like the posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). Ultrasound and dynamic assessments can evaluate the correlation between talus position and dorsiflexion range of motion after a lateral ankle sprain. The effects of ligament injuries on ankle mechanics are revealed by these methods. Ultrasound allows a clear view of the lateral ligament complex and other lesions, which is essential for understanding talus position changes and dorsiflexion range of motion. Ultrasound can detect ATFL, PTFL, and CFL injuries, which affect ankle stability and talus position. Ultrasound can detect isolated ATFL injuries and those with ligament injuries, giving a complete ankle assessment [3]. Furthermore, this study did not determine the intensity of pain. Studies examining the impact of mobilization techniques on ankle sprains have shown that the Visual Analog Scale (VAS) is commonly used to numerically assess the intensity of pain during dorsiflexion movements. This scale is frequently used to gauge how painful dorsiflexion movements are for people with lateral ankle sprains. It offers a measurable indicator of pain, making it possible to evaluate how much pain has changed after mobilization and other interventions [4]. In addition, this study evaluates the talus deviation only in non-weight bearing or unstressed positions. When a patient has a lateral ankle sprain, weight-bearing DFROM tests, like the weight-bearing lunge test, are essential for identifying limitations that might not be noticeable in non-weight-bearing circumstances. This is so because functional movement patterns and joint stability after an injury are more accurately reflected under weight-bearing conditions. Weight-bearing DFROM in injured limbs can be considerably reduced when compared to uninjured ones, according to studies, even when non-weight-bearing DFROM seems normal [5]. Lastly, this study did not mention the long-term complications of talus anterior deviation like chronic ankle instability (CAI), anterior ankle impingement syndrome, and posttraumatic osteoarthritis. The degenerative changes linked to chronic lateral ankle instability may be exacerbated by altered kinematics in the talus position. One possible explanation for the increased incidence of joint cartilage lesions in chronic ankle instability is increased talar anterior deviation. Previous studies have shown a correlation between early onset of posttraumatic osteoarthritis and lateral ankle instability. Several researchers have hypothesized that changing kinematics and cartilage loading may account for osteoarthritic lesions on the medial talus in chronic ankle instability [6]. Also, there is a lack of effectual interventions like manual therapy which helps to improve dorsiflexion and to restore the normal talus position. In conclusion, we are thankful to the author for giving us the privilege for further investigation on this appreciable topic to enhance the findings regarding the limitations. Future research is recommended to further amplify this study. Syed Hassan Ali: conceptualization, data curation, formal analysis, resources, and writing – original draft. Shanza Shakir: formal analysis, data curation, resources, writing – original draft, writing – review and editing. Javed Iqbal: writing – original draft, writing – review and editing. The authors would like to thank the study entitled “Talus Position Correlates With Dorsiflexion Range of Motion Following a Lateral Ankle Sprain: A Cross-Sectional Study” and its authors for sharing their insights. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.

Background:Anatomic lateral ankle ligament reconstruction has been proposed for patients with chronic ankle instability. A reliable approach is a reconstruction technique using an allograft and 2 fibular tunnels. A recently introduced approach that entails 1–fibular tunnel reconstruction might reduce the risk of intraoperative complications and ultimately improve patient outcome.Hypothesis:We hypothesized that both reconstruction techniques show similar ankle stability (joint laxity and stiffness) and are similar to the intact joint condition.Study Design:Controlled laboratory study.Methods:A total of 10 Thiel-conserved cadaveric ankles were divided into 2 groups and tested in 3 stages—intact, transected, and reconstructed lateral ankle ligaments—using either the 1– or the 2–fibular tunnel technique. To quantify stability in each stage, anterior drawer and talar tilt tests were performed in 0°, 10°, and 20° of plantarflexion (anterior drawer test) or dorsiflexion (talar tilt test). Bone displacements were measured using motion capture, from which laxity and stiffness were calculated together with applied forces. Finally, reconstructed ligaments were tested to failure in neutral position with a maximal applicable torque in inversion. A mixed linear model was used to describe and compare the outcomes.Results:When ankle stability of intact and reconstructed ligaments was compared, no significant difference was found between reconstruction techniques for any flexion angle. Also, no significant difference was found when the maximal applicable torque of the 1-tunnel technique (9.1 ± 4.4 N·m) was compared with the 2-tunnel technique (8.9 ± 4.8 N·m).Conclusion:Lateral ankle ligament reconstruction with an allograft using 1 fibular tunnel demonstrated similar biomechanical stability to the 2-tunnel approach.Clinical Relevance:Demonstrating similar stability in a cadaveric study and given the potential to reduce intraoperative complications, the 1–fibular tunnel approach should be considered a viable option for the surgical therapy of chronic ankle instability. Clinical randomized prospective trials are needed to determine the clinical outcome of the 1-tunnel approach.

Surgical strategy regarding chronic lateral ankle instability is undergoing an evolution from traditional open procedures to minimally invasive and arthroscopic techniques. The development of arthroscopic techniques for the ankle mirrors the processes witnessed for the shoulder and knee over the last 30 years. The arthroscopic Brostrom is a novel technique that allows the surgeon to use an arthroscope to perform a lateral ankle ligament reconstruction that was previously thought possible only through open surgical technique. Indications and contraindications for the arthroscopic technique are essentially the same as those for an open Brostrom type of procedure. The arthroscopic Brostrom procedure is easy to remember and relatively simple to perform for the surgeon who has mastered basic ankle arthroscopy. The authors' results discussed in this article reveal that the arthroscopic Brostrom is a safe and effective procedure with outcomes at least equal to published results for traditional open techniques. Level V, expert opinion.

Objective To evaluate the efficacy of arthroscopic Brostrom technique in the treatment of chronic ankle instability. Methods Seventeen patients with chronic ankle instability were treated at Department of Foot and Ankle Surgery, Wuhan Fourth Hospital from March to December 2016. They were 5 males and 12 females, aged from 18 to 52 years (mean, 28 years). The ankle instability confirmed preop-eratively involved the left side in 9 cases and the right side in 8 ones. Arthroscopic Brostrom technique was used to repair the anterior talofibular ligament. All the patients were evaluated preoperatively and at the last follow-up using American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS). The talar tilt angle and anterior translation were also assessed radiographically in pre-and postoper-ative ankle stress views. Results They obtained a mean follow-up of 12 months (range, from 10 to 18 months). Wound infection occurred in none of the patients; paresthesia appeared in the superficial fibular nerve area in one case which was recovered spontaneously. At the last follow-up, their AOFAS scores were improved from preoperative 47.5±3.4 to 95.7±2.1, VAS pain scores were decreased from preoperative 5.7±1.8 to 1.6±1.4, anterior talar translation was reduced from preoperative 10.12±3.23 mm to 4.02±1.68 mm, and talar tilt angle decreased from 15.20°±3.43° to 6.02°±2.64°. All the above differences were statistically significant(P<0.05). Conclusion Arthroscopic Brostrom technique may be consid-ered as a valid option for treatment of chronic ankle instability, because it can well restore the stability of ankle joint and lead to satisfactory short-term results. Key words: Ankle; Arthroscopy; Ligaments; Wounds and injuries

Arthroscopic anterior talofibular ligament reconstructin in chronic ankle instability: Two years results