Comparison of arthroscopic and open Brostrom-Gould surgery for chronic ankle instability: a systematic review and meta-analysis

Background:Arthroscopic lateral ligament repair is widely performed to treat chronic lateral ankle instability (CLAI), with good clinical outcomes. However, some patients show residual or recurrent instability after surgery. Although some risk factors of recurrent instability have been reported, the morphological characteristics of lateral ankle ligament injuries with residual or recurrent instability remain unclear.Hypothesis:Characteristic patterns of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injuries may be observed in patients with CLAI who have residual instability after isolated ATFL repair or recurrent instability after arthroscopic lateral ligament repair.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively reviewed 27 patients with CLAI and 10 controls without CLAI who underwent arthroscopic surgery. Three-dimensional volume-rendering models were reconstructed from preoperative magnetic resonance imaging scans of the ankle joints. For the primary outcome, the distance between the tip of the fibula and the proximal end of the CFL (dCFL), 3 vectors of the dCFL, and the horizontal angle of the ATFL (ATFL angle) were measured. For the secondary outcome, the clinical scores of patients with CLAI were evaluated pre- and postoperatively. Differences in parameters were compared among patients with no residual ankle instability, those with residual ankle instability immediately after arthroscopic ATFL repair, and the control patients. In addition, these parameters were compared between patients with non-recurrent and recurrent ankle instability at 1 year postoperatively.Results:As the primary outcome, the dCFL was greater, and its mediolateral vector, defined as the lateral direction as positive, was lower, indicating a medially shifted dCFL, in patients with residual ankle instability compared with patients without residual ankle instability and control patients. As a secondary outcome, there were no significant differences in clinical scores between the non-recurrence and recurrence groups. However, the ATFL angles in patients in the recurrent group were significantly smaller, indicating the talar side drooping of the ATFL, than in the nonrecurrence group.Conclusion:The CFL was injured and shifted medially in patients with residual ankle instability. Moreover, the ATFL in patients with recurrent instability showed talar side drooping. These findings suggest that additional CFL repair or ATFL augmentation may be beneficial in preventing recurrent instability after arthroscopic repair.

Chronic lateral ankle instability is treated operatively, whereas most acute ankle sprains associated with acute anterior talofibular ligament injury are usually treated nonoperatively. This treatment strategy is widely accepted and has been validated using a variety of clinical or radiological methods. We suspected that there may be biological differences between chronic and acutely injured ligaments, particularly with respect to apoptosis. Apoptosis is known to cause ligament degeneration. If it could be demonstrated that apoptosis occurs more in the anterior talofibular ligament tissues of patients with chronic lateral ankle instability compared with patients with acute anterior talofibular ligament injury, biological evidence could be supported. We sought to (1) elucidate the difference in the extent of apoptosis between patients with chronic lateral ankle instability and those with acute anterior talofibular ligament injury. In addition, we asked: (2) What is the expression level of apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c in each patient group? (3) Is there a correlation between apoptotic activities and the symptom duration period of chronic lateral ankle instability? Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Anterior talofibular ligament tissues were harvested from patients who were divided into two groups: the chronic lateral ankle instability group and the acute anterior talofibular ligament injury group. Patients with insufficient remaining ligaments were excluded from the chronic lateral ankle instability group, and cases in which the tissue was severely damaged or the quality of collected tissue was insufficient because of severe impingement into the fracture site were excluded from the acute anterior talofibular ligament injury group. Tissues were collected from 21 patients (11 males and 10 females) in the chronic lateral ankle instability group with a mean age of 37 ± 14 years and from 17 patients (6 males and 11 females) in the acute anterior talofibular ligament injury group with a mean age of 49 ± 17 years. To investigate our first purpose, apoptotic cells were counted using a TUNEL assay. To answer our second question, Western blotting for apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c was performed to investigate apoptotic activity. Immunohistochemistry was also used to detect apoptotic enzymes. To answer our third question, the time elapsed after the first symptom related to chronic lateral ankle instability occurred and the expression level of each enzyme was investigated. More apoptotic cells were observed in the chronic lateral ankle instability group than in the acute anterior talofibular ligament injury group in the TUNEL assay. Western blotting revealed that the apoptotic activities of the chronic lateral ankle instability group were higher than those of the acute anterior talofibular ligament injury group: caspase 3 was 117 in the chronic lateral ankle instability group and 59 in the acute anterior talofibular ligament injury group (mean difference 58 [95% confidence interval (CI) 31 to 86]; p < 0.001), caspase 7 was 138 in the chronic lateral ankle instability group and 45 in the acute anterior talofibular ligament injury group (mean difference 93 [95% CI 58 to 128]; p < 0.001), caspase 8 was 126 in the chronic lateral ankle instability group and 68 in the acute anterior talofibular ligament injury group (mean difference 58 [95% CI 29 to 89]; p < 0.001), caspase 9 was 128 in the chronic lateral ankle instability group and 54 in the acute anterior talofibular ligament injury group (mean difference 74 [95% CI 44 to 104]; p < 0.001), and cytochrome c was 139 in the chronic lateral ankle instability group and 51 in the acute anterior talofibular ligament injury group (mean difference 88 [95% CI 46 to 129]; p < 0.001). Immunohistochemistry revealed higher expression of caspases 3, 7, 8, and 9 and cytochrome c in the chronic lateral ankle instability group compared with those in the acute anterior talofibular ligament injury group. Caspases 3, 7, and 9 showed no correlation with duration of chronic lateral ankle instability symptoms: the Pearson correlation coefficient was 0.22 [95% CI -0.25 to 0.69] for caspase 3 (p = 0.36), 0.29 [95% CI -0.16 to 0.74] for caspase 7 (p = 0.23), and 0.29 [95% CI -0.16 to 0.74] for caspase 9 (p = 0.23). In chronic lateral ankle instability, apoptotic activity in the anterior talofibular ligament was higher than in acute anterior talofibular ligament injury. Apoptosis occurs more in chronic injured ligaments than in acutely injured ligaments. Although urgent surgical repair is not required for acute anterior talofibular ligament injury, chronic lateral ankle instability may progress if the nonoperative treatment is not successful. Further research should focus not only on timing of apoptotic progression, but also on biological augmentation to reverse or prevent apoptosis within the anterior talofibular ligament.

BackgroundThe aim of this study is to report our institution’s experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability.MethodsThis retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints.ResultsThirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24–35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01).ConclusionIn this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.

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

Purpose: Anterior drawer and varus stress radiographs are commonly to diagnose chronic lateral ankle instability. We compared the preoperative stress radiographs with the intraoperative radiographs under anesthesia to determine the accuracy and efficacy of stress radiographs in an outpatient clinical environment. Materials and Methods: Data was collected from patients who underwent a modified Broström operation for painful chronic unilateral lateral ankle instability between January 2014 and June 2016. Subjects were divided into three groups—complete tear, partial tear, and instability without rupture—according to the status of preoperative MRI findings of the anterior talofibular ligament. The anterior drawer and varus stress radiographs were taken preoperatively and intraoperatively under anesthesia. Results: Ninety-six patients, with a mean age of 29.63 years, were enrolled. There were 39, 46, and 11 patients in the complete tear, partial tear, and instability without rupture groups, respectively. On the anterior drawer and varus stress radiographs of the affected limb, talar anterior translation and varus tilting were significantly increased by 2.56 mm and 2.0°. The gaps between the unaffected limbs were also increased by 2.47 mm and 1.32° after anesthesia. Although the stress radiographs were taken under anesthesia, the results were often smaller than the diagnostic value. Conclusion: Stress radiographs for painful chronic lateral ankle instability taken at the outpatient clinic might be inaccurate for diagnosis.

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 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.

Objective To evaluate the clinical efficacy and safety of all-inside arthroscopic repair of anterior talofibular ligament (ATFL) for chronic lateral ankle instability (CLAI). Methods From Oc-tober 2016 to September 2017, 19 patients with CLAI were treated with all-inside arthroscopic repair of ATFL at Department of Orthopaedic Surgery, Zhejiang Provincial People’s Hospital and Department of Foot and Ankle Surgery, Guangzhou Orthopaedic Hospital.They were 12 men and 7 women, aged from 18 to 35 years (mean, 27.3 years).Their defective ATFLs had no effective tension.After the fibular foot-print zone of ATFL was refreshed, an absorbable anchor was inserted accurately and its suture was threaded into the remnant of ATFL using the all-inside arthroscopic technique.The remnant of ATFL was fixated by the suture using Las-so-Loop method and anatomically repaired into the foot-print zone to restore the ligamentous tension.The American Orthopedic Foot and Ankle Surgery Society (AOFAS) ankle-hindfoot score, Karlsson ankle function score, Tegner activity score and visual analogue scale (VAS) were used to assess funtion of ankle before and after operation. Results All the 19 patients were followed up for a mean time of 15.6 months (from 12 to 22 months).Their ankle symptoms were all relieved after operation; their ankles recovered fine range of motion; their anterior drawer tests and varus stress tests were negative.Their preoperative AOFAS scores (64.6±11.4), Karlsson ankle function scores (63.5±11.4), Tegner activity scores (3.2±0.7) and VAS(5.8±1.7) were significantly improved at the final follow-up (92.3±3.2, 91.2±4.4, 5.7±0.6 and 1.4±1.0, respectively) (P<0.05).Complications such as incision and articular infections, superficial peroneal nerve injury, sural nerve injury and iatrogenic fracture were not demonstrated in the cohort.By the final follow-up, no patient had been found who needed a secondary revision. Conclusions The all-inside arthroscopic repair of ATFL can be used effectively and safely for CLAI, because it leads to accurate anchor insertion, anatomic repair, limited invasion, and reliable restoration of ligamentous tension.To avoid com-plications, surgeons should familiarize themselves with arthroscopic procedures. Key words: Ankle; Lateral ligament, ankle; Arthroscopy; Chronic anterolateral ankle in-stability; Anatomical ligament repair

Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

Objective To study the clinical efficacy of lateral collateral ligament reconstruction surgery combined with arthroscopy in treatment of chronic lateral ankle instability. Methods 60 cases with chronic lateral ankle instability were selected,the patients were divided into the study group and the control group according to a random number table,which has 30 cases in each group.The control group was received conservative treatment,the study group was underwent exploratory arthroscopic ankle cleanup combined with peroneus brevis tendon lateral ligament reconstruction surgery.Scores before and after treatment of the two groups were detected in American bare foot and ankle surgery-hindfoot score system(AOFAS).And excellent rate,the recurrence rate and complication rate between the two groups were compared. Results AOFAS score before treatment of the two groups had no significant difference (P> 0.05),AOFAS score after treatment of two groups were significantly higher,and that of the study group was significantly higher than the control group,the difference was statistically significant(t= 9.837,10.873,8.789,all P< 0.05);Excellent rate of the study group was 96.7%(29/30)significantly higher than the 73.3%(22/30)in the control group,recurrence rate of the study group was 0.0%(0/30),significantly lower than the 13.3%(4/30)in the control group,the complication rate of the study group was 3.3%(1/30),significantly lower than the 20.0%(6/30)in the control group,the difference was statistically significant(χ2= 13.982,15.037,13.298,all P< 0.05). Conclusion Lateral collateral ligament reconstruction surgery combined with arthroscopy in treatment of chronic lateral ankle instability has better clinical efficacy,the recurrence rate is low,and has less complications. Key words: Ankle Joint; Joint Instability; Collateral Ligament,Ankle; Arthroscopy

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.

Category:Ankle ArthritisIntroduction/Purpose:There is limited information regarding the outcomes of operative treatment for ankle instability with coexisting arthritic changes in the medial gutter. This study was performed to evaluate the intermediate-term clinical and radiological outcomes following a modified Broström procedure and arthroscopic debridement in middle-aged patients with combined medial gutter osteoarthritis and chronic lateral ankle instability.Methods:Twenty-four patients with medial gutter osteoarthritis related to chronic lateral ankle instability were followed for more than 3 years after operative treatment. All patients showed medial joint space narrowing of Takakura stage II at the time of surgery. The clinical evaluation consisted of the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) for medial ankle pain during walking, and Foot and Ankle Ability Measure (FAAM).Results:Mean AOFAS and FAAM scores significantly improved from 51.2 and 45.7 points preoperatively to 80.3 and 78.4 points at final follow-up, respectively (P < .001). Although mean pain-VAS significantly improved from 6.8 points to 3.1 points (P < .001), 5 patients (20.8%) complained of gait discomfort with considerable pain of 4 or more points. There was only 1 patient (4.2%) with recurrent ankle instability, while 6 patients (25%) showed a progression of arthritis stage.Conclusion:Modified Broström procedure combined with arthroscopic debridement appears to be an effective operative option for medial gutter osteoarthritis secondary to chronic ankle instability. Despite the onset of arthritis, most patients were able to achieve significant improvement in reducing pain while eliminating instability.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability

A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability

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