Minimally Invasive Lateral Complex Ankle Reconstruction for Chronic Ankle Instability: Surgical Technique

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.

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.

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.

T1rho MRI of the subtalar articular cartilage is increased in those with chronic ankle instability

BackgroundThis study aimed to evaluate the prevalence and potential associations among lateral ankle sprains (LAS), recurrent LAS, chronic ankle instability (CAI), and CAI by criteria for clinical practice (CAI-C). Chronic ankle instability by criteria for clinical practice is a condition that meets CAI inclusion criteria but also falls under the exclusion criteria defined by the International Ankle Consortium (IAC). Chronic ankle instability by criteria for clinical practice represents a broader clinical definition of CAI.MethodsThis study was a descriptive epidemiological study of the prevalence of LAS, recurrent LAS, CAI, and CAI-C in sports disciplines. A total of 2,175 athletes (1,522 males and 653 females) from 12 sports were surveyed using a structured questionnaire incorporating the Japanese version of the Identification of Functional Ankle Instability. Classification was based on criteria from the IAC.ResultsThe results showed that 52.9% of the participants experienced LAS, and 36.2% had a recurrence. Among those with LAS history, 68.5% had recurrent episodes. Chronic ankle instability was observed in 17.9% of athletes, and CAI-C was present in 32.6%, nearly 1.8 times more prevalent than typical CAI. In particular, the prevalence of CAI-C was more than twice that of CAI in rugby football, cheerleading, and soccer. Furthermore, 90.0% of recurrent LAS cases progressed to CAI-C. Chronic ankle instability was most prevalent in basketball and handball, whereas CAI-C was prevalent not only in these sports but also in soccer and judo, based on adjusted residuals ≥1.96.ConclusionsWe found that the number of participants with CAI-C differed from that of participants with CAI. This finding suggests that CAI may not reflect the entire clinical population with CAI conditions. Therefore, it has been suggested that it is also necessary to identify CAI-C in clinical practice. These findings underscore and support the need to consider tailored prevention programs and clinical attention to at-risk sports to reduce the long-term impact of ankle instability in athletes.Levels of Evidence:Prognostic, Level IV: case series.

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

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.

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.

Fibular tip ossicle separation can cause ligament injury leading to chronic lateral ankle instability. A cadaveric study was conducted to preliminarily assess the effects of fibular tip separated ossicle location and size on lateral ankle ligament complex integrity. X-ray examinations and dissection of the anterior talofibular and calcaneofibular ligaments were conducted in ten radiographically confirmed normal below-knee cadaveric specimens extracted from donated fresh cadavers. Ossicle and bone fragment location and size were recorded, and distal fibula, articular surface, and adjacent ligament effects were determined by a novel 9-region matrix. Ligament risk varied by region. Anterior talofibular ligament width, perpendicular distance to fibular tip, sagittal width of distal fibula, and coronal width of distal fibula at attachment were 7.45 ± 0.22, 11.75 ± 1.03, 20.56 ± 1.54, and 8.68 ± 0.12 mm, respectively. Sagittal distal fibula and calcaneofibular ligament maximum widths at fibular attachment articular surfaces were 16.81 ± 0.96 and 3.50 ± 0.44 mm, respectively. Anterior talofibular to calcaneofibular ligament distance was 2.35 ± 0.14 mm. Separated ossicles >10 mm in regions 1-3 affected anterior talofibular ligaments, calcaneofibular ligaments, and fibular ankle joints; while those in regions 4, 8, and 7 or 9 affected anterior talofibular or calcaneofibular ligaments or were without impact. At the fibular tip, separated ossicles sized >10 mm impact collateral ligaments and articular surfaces, while those 5-10 and <5 mm impact anterior talofibular or calcaneofibular ligaments, potentially impairing the lateral ankle ligament complex. Thus, systematic matric-based assessment of ossicle size and location can potentially improve and standardize ankle fracture care.

Ankle sprains are one of the most common sports injuries which are about 40% of total sports injuries and 20~40% of them would be progressed to chronic ankle instability (CAI) [1]. Rehabilitation and surgical therapy have been used to treat CAI, and the open modified Brostrm operation (MBO) is the gold standard surgical procedure. There are various evaluation methods in CAI treatments, such as the interview, visual analogue scale (VAS), and the measurement of range of motion (ROM) and the ankle torque. However, in reality, it is difficult to measure the maximum ROM and torque. Therefore, some studies measured ankle ROM and torque with cadaver specimens [2,3]. In this study, both open and arthroscopic MBO were performed on cadavers, and ankle torque and angle were measured during ankle inversion using the axial-torsion testing system. Ankle stiffness was calculated from measured data, and effects of both operations were compared quantitatively. For this study, matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from seven males and four females (average age 71.5 (range 58–98) years). Each specimen consisted of the distal half of a leg. The soft tissues were removed from the calcaneus and distal tibiofibular part, except for the ankle joint and ligament. The anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) were transected. The specimens for the arthroscopic and open MBO were chosen from the left and right legs alternately. Then, each specimen was fixed in the specially-designed jig that was mounted on the axial-torsion fatigue testing system (Instron 8874, Norwood, MA, USA). The test consisted of a single ramp from 0° to 70° by inverting the ankle at 5°/s, while measuring the angular position and resultant torque. There was no statistical difference in torque to failure between open and arthroscopic MBO. The maximum torque was 16.3±7.2 N•m at 45° for open MBO and 19.9±10.8 N•m at 40° for arthroscopic MBO (Figure ​(Figure1).1). Ankle stiffness increased faster in arthroscopic MBO (0.31±0.22 N•m/deg) than in open MBO (0.18±0.15 N•m/deg) in initial inversion range (<5°), but no statistically significant differences were observed. The maximum stiffness was 0.41±0.18 N•m/deg at 35° in open MBO and 0.50±0.27 N•m/deg at 40° in arthroscopic MBO (Figure ​(Figure11). Figure 1 Ankle torque and stiffness during inversion test during open and arthroscopic MBO In this study, biomechanical analysis was performed for operations of CAI and there was no statistically significance in torque and stiffness. In comparison to open MBO, arthroscopic MBO is good alternative technique for CAI.

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.

The International Ankle Consortium (IAC), formed in 2004, is an international community of researchers and clinicians who seek to promote and improve the progression and dissemination of information related to conditions affecting the ankle complex, particularly lateral ankle sprains (LASs) and chronic ankle instability (CAI), among physically active populations. We are a collegial network that strives to support the ongoing growth of scientific and clinical evidence to elucidate the mechanisms and characteristics of ankle injuries in an effort to optimize interventions and improve the lives of affected patients.The primary venue by which the IAC disseminates the work of its collegial network is the International Ankle Symposium (IAS). This meeting has been hosted every 2 to 3 years by selected members of the IAC in an effort to present and discuss the most contemporary theories and research related to acute and chronic ankle sprains and instability.Another focus of the IAC is to endorse standards of clinical research on ankle injuries. These endorsements exist as isolated statements of standards (eg, patient inclusion criteria for studies of CAI, best practices for the evaluation of ankle instability), as well as summary statements from each IAS meeting that present the major findings and updates from the scientific discourse.The IAC was an idea that arose in 2004. Four years earlier, a small group of international researchers met in Ulm, Germany, to convene the first IAS. Athletic training researchers Jay Hertel, PhD, ATC, FNATA, FACSM, and Thomas W. Kaminski, PhD, ATC, FNATA, FACSM, attended this meeting. They decided to perpetuate the idea and hosted the second IAS at the University of Delaware in 2004. The concluding town hall–style session led to the idea that a consortium of international experts should be established to maintain the momentum from the first 2 IAS meetings, and Drs Hertel and Kaminski became the first codirectors of the IAC. Along with international researchers and clinicians, they guided the growth of the IAC over the next several years through subsequent symposia held in Dublin, Ireland, in 2006 and Sydney, Australia, in 2009.Before the fifth IAS meeting held in Lexington, Kentucky, in 2012, a group of individuals led by Drs Hertel and Kaminski, who had been involved in the IAS meetings since 2004, held a retreat to review the progress and discuss the trajectory of the IAC. Plans were formalized for the group to serve as the executive committee of the IAC. Drs Hertel and Kaminski recommended that they pass the leadership on as the group transitioned into a consortium, and we were asked to assume the new roles of IAC codirectors.The IAC Executive Committee believed that the influence of this international group could extend beyond organizing successful research meetings. Other similar organizations had been successful in promoting their disciplines by creating position statements to help guide research in their field and the day-to-day practice of clinicians. We determined that clarity was needed to improve the quality and consistency of studies involving patients with CAI. Much of the work presented at the IAS meetings and in the published literature1 demonstrated a lack of consistency regarding the inclusion criteria for CAI cohorts. Therefore, we produced the first consensus statement from the IAC to address this topic. This position statement outlined a recommended minimum set of standard inclusion criteria for enrolling participants with CAI as well as recommendations to improve the reporting of their characteristics in research studies. We envisioned that this initiative would enhance the ability of the international community to more consistently compare and share information about these patients. The Journal of Orthopedic and Sports Physical Therapy (JOSPT) agreed to publish our work as the primary source in 2013.2 As a testament to the editors of JOSPT and the reputation of our group of authors, JOSPT agreed to a publication in partnership with the Journal of Athletic Training (JAT)3 and the British Journal of Sports Medicine (BJSM).4 To date, the consensus statement published in these 3 journals has been cited 313 times (unpublished data, Scopus, accessed May 14, 2019).After the first consensus statement was published, the executive committee determined the next topic area that needed addressing was to inform the research and clinical communities of the long-term consequences of ankle sprains. The phrase “it's not just an ankle sprain” had become very common at the IAS meetings. Patients who sustain an LAS early in life are likely to develop lingering joint instability and pain and high rates of reinjury, which lead to reductions and interruptions in physical activity and the early onset of ankle osteoarthritis. The long-term effects of an ankle sprain create a substantial public health care burden. This document was presented in 2016 as a 2-part publication in BJSM: a consensus statement5 and accompanying comprehensive evidence-informed literature review.6 In that short time, these 2 articles have been cited 83 times (unpublished data, Scopus, accessed May 14, 2019).Most recently, a third statement from the IAC was published in 2018 in BJSM to present an evidence-informed consensus on the clinical assessment of patients with acute LASs.7 Using a Delphi method, the executive committee and selected clinicians from around the world arrived at recommendations for undertaking a structured clinical assessment of acute lateral ankle sprains. This consensus yielded the Rehabilitation-Oriented ASessmenT (ROAST) statement, which guides clinicians in objectively identifying mechanical and sensorimotor impairments after acute LAS that are associated with CAI. The message conveyed in ROAST has also been summarized in an accompanying infographic.8 We expect that these resources will help clinicians to use the objective outcomes of their structured clinical assessment to guide the treatment they administer to patients with acute LASs.The IAC Executive Committee has been very active since 2013 in producing consensus statements. These have been well received in the scientific community and appear to be influencing ankle research and clinical practice internationally. Our hope is that the IAC will continue to shape evidence that provides utility to clinicians and researchers interested in improving the condition of patients with ankle sprains and ankle instability.The eighth IAS will take place October 3–4, 2019, in Amsterdam, the Netherlands. As codirectors of the IAC, we are excited to have the opportunity to share the history and trajectory of the IAC in this special issue of JAT. At the upcoming meeting, we will present a plan to realign the leadership of the IAC to be more inclusive and to formalize membership. We hope this will begin the next important growth phase of the IAC. We are grateful to the many supporters of the IAC, including the current and past editors of JAT, JOSPT, and BJSM, who have provided a platform for the IAC to grow and become known to international researchers and clinicians. For those interested in patients with ankle sprains and instability, we invite you to attend the next IAS meeting and to consider becoming involved with the IAC as the organization continues to expand. More information is available at https://www.ias2019.amsterdam.

A Re-look at chrisman-snook: A narrative review and technique guide for lateral ankle ligament reconstruction with tendon allograft

Chronic ankle instability (CAI) is a clinical sequela that causes the recurrence of ankle sprain by inducing ankle sensorimotor dysfunction. Animal models of CAI have recently shown that ankle ligament injuries mimicking an ankle sprain result in chronic loss of ankle sensorimotor function. However, the underlying mechanisms determining the pathogenesis of CAI remain unclear. Ankle instability after an ankle sprain leads to the degeneration of the mechanoreceptors, resulting in ankle sensorimotor dysfunction and the development of CAI. Controlled laboratory study. Four-week-old male Wistar rats (N = 30) were divided into 2 groups: (1) the ankle joint instability (AJI) group with ankle instability induced by transecting the calcaneofibular ligament (n = 15) and (2) the sham group (n = 15). Ankle instability was assessed using the anterior drawer test and the talar tilt test at 4, 6, and 8 weeks after the operation (n = 5, for each group at each time point), and ankle sensorimotor function was assessed using behavioral tests, including ladder walking and balance beam tests, every 2 weeks during the postoperative period. Morphology and number of mechanoreceptors in the intact anterior talofibular ligament (ATFL) were histologically analyzed by immunofluorescence staining targeting the neurofilament medium chain and S100 proteins at 4, 6, and 8 weeks postoperatively (n = 5 per group). Sensory neurons that form mechanoreceptors were histologically analyzed using immunofluorescence staining targeting the mechanosensitive ion channel PIEZO2 at 8 weeks postoperatively (n = 5). Ankle sensorimotor function decreased over time in the AJI group, exhibiting decreased ankle instability compared with the sham group (P = .045). The number of mechanoreceptors in the ATFL was reduced (P < .001) and PIEZO2 expression in the sensory neurons decreased (P = .008) at 8 weeks postoperatively. The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction (P < .001). The AJI model demonstrated degeneration of the mechanoreceptors in the ATFL and decreased mechanosensitivity of the sensory neurons, which may contribute to CAI. Ankle instability causes degeneration of mechanoreceptors and decreases the mechanosensitivity of sensory neurons involved in the development of CAI. This finding emphasizes the importance of controlling ankle instability after ankle sprains to prevent recurrence and the onset of CAI.

Hindfoot varus alignment is a risk factor for chronic lateral ankle instability (CLAI) and recurrent ankle instability following anterior talofibular ligament (ATFL) repair for CLAI. This study aimed to assess whether combining calcaneofibular ligament (CFL) repair with ATFL repair can correct hindfoot varus alignment and reduce recurrent ankle instability. This study retrospectively examined 74 ankles from 71 patients with hindfoot varus alignment who had lateral ankle ligament repair for CLAI. Arthroscopic ATFL repair was performed on 37 ankles (from 36 patients) between 2018 and 2021 (ATFL-only group), whereas open ATFL and CFL repair were conducted on another 37 ankles (from 35 patients) between 2021 and 2023 (CFL-repair group). Long axial hindfoot alignment radiographs were utilized to measure tibiocalcaneal angles (TCA) pre- and postoperatively. The primary outcome includes recurrent ankle instability (i.e., respraining of the operated ankle after surgery), whereas the secondary outcome involves Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores. A comparison of patient demographics between the two groups revealed no marked differences. Additionally, pre- and postoperative TCA demonstrated that neither ATFL repair only nor CFL repair combined with ATFL repair corrected hindfoot varus alignment. Furthermore, no significant differences were observed in postoperative recurrent ankle instability and SAFE-Q scores between the two groups. Combining ATFL and CFL repair could not correct hindfoot varus alignment, and this procedure for CLAI with hindfoot varus alignment was not more effective in reducing recurrent ankle instability than ATFL repair alone.