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Lateral ankle avulsion fracture is a common sports injury that can lead to chronic lateral ankle instability and substantial deterioration of the joint function. Currently, problems such as misdiagnosis, inappropriate treatment, disparate outcomes and lack of standardization are usually met in the diagnosis and treatment of lateral ankle avulsion fracture. The Foot and Ankle Committee of Chinese Association of Sports Medicine Physicians thus organized a working group of experts in the field of sports medicine and ankle surgery from China to develop "An evidence-based clinical guideline for the diagnosis and treatment of lateral ankle avulsion fractures (2022 version)" in accordance with the principle of evidence-based medicine and scientificity and practicability. The guideline covered the topics of imaging diagnosis, indications and methods of non-operative and operative treatment as well as postoperative rehabilitation, in order to provide guidance for the diagnosis and treatment of lateral ankle avulsion fracture.
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Objective:To compare the efficacy of arthroscopic all-inside ligament repair with suture augmentation and ligament reconstruction with tendons in the treatment of chronic ankle instability with poor remnant quality of the anterior talofibular ligament (ATFL) tissue.Methods:A retrospective cohort study was conducted to analyze the clinical data of 37 patients with chronic ankle instability treated at Huashan Hospital Affiliated to Fudan University from January 2018 to August 2020, including 34 males (34 ankles) and 3 females (3 ankles); aged 18-57 years [(32.2±7.2)years]. The time from injury to operation ranged from 3-360 months [48(12, 120)months]. All patients underwent arthroscopic all-inside ankle stabilization surgery, of which 19 underwent ligament repair with suture augmentation (augmented repair group) and 18 underwent traditional ligament reconstruction with allograft/autograft tendons (tendon reconstruction group). The degree of ATFL injury and intra-articular lesions (osteophytes, loose bodies and cartilage damage) were recorded during the operation. The Karlsson scale and Tegner scale were evaluated before operation and at the last follow-up. The number of patients who were able to complete partial weight-bearing/return to normal walking/return to sports postoperatively and the time required were compared between the two groups. Postoperative complications were observed.Results:All patients were followed up for 12-32 months [21(16, 28)months]. There were no significant differences in the degree of ATFL injury and intra-articular lesions (osteophytes, loose bodies and cartilage damage) seen during the operation between the two groups (all P>0.05). At the last follow-up, the Karlsson score in augmented repair group and tendon reconstruction group [95.0(90.0, 98.5)points and 95.0(87.8, 99.3)points] was significantly higher than the preoperative level [65.0(51.0, 75.0)points and 65.0(53.3, 78.0)points] (all P<0.01). At the last follow-up, the Tegner score in augmented repair group and tendon reconstruction group [5.0(3.5, 6.0)points and 5.0(3.3, 6.0)points] were significantly higher than the preoperative level [3.0(2.0, 4.0)points and 2.5(1.3, 4.0)points] (all P<0.01). There were no significant differences in Karlsson score and Tegner score between the two groups (all P>0.05). All patients completed partial weight-bearing after 3.0(2.0, 4.0)weeks in augmented repair group and 4.0(3.5, 6.0)weeks in tendon reconstruction group. All patients returned to normal walking after 8.0(6.0, 9.0)weeks in augmented repair group and 8.0(5.5, 12.0)weeks in tendon reconstruction group. A total of 13 patients (63%) in augmented repair group and 13 patients (72%) in tendon reconstruction group successfully returned to sports postoperatively and the time required was 6.0(3.5, 8.0) months and 6.0(4.5, 12.0)months, respectively. There were no significant differences in the above indicators between the two groups (all P>0.05), but augmented repair group had a trend of faster completion of partial weight-bearing than tendon reconstruction group. There was 1 patient [5%(1/19)] in augmented repair group and 1 patient [6%(1/18)] in tendon reconstruction group who reported feelings of instability during exercise postoperatively ( P>0.05). None of the patients in augmented repair group had limited ankle range-of-motion, not different from 1 patient [6%(1/18)] in tendon reconstruction group ( P>0.05). Conclusion:In the treatment of chronic ankle instability with poor remnant quality of the anterior talofibular ligament (ATFL) tissue, both arthroscopic all-inside ligament repair with suture augmentation and ligament reconstruction with tendons can improve the short-term postoperative ankle function and activity level of the patients, and the former one has advantages such as simple operative procedures and none use of grafts.
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Objective To evaluate the angle between the anterior talofibular ligament (ATFL) and posterior talofibular ligament (PTFL) in patients with mechanical ankle instability,so as to find out a new indirect diagnosis method for the chronic ATFL lesion.Methods One hundred subjects were included in this study,among which 50 patients with mechanical ankle instability were assigned to group A and 50 counterparts without it were selected into group B All patients were taken MR Images and the ATFL and PTFL angle at the axial plane was evaluated.The difference between two groups was evaluated.Results The ATFL and PTFL angle increased significantly in group A when compared to group B (82.1° ± 8.0° v.s,74.4° ± 5.9°,P＜0.01).The area under receiver operating characteristic curve (ROC)was 0.874 (P＜0.01),indicating great significance in diagnosing the chronic ATFL tear.Moreover,the angle was 79 degree,showing high sensitivity (0.88) and specificity (0.64) of diagnosing ATFL tear.Conclusion The ATFL and PTFL angle increases significantly in patients with the mechanical instability.Moreover,the possibility of ATFL tear increases when the ATFL and PTFL angle is greater than 79 degree.
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Purpose To clarify the morphological parameter and describe the distance from the insertion of the lateral ankle ligaments to the adjacent bony landmarks through precisely anatomical explore of human cadaveric ankles,so as to provide anatomical evidences for the reconstruction of lateral ankle ligaments.Methods Nineteen ankle specimens were dissected to isolate the lateral ankle ligaments and measure the morphological parameters such as length,width,thickness and the distance from the insertion of the lateral ankle ligaments to the adjacent bony landmarks.Results The average length of anterior talofibular ligaments (ATFL) was 23.1 ± 2.98 mm,among which 8 were single-banded(42.1％)and 11 were double-banded(57.9％).The average distance from the fibular origination of ATFL to the anterior tubercle of fibula(AA)was 17.1 ± 3.00 mm,to the fibular obscure tubercle(AO)was 5.1 ± 1.69 mm,to the tip of the fibula(AT)was 14.1 ± 2.86 mm.The distances from the talus insertion of ATFL to the superior and inferior talus articular surface were 11.4 ± 2.25 mm and 18.4 ± 2.30 mm respectively,to the anterior lateral talus chondral surface was 4.8 ± 1.42 mm.The average length of calcaneofibular ligament(CFL)was 31.4 ± 3.55 mm.The average distance of the fibular origination from ATFL to CFL was 6.4 ± 2.55 mm.The average angle between ATFL and CFL was 116.6 ± 12.69°.The distance from the calcaneus insertion of CFL to the peroneal tubercle(CP)was 15.4 ± 2.86 mm,to the posterior superior border of calcaneus(CC)was 13.9 ± 2.46 mm,to the subtalar joint surface was 15.2 ± 3.21 mm.The coefficient variation assessing the anatomical reliability of different bony landmarks were as follows:ATFL fibular origination AA(17.54％) ＜AT(20.28％) ＜ AO(33.14％),CFL calcaneus insertion CC(17.70％)＜CP(18.57％)＜CS(21.1％).Conclusion Certain variations exist in the morphological parameters and the distances from the insertion of the lateral ankle ligaments to the adjacent bony landmarks.It provides anatomical evidence for lateral ankle ligament reconstruction in treating chronic ankle instability.
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Objective To compare T2* value in healthy and diseased achilles tendons (AT) using 3D-ultra-short echo time (UTE),and to analyze the correlation between T2* value and clinical scores.Methods Fifteen patients (patients group) and ten volunteers (control group) were included and underwent an MR scan with UTE sequence.The T2* value of four ROI in AT were calculated.Independent sample t-test was used to compare the differences of T2* value between two groups.The correlation of T2* values with the American Orthopaedic Foot and ankle society ankle hindfoot scale (AOFAS) and achilles tendon total rupture score (ATRS) were analyzed.Results The T2* value of four ROI were statistically significantly higher in patients group than those of control group.There were negative correlation between T2* and AOFAS or ATRS scores (r=-0.92,-0.90,both P＜0.01).Conclusion The T2* value of pathologic AT increases.The quantitative MRI UTE-T2* can evaluate AT from the biochemical structure and correlates with clinical outcomes,which is helpful to diagnose AT in the early stage.
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Objective To quantitatively analyze the histological and MR images of repaired tissue (RT) following microfracture for knee joint osteochondritis dissecans (OCD) in rabbit models at different time points,make comparisons with the RT performances of joint debribement,explore the efficiency of the microfracture treatment for OCD.Methods Twenty-seven New Zealand rabbits were randomly assigned into 3 groups (sacrificed at the end of 3,5 and 7 weeks post-operation respectively),with 9 in each group.For each rabbit,one knee joint was made into an OCD model.In each group,6 were for microfracture treatment,and the other 3 were for joint debridement as control.MR scan,which mainly included sequences of 3D double echo steady state sequence (3D-DESS) and T2-mapping,was taken at 3,5 and 7 weeks postoperation.The thickness index and T2 value index of RT were calculated and T2-mapping of repaired region was drafted.Then the operation sites were removed to make histological sections of HE and Masson staining.The modified O' Driscoll score system was employed to make semi-quantitative evaluation for the histological performance of RT.Comparisons were made with respect to MR and histological findings between two treatments at each time point using unpaired Student t test.Effects of two treatments were evaluated longitudinally by comparing the results of three time points using one-way ANOVA.Results The post-operation thickness indexes of two groups increased gradually (F =33.940,28.841,P ＜ 0.05),T2 value indexes decreased (F =80.183,206.206,P ＜ 0.05),and O'driscoll scores increased gradually (F =29.867,17.167,P ＜ 0.05).At each time point,the thickness index of microfracture was higher than that of debridement group(3-week:0.743 ±0.048 vs 0.624 ±0.013,t =4.077 ;5-week:0.813 ±0.031 vs 0.734 ±0.015,t =4.107 ; 7-week: 0.972 ± 0.064 vs 0.777 ± 0.039,t =4.782 ; P ＜ 0.05),and the defects of microfracture in 7-week group were almost fully recovered while the defects of the debridement in 7-week group were not.The T2 value index of microfracture group was lower than that of debridement group at 3-week point(1.338 ±0.043 vs 1.510 ± 0.009,t =6.583,P ＜ 0.05),but it was higher than that of debridement group at 5-week and 7-week points (5-week: 1.284 ± 0.097 vs 1.116 ± 0.068,t =2.663 ; 7-week: 0.916 ± 0.036 vs 0.843 ± 0.016,t =3.283 ; P ＜ 0.05).The O'Driscoll score of microfracture group was higher than that of joint debridement at every time point(3-week:7.167 ±0.753 vs 4.667 ±0.577,t =5.000;5-week: 9.833 ± 1.169 vs 7.667 ± 0.577,t =2.960 ; 7-week: 11.167 ± 0.753 vs 8.333 ± 1.155,t =4.520 ; P ＜ 0.05).For microfracture group,the RT was mainly repaired by fibrocartilage and got matured gradually with more production of well-distributed collagen fibrils ; while for joint debridement group,the RT was mainly repaired by fibrous and scar tissue.Conclusions The post-operation repairing thickness and tissue composition of microfracture for OCD are superior to that of joint debridement.MR 3D-DESS and T2-mapping can show the thickness and tissue composition of the RT after OCD treatments,provide effective evaluation of repairing conditions,and they are of great importance on the OCD post-op follow-up.
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Objective To compare the clinical results of anterior cruciate ligament(ACL)reconstruction using anterior tibial muscle tendons allograft and hamstring tendons autograft.Methods According to the graft used for ACL reconstruction,60 patients with chronic ruptures of ACL were divided into group A(30 patients,using anterior tibial muscle tendons allograft)and group B(30 patients,using semitendinosus and gracilis tendons autograft).The average follow-up periods after surgery were 29.4 and 31.6 months respectively.Lysholm,Tegner,IKDC clinical rating scales and KT2000 were used for evaluation pre-and post-operation.The muscle strength of the extension,flexion,internal rotation and external rotation of knees was evaluated by the isokinetic tester.Results There were statistically significant differences in Lysholm,Tegner,IKDC clinical rating scales and KT2000 results between pre-and postoperation(P0.05).The Isokinetic muscle strength tester showed that the knee muscle strength of the internal rotation and flexion were decreased post-operative in group B,rather than group A,which showed no significant differences between pre-and post.operation(P<0.05).Conclusion For ACL reconstruction under arthroscopy,anterior tibial muscle tendons allograft was a favorable substitute for autograft materials for its convenience,satisfactory clinical effect and less complications.