Resultados clínicos y funcionales de la plastía Broström-Gould para inestabilidad lateral de tobillo: evaluación con tres escalas / Clinical and functional results of the Broström-Gould technique for lateral ankle instability: evaluation with three scales

Resumen: Antecedentes: La secuela más frecuente del esguince de tobillo es la inestabilidad del complejo ligamentario lateral; los resultados del tratamiento quirúrgico no han sido evaluados con varias escalas simultáneamente. El objetivo del estudio fue evaluar los resultados clínicos y funcionales con tres escalas en pacientes con inestabilidad lateral de tobillo sometidos a plastía de Broström-Gould, utilizando para su fijación anclas con sutura al peroné distal. Material y métodos: El diseño del estudio fue transversal y descriptivo; se incluyeron pacientes con inestabilidad lateral de tobillo y ruptura parcial o completa del ligamento PAA y/o PC, sometidos a reparación con plastía de Broström-Gould. Se realizó resonancia magnética nuclear para confirmar el diagnóstico; los resultados clínicos y funcionales se determinaron con tres escalas: EVA, SF-36 y AOFAS. Los pacientes fueron evaluados a los seis meses o más posteriores al procedimiento quirúrgico. Resultados: Se incluyeron 13 pacientes; la calidad de vida (cuestionario SF-36) arrojó un resultado bueno con promedio de 90; 10 (77%) pacientes mostraron resultados excelentes en la función, ausencia de dolor y alineación del tobillo (AOFAS 90-100). Asimismo, se observó mejoría importante en el dolor (EVA prequirúrgico: 6, comparado con 1 en el período postquirúrgico). Conclusiones: El procedimiento quirúrgico demostró excelentes resultados en el corto plazo con resolución del dolor y estabilidad del tobillo.

Abstract: Background: The most frequent sequel to the ankle sprain is the instability of the lateral ligament complex; the results of surgical treatment have not been evaluated with multiple scales simultaneously. The objective of the study was to assess the clinical and functional results with three scales in patients with lateral instability of ankle undergoing Broström-Gould technique, using for fixation, anchors with suture to distal fibula. Material and methods: The design of the study was cross-sectional and descriptive; we included patients with lateral instability of ankle and partial or complete rupture of the APA or CP ligament subject to repair with Broström-Gould technique. Magnetic resonance imaging was performed to confirm the diagnosis; clinical and functional outcomes were determined with three scales: EVA, SF-36 and AOFAS. Patients were evaluated at six months, or more, after the surgical procedure. Results: We included 13 patients; quality of life (SF-36 questionnaire) showed a good result with average score of 90; 10 (77%) patients showed excellent results in function, absence of pain and alignment of the ankle (AOFAS 90-100). Also found significant improvement in pain (presurgical EVA: 6, compared with 1 in the postoperative period). Conclusions: The surgical procedure showed excellent results, in the short term with resolution of pain and ankle stability.

El adelantamiento del vasto medial ofrece buenos resultados clínicos y funcionales para la inestabilidad lateral femororrotuliana / Vastus medialis advancement provides good clinical and functional outcomes for lateral patellofemoral instability

Introducción La inestabilidad lateral femororrotuliana es una patología de etiología multifactorial aunque existen múltiples opciones para su tratamiento. El adelantamiento del vasto medial con liberación retinacular lateral asistida por artroscopia (AVMLRAA) se realiza cuando no hay alteraciones de alineación ni de la estructura ósea. El objetivo del estudio es evaluar los resultados clínicos y funcionales de pacientes con inestabilidad lateral femororrotuliana (ILFR) tratados con AVMLRAA. Material y métodos Estudio descriptivo y transversal realizado entre septiembre de 2014 y enero de 2016. Se incluyó a pacientes con ILFR tratados con AVMLRAA. Se presentan los resultados evaluados por las escalas de Tegner-Lysholm y Kujala antes de la cirugía y 12meses después de operados. Resultados Seis pacientes, 5 mujeres (83,3%) y 1 hombre (16,7%); media de edad al presentar la primera luxación: 15,83 (7-30) ±8,47 años; rodilla afectada: 4 derechas (66,7%) y 2 izquierdas (33,3%); tiempo promedio desde la primera luxación hasta la cirugía: 10,08 (0,5-17) ±5,16 años; las evaluaciones prequirúrgicas y posquirúrgicas de las escalas Tegner-Lyshom y Kujala para el género y lado afectado no mostraron diferencias estadísticamente significativas (p>0,05). La mediana prequirúrgica de la escala Tegner-Lysholm fue 37,50 (6-78) ±26,66; posquirúrgica: 88,17 (77-99) ±7,73 (p = 0,028); mediana de la escala Kujala prequirúrgica: 36,67 (2-77) ±29,703; posquirúrgica: 84,83 (75-100) ±9,368 (p = 0,027). El seguimiento promedio fue 14,0 (12-18) ±2,44 meses; la aprensión posquirúrgica fue 100% negativa. El 100% respondió que se volverían a operar en caso de presentar nuevamente los síntomas. Discusión El AVMLR para el manejo de la ILFR en pacientes sin malformaciones óseas ni mala alineación ofrece buenos resultados clínicos. Nivel de evidencia clínica Nivel IV.

Background Patellofemoral lateral instability is a condition of multifactorial origin, and has multiple options for its treatment. Vastus medialis advancement with arthroscopic assisted lateral retinacle replication (AALRR) is performed when there is no alteration of alignment or bone structure. The purpose of this study is to evaluate the clinical and functional results of patients with patellofemoral lateral instability (PFLI) treated with AALRR. Material and methods A descriptive, cross-sectional study was conducted from September 2014 to January 2016 on patients with PFLI treated with AALRR. The results before surgery and 12months after surgery, were evaluated using the Tegner-Lysholm and Kujala scales. Results The study included 6 patients, 5women (83.3%), and 1man (16.7%). The median age at first dislocation was 15.83 (7-30) ±8.47years. The affected knees were 4right (66.7%) and 2left (33.3%). The mean time from first dislocation to surgery was 10.08 (0.5-17) ±5.16years. The pre- and post-surgical evaluations using the Tegner-Lysholm and Kujala scales for the affected gender and side showed no statistically significant differences (P>.05). The pre-surgical median of the Tegner-Lysholm scale was 37.50 (6-78) ±26.66, and post-surgical, 88.17 (77-99) ±7.73 (P=.028). The pre-surgical and post-surgical median of the Kujala scale was 36.67 (2-77) ±29.703, and 84.83 (75-100) ±9.368, respectively (P=.027). The mean follow-up was 14.0 (12-18) ±2.44months.; Post-surgical apprehension was 100% negative. All patients responded that they would have a further operation in case of presenting with the symptoms again. Discussion The AALRR for the management of PFLI in patients without bone malformations or misalignment offers good clinical results. Evidence level IV.

Anatomical Repair for Chronic Lateral Ankle Instability / 대한정형외과학회잡지

Ankle sprain secondarily leads to chronic lateral ankle instability in 20%-30% of cases. Many surgical procedures have been presented for lateral ankle instability; however, controversy remains regarding the ideal surgical option. The Brostrom procedure or its modifications have been widely used; however, they have some limitations for the instabilities of over-weight, physically high demanding patients, generalized ligamentous laxity, and especially for significantly deficient or attenuated ligaments. This article reports on the difference between the bone tunnel technique and the suture anchor technique of the modified Brostrom procedure, and also provides a review of several recent debates.

Surgical Treatment of Chronic Ankle Lateral Instability: Reconstruction with Tenodesis or Tendon Graft / 대한정형외과학회잡지

Numerous reconstructive procedures have been described for treatment of chronic lateral ankle instability; however, controversy remains regarding the ideal surgical option. Numerous studies of the Brostrom procedure or its modifications have followed, reporting good to excellent results. However they have some limitations regarding the instabilities for over-weight, physically high demanding patients, failed anatomical repair, and particularly for significantly deficient or attenuated ligaments. This may indicate the need for non-anatomical reconstruction using peroneus brevis tendon or anatomical reconstruction using the allo/autograft tendon.

Outcomes of the Modified-Brostrom Procedure Using Suture Anchor for Chronic Lateral Ankle Instability: a Prospective, Randomized Comparison with the Bone Tunnel Technique / 대한정형외과학회잡지

PURPOSE: This study was performed prospectively and randomly to compare the clinical outcomes of modified-Brostrom procedures using the suture anchor and the bone tunnel for chronic lateral ankle instability. MATERIALS AND METHODS: Thirty patients were followed up for more than 1 year after the modified-Brostrom procedures. Fifteen procedures treated with a suture anchor and 15 procedures treated with a bone tunnel technique assigned randomly were performed by a single surgeon. The clinical evaluation was performed according to the VAS for pain, the Karlsson scale and Sefton grading system. Measurements of the talar tilt and anterior talar translation was performed using anterior and varus stress radiographs. RESULTS: There were no significant differences in the pain VAS between the 2 techniques postoperatively. However, the pain VAS at postoperative 4th day was significantly higher in the bone tunnel group. The Karlsson scale had improved significantly from a preoperative average of 45.2 points to 90.1 points in the suture anchor group, and from 44.6 points to 88.3 points in the bone tunnel group. According to the Sefton grading system, 13 cases (86.7%) in the suture anchor group and 12 cases (80%) in the bone tunnel group achieved satisfactory results. The talar tilt angle and anterior talar translation had improved significantly from preoperative average of 14.2degrees and 6.2 mm to 6.4degrees and 4.5 mm in the suture anchor group, from 13.8degrees and 6.4 mm to 6.1degrees and 4.2 mm in the bone tunnel group. There were no significant differences between 2 techniques. CONCLUSION: The techniques for ligament reattachment produced similar clinical and functional outcomes except for early-stage postoperative pain. Both modified-Brostrom procedures using the suture anchor and bone tunnel appear to be effective treatment methods for chronic lateral ankle instability. However, the suture anchor technique has an advantage of less early-stage postoperative pain.

Reconstruction for Chronic Lateral Instability of the Ankle by Chen Method / 대한족부족관절학회지

PURPOSE: This study was designed to evaluate the clinical and radiographical results of anatomical reconstruction by Chen method for chronic lateral ankle instability. MATERIALS AND METHODS: Fifteen patients with chronic lateral ankle instability who had undergone anatomical reconstruction of anterior talofibular and calcaneofibular ligaments by Chen method were evaluated retrospectively. Average age of the patients was 31.3 years, and average follow-up period was 15.5 months. Preoperative and postoperative radiographs including varus stress view and magnetic resonance imaging (MRI) were analyzed. The clinical evaluation was performed according to the American Orthopaedic Foot and Ankle Society (AOFAS) scale. RESULTS: Radiographically average talar tilt angle was 15.3degrees preoperatively, and the difference with contralateral normal side was 10.1degrees. At last follow up, talar tile angle and the difference with contralateral side improved to 5.9degrees and 1.3degrees respectively. AOFAS scale was 66.6 preoperatively and 87.3 postoperatively. In MRI findings, four patients had associated intra-articular lesion such as articular cartilage defect, synovitis and osteoarthritis. The talar tilt angle improvement and AOFAS scale of patients without intra-articular lesion was better than those of four patients with intra-articular lesions. Surgical wound pain occurred in six patients and sural neuropathy in three patients. CONCLUSION: The anatomical reconstruction by Chen method was an easy and effective procedure for symptomatic chronic lateral ankle instability. Careful operative technique may prevent the surgical wound pain and sural neuropathy.

Treatment of Chronic Ankle Lateral Instability using Modified Brostrom Procedure with Anchor suture&Arthroscopy / 대한족부족관절학회지

PURPOSE: To evaluate the result of modified Brostrom procedure with anchor suture and explore associate lesion under arthroscopy for chronic lateral instability. MATERIALS AND METHODS: From May 2005 to March 2009, Retrospective analysis of 126 patients with chronic lateral instability who underwent modified Brostrom procedure with anchor suture and arthroscopic procedure was done. Mean follow-up period was 13 months. RESULTS: Chronic lateral instability of the ankle almost had local synovitis by arthroscopic examination. There were osteochondral lesion of talus on the anteromedial aspect in 63 cases, on the anterolateral aspect in 25 cases, osteochondral lesion of tibia side in 8 cases, fat hypertrophy of tibiofibular space in 120 cases, anterior fat impingement in 26 cases, intra-articular loose body in 13 cases. Mean Karlsson scoring scale was improve from 53 preoperatively to 91 postoperatively, There were 70 cases excellent, 27 cases good, 26 cases fair, 3 cases poor result according to the Sefton procedure. CONCLUSION: Modified Brostrom procedure with anchor suture and arthroscopic procedure are reliable treatment method for chronic ankle lateral instability which has intraarticular pathology.

Associated Lesions of Magnetic Resonance Image in the Chronic Lateral Ankle Instability / 대한족부족관절학회지

PURPOSE: This retrospective study was designed to determine the type and frequency of associated lesions in patients with chronic lateral ankle instability who had modified Brostrom lateral ankle ligament reconstruction. MATERIALS AND METHODS:Between 2004 and 2007, 60 cases of 60 patients were enrolled in this study. A retrospective review of the magnetic resonance images of the affected ankle was conducted by two orthopedic surgeons who did not get any information about intraoperative findings and the lesions were admitted when two doctors were coincident. RESULTS:The overall incidence of associated lesions found in this study was about 83%. Peroneal tenosynovitis was the highest frequency (32%), followed by osteochondral lesion of talus (28%), anterolateral impingement (15%), Os subfibula (13%), Os trigonum (12%), ankle synovitis (12%), anterior tibiofibular ligament tear (15%), anterior bony spur (7%). Another findings were loose bodies (5%), flexor tendon tenosynovitis (5%), medial osteophyte (3%). CONCLUSION: Identifying these associated lesions will be helpful in treating chronic lateral ankle instability especially when the surgeon have a plan to operate the instability. We suggest that the better results can be obtained when the associated lesions are corrected simultaneously.

Treatment of Chronic Ankle Lateral Instability using Modified Brostrom Procedure / 대한정형외과학회잡지

Purpose: To analyze the results of modified Brostrom procedure for chronic ankle lateral instability. Materials and Methods: Twenty six patients were followed up for more than 1 year after performing the modified Brostrom procedure. The mean age was 35.3 years, and the mean follow-up period was 2.4 years. Anterior and varus stress radiographs were taken in all cases, and a preoperative MRI was taken in 22 cases. Clinically, the Karlsson scale and Sefton grading were used. The effects of age, injury pattern and associated injury such as osteochondral fracture on the clinical results were analyzed. Results: Radiologically the difference in anterior displacement between the affected side and contralateral side was 3.1 mm, and that of the varus tilt was 4.2degrees. At the last follow-up, the Karlsson scale had increased from preoperative 47.5 points to 90.3 points. There were 14 excellent, 8 good, 3 fair and 1 poor results according to the Sefton grading. The results were significantly worse in patients over 50 years of age. An osteochondral fracture or degenerative changes also lowered the level of patient satisfaction. Conclusion: The modified Brostrom procedure appears to be a safe and highly satisfactory procedure. However, a more careful approach is needed for patients over 50 years of age or with associated degenerative changes.

Operative Treatment of Symptomatic Os Subfibulare / 대한족부족관절학회지

PURPOSE: To evaluate the clinical results of resection of os subfibulare and lateral ligament reattachment or modified Brostrom procedure in patients with symptomatic os subfibulare. MATERIALS AND METHODS: This is a retrospective study on fourteen patients (14 ankles) who have symptoms associated with os subfibulare. Between August 1999 and July 2004, they underwent 4 resection of os subfibulare and lateral ligament reattachment for ankle pain due to os subfibulare or 10 resection of os subfibulare and modified Brostrom procedure available for ankle instability due to os subfibulare. Follow-up period is averaged for 17.6 months (12-24 months). Clinical results were graded according to the AOFAS clinical rating system. RESULTS: Clinical results were rated as good in 4 ankles after resection of os subfibulare and lateral ligament reattachment, excellent in 5, good in 4, and fair in 1 ankle after the resection of os subfibulare and modified Brostrom procedure. In the last follow up period, 1 case of anterolateral ankle instability, 1 case of ankle pain and 1 case of inversion limitation were present postoperatively, but all symptoms were improved progressively. CONCLUSION: Resection of os subfibulare and modified Brostrom procedure is a good surgical technique for chronic ankle instability due to os subfibulare. But if just the ankle pain is present, resection of os subfibulare and lateral ligament reattachment is a sufficient procedure.

Lateral Ankle Ligament Reconstruction using Achilles Allograft for Chronic failed Instability: Two Cases Report / 대한족부족관절학회지

We performed lateral ankle ligament reconstructions using Achilles allograft on patients who had failed previous Brostrom repair. The bone plug is fixed with an interference screw into the calcaneus, the tendon graft is passed through a fibular tunnel, and then anchored into the talus with the biotenodesis screw. The graft is strong enough to maintain joint stability until graft incorporation and remodeling occurs. In patients with chronic failed lateral ankle instability requiring graft for ligament reconstruction, this technique allows anatomic reconstruction without the need to sacrifice autogenous peroneal tendons.

Lateral Ankle Ligament Reconstruction using Achilles Allograft for Chronic failed Instability: Two Cases Report / 대한족부족관절학회지

We performed lateral ankle ligament reconstructions using Achilles allograft on patients who had failed previous Brostrom repair. The bone plug is fixed with an interference screw into the calcaneus, the tendon graft is passed through a fibular tunnel, and then anchored into the talus with the biotenodesis screw. The graft is strong enough to maintain joint stability until graft incorporation and remodeling occurs. In patients with chronic failed lateral ankle instability requiring graft for ligament reconstruction, this technique allows anatomic reconstruction without the need to sacrifice autogenous peroneal tendons.

Comparison of Results obtained from the Modified Brostrom and the Chrisman-Snook Procedures for Chronic Lateral Ankle Instability / 대한정형외과학회잡지

PURPOSE: To compare results of the modified Brostrom procedure and the Chrisman-Snook procedure for chronic lateral ankle instability. MATERIALS AND METHODS: Twenty-eight patients (30 ankles) who underwent 20 modified Brostrom procedures or 10 Chrisman-Snook procedures were available. Follow-up averaged 3.2 years (1.3-5.4 years). Clinical results were graded according to the AOFAS clinical rating system. The talar tilting angle was also measured. RESULTS: Clinical results were rated as excellent in 15, good in 4, and fair in 1 ankle after the modified Brostrom procedure, and excellent in 7, and good in 3 ankles after the Chrisman-Snook procedure. Three complications occurred after the Chrisman-Snook procedure; delayed wound healing in 1 ankle, and transient neuralgia in 2. Mean talar tilting angle was improved from 17.4+/-6.6degrees to 6.6+/-1.2degrees by the modified Brostrom procedure, and from 15.6+/-5.9degrees to 3.0+/-1.1degrees by the Chrisman-Snook procedure. CONCLUSION: Significant differences were found in the clinical results obtained using the two procedures, and good function was obtained in a high percentage of patients. The procedure of choice should be decided upon based on the patient's condition and the doctor's preference.

The Larsen Procedure for Chronic Ankle Lateral Instability / 대한정형외과학회잡지

Injury of the ankle ligaments is one of the most common sports-related injuries. Although there are some debates as to the best initial treatment for an acute tear of a lateral ligament, persistent functional instability of the ankle develops in approximately 20% of patients regardless of the type of initial treatment. In these patients, late reconstruction of the lateral ankle ligaments may become necessary. Among 13 cases which have been operated with Larsen procedure using peroneus brevis tendon from March 1991 to February 1993, the 11 cases followed up over 1 year were examined clinically and radiologically. We introduced the clinical analysis and results with the brief review of the literatures. 1. The indication of surgical treatment was the ankle instability which had differences over 10° in talar tilting angle or over 3mm in anterior displacement compared wit the uninjured site. 2. The postoperative results were 5 cases in excellent and 4 in good. 3. The Larsen procedure was considered a good method to anatomically and simply stabilize both the ankle and subtalar joint and to fix tendon depending on the type of instability.