Anatomic reconstruction of lateral ankle ligaments: is there an optimal graft option?

PURPOSE: Different graft options are available for the reconstruction of lateral ankle ligaments to treat chronic ankle instability (CAI), which fall in two categories: allografts and autografts. This study aims to provide an updated comparison of the clinical outcomes after stabilisation procedures using allografts and autografts, to correctly advise the clinician during the choice of the best material to be used for the reconstruction of the lateral ligamentous complex of the ankle. METHODS: A systematic review was performed to analyse the use of autografts and allografts for anatomic reconstruction of the lateral ligamentous complex of the ankle in CAI patients. The presence of a postoperative assessment through outcome measures with proofs of validation in the CAI population or patient's subjective evaluation on the treatment were necessary for inclusion. The quality of the included studies was assessed through the modified Coleman Methodology Score (mCMS). Relevant clinical outcome data were pooled to provide a synthetic description of the results in different groups or after different procedures. RESULTS: Twenty-nine studies (autograft: 19; allograft: 9; both procedures: 1) accounting for 930 procedures (autograft: 616; allograft: 314) were included. The average mCMS was 55.9 ± 10.5 points. The Karlsson-Peterson scale was the most frequently reported outcome scale, showing a cumulative average post- to preoperative difference of 31.9 points in the autograft group (n = 379, 33.8 months follow-up) and of 35.7 points in the allograft group (n = 227, 25.8 months follow-up). Patient satisfaction was good or excellent in 92.8% of autograft (n = 333, 65.2 months follow-up) and in 92.3% of allograft procedures (n = 153, 25.0 months follow-up). Return to activity after surgery and recurrence of instability were variably reported across the studies with no clear differences between allograft and autograft highlighted by these outcomes. CONCLUSIONS: The systematic analysis of validated CAI outcome measures and the patient's subjective satisfaction does not support a specific choice between autograft and allograft for the reconstruction of the ankle lateral ligamentous complex in CAI patients. Both types of grafts were associated to a postoperative Karlsson-Peterson score superior to 80 points and to a similar rate of patient's subjective satisfaction. LEVEL OF EVIDENCE: Level IV.

Diagnosing instability of ligamentous syndesmotic injuries: A biomechanical perspective.

BACKGROUND: High ankle sprains are insidious injuries associated with a long recovery period, functional impairment and long-term sequelae if mistreated. This systematic review investigates the biomechanical knowledge on the kinematic consequences of sequential syndesmotic ligamentous injuries, aiming to furnish an updated and objective contribution for the critical appraisal and further elaboration of current diagnostic algorithms for high ankle sprains. METHODS: A systematic review was performed to identify human biomechanical studies evaluating the stabilizing role of the syndesmotic ligaments. Special attention was paid to identify the smallest lesion within the progressive simulated injuries able to provoke statistically significant changes of the syndesmotic kinematic on the specimen, the mechanical solicitation that provoked it, and the measurement methodology. FINDINGS: Fourteen studies were included. In eight articles already an isolated injury to the anterior inferior tibiofibular ligament provoked significant changes of the syndesmotic kinematic, which was always depicted under an external rotation torque. In three articles an isolated deltoid ligament injury provoked significant changes of the syndesmotic kinematic. Four articles described a direct measure of the bony movements, whereas seven collected data through conventional radiography or CT-scan imaging and three via a 3D motion analysis tracking system. INTERPRETATION: An isolated lesion of the anterior inferior tibiofibular ligament can provoke significant kinematic modifications in ex vivo syndesmotic models and may be responsible of subtle patterns of dynamic instability, regardless of further syndesmotic ligamentous injuries. The data observed support efforts to define reliable CT imaging parameters to improve non-invasive diagnostic of subtle forms of syndesmotic instability.

Evaluation modalities for the anatomical repair of chronic ankle instability.

PURPOSE: Several evaluation modalities are reported in the literature dealing with the operative treatment of chronic ankle instability (CAI) both to establish the CAI diagnosis leading to the surgical indication and to assess the effectiveness of ankle stabilisation procedure. The purpose of this study is to present an overview of the pre- and postoperative evaluation modalities reported in the literature dealing with CAI operative treatment. The comprehensive analysis of the different modalities chosen by researchers is expected to suggest critical points in current evaluation ability of CAI surgical treatment. METHODS: Systematic review of the literature on surgical treatment of CAI through anatomic procedures. Pubmed, Embase and Cochrane electronic databases were analysed, from 2004 to 2018. RESULTS: One-hundred-and-four studies met inclusion in this systematic review. 88 out of 104 studies analysed preoperative mechanical laxity of the ankle to depict the ligamentous insufficiency related to the subjective feeling of functional instability. Stress radiographs and manual stress examination of the ankle were the two most common modalities to evaluate joint laxity, reported in 67 and 53 studies, respectively. Clinical Outcome Measurement Scales (COMs) is the most common evaluation modality (102 out of 104 studies) to assess CAI surgical outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS) and the Karlsson score are the most frequent COMs, reported in the 66% and 33%, respectively of the included literature. The radiographic analysis of ankle laxity after stabilisation procedures is the second most frequent postoperative evaluation modality, reported in 55 out 104 studies. CONCLUSIONS: There is a lack of standardization among researchers related to both the criteria to establish the CAI diagnosis leading to the surgical indication and the modality chosen to evaluate the effectiveness of surgical treatment. Future standardization of evaluation modalities in the CAI population is desirable to increase consistency of reported data. LEVEL OF EVIDENCE: Level IV, review of level I, II, III and IV studies.

Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Diagnosis: History, Physical Examination, Imaging, and Arthroscopy" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%. RESULTS: A total of 12 statements on the diagnosis of cartilage injuries of the ankle reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support and 10 reached strong consensus (greater than 75% agreement). All statements reached at least 86% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians in the diagnosis of cartilage injuries of the ankle.

Correction to: The ESSKA-AFAS international consensus statement on peroneal tendon pathologies.

Unfortunately, the spelling of the names Daniel Haverkamp and Ákos Kynsburg were incorrect in the original online publication of the article.

Surgical Treatment Paradigms of Ankle Lateral Instability, Osteochondral Defects and Impingement.

Ankle sprain is amongst the most frequent musculoskeletal injuries, particularly during sports activities. Chronic ankle instability (CAI) resulting from an ankle sprain might have severe long-lasting consequences on the ankle joint. Despite the fact that most patients will respond favourably to appropriate conservative treatment, around 20% will develop symptomatic CAI with sense of giving away and recurrent sprains leading to functional impairment. "Classical" surgical repair by Brostrom-like surgery in one of its many modifications has achieved good results over the years. Recently, major advances in surgical techniques have enabled arthroscopic repair of ankle instability with favourable outcome while also enabling the treatment of other concomitant lesions: loose bodies, osteochondral defects (OCDs) or ankle impingement. Moreover, when the tissue remnant does not permit a repair technique, anatomic reconstruction by means of using a free graft has been developed. In many cases, OCDs occur as a consequence of CAI. However, traumatic and non-traumatic aetiologies have been described. There is no evidence favouring any surgical treatment over another concerning OCDs. Considering lower cost and limited aggression, microfracture is still the most frequent surgical approach. Herein, the authors describe their algorithm in the treatment of these conditions. Similarly, anterior or posterior impingement might be linked with CAI. These are clinical syndromes based on clinical diagnosis which are currently managed arthroscopically upon failure of conservative treatment.

The ESSKA-AFAS international consensus statement on peroneal tendon pathologies.

INTRODUCTION: Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies. PURPOSE: The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies. METHODS: Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached. CONCLUSION: This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature. LEVEL OF EVIDENCE: V.

Cross-cultural adaptation and multi-centric validation of the Italian version of the Achilles tendon Total Rupture Score (ATRS).

PURPOSE: The purpose of this study was to translate the Achilles tendon Total Rupture Score (ATRS) into Italian and establish its cultural adaptiveness and validity. METHODS: The original version of the ATRS was translated into Italian in accordance with the stages recommended by Guillemin. A web-based survey was developed to test the construct validity of the Italian ATRS. Eighty patients with an average age of 45.5 years (SD 11) were included in the study. The ATRS was completed twice at 5 days intervals for test-retest reliability. The intraclass correlation coefficient was used to calculate the test-retest reliability, and Cronbach's α coefficient was used for internal consistency. Validity was evaluated by external correlation (Spearman's rank correlation coefficient, r) of the ATRS with the Italian versions of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the 17-Italian Foot Function Index (17-FFI), the Lower Extremity Functional Scale (LEFS), and the Short-Form 36 (SF-36). RESULTS: The internal consistency (α = 0.97) and the test-retest reliability (ICC = 0.96) were excellent. The correlation coefficient showed strong correlation of the Italian ATRS with the VISA-A and the LEFS (r = 0.72 and r = 0.70, respectively, p < 0.0001), a weak correlation with the 17-FFI (r = -0.30, p = 0.007), and high-to-moderate correlation with the physical functioning, bodily pain, physical role functioning, social functioning, role emotional, and vitality of the SF-36 (r = 0.75, r = 0.61, r = 0.52, r = 0.49, r = 0.40 and r = 0.34, respectively, p < 0.0001). CONCLUSION: The Italian version of the ATRS is a valid instrumentation to assess the functional limitations of Italian patients after Achilles tendon rupture. LEVEL OF EVIDENCE: III.

Outcome evaluation after Achilles tendon ruptures. A review of the literature.

The optimal treatment and the best rehabilitation protocol after an acute Achilles tendon rupture (ATR) remain a matter of controversy in orthopaedic and sports medicine. The use of validated injury-specific outcome instruments is the only way to clarify these issues, in order to ensure that patients receive the best possible treatment. This article describes the most commonly reported outcome measures used to assess patients treated for ATR. On the basis of the available evidence, the Achilles tendon Total Rupture Score (ATRS) is the most appropriate outcome measure for evaluating the management of acute ATR.

Evidence-based indications for hindfoot endoscopy.

PURPOSE: The 2-portal hindfoot endoscopic technique with the patient in prone position, first introduced by van Dijk et al. (Arthroscopy 16:871-876, 2000), is currently the most used by foot and ankle surgeons to address endoscopically pathologies located in the hindfoot. This article aims to review the literature to provide a comprehensive description of the level of evidence available to support the use of the 2-portal hindfoot endoscopy technique for the current generally accepted indications. METHODS: A comprehensive review was performed by use of the PubMed database to isolate literature that described therapeutic studies investigating the results of different hindfoot endoscopy treatment techniques. All articles were reviewed and assigned a classification (I-V) of level of evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for hindfoot endoscopy. A subscale was used to further describe the evidence base for indications receiving a grade of recommendation indicating poor-quality evidence. RESULTS: On the basis on the available evidence, posterior ankle impingement syndrome, subtalar arthritis and retrocalcaneal bursitis have the strongest recommendation in favour of treatment (grade Cf). CONCLUSION: Although a low level of evidence of the included studies, the review showed that adequate literature to support the use of the 2-portal endoscopic techniques for most currently accepted indications exists. Future "higher quality" evidence could strengthen current recommendations and further help surgeons in evidence-based practice. LEVEL OF EVIDENCE: Level V, Review of Level III, IV and V studies.

Long-term outcome after arthroscopic rotator cuff treatment.

PURPOSE: Arthroscopic techniques have become the gold standard in the operative management of several pathologic conditions of the shoulder. The purpose of this systematic review was to present the long-term outcomes following arthroscopic treatment of rotator cuff pathology. METHODS: A comprehensive literature review was performed to identify studies reporting clinical or structural results of arthroscopic rotator cuff repairs (ARCRs) at least 5 years after surgery. RESULTS: Ten articles were selected, which described 483 procedures. Study type, surgical approaches, complications, evidences of structural integrity of the repaired lesions, preoperative and postoperative functional scores are identified, analyzed and discussed. Satisfactory results are presented by all authors, and significant postoperative improvement is reported by all the studies with available preoperative data; 16 of 483 cases were re-operated. CONCLUSION: Although high-level evidences are lacking, ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. Current evidences are insufficient to clearly define the relationship between structural integrity of repaired cuffs and long-term clinical outcome. The available data do not allow to draw conclusions regarding the long-term superiority of double-row versus single-row repairs. LEVEL OF EVIDENCE: Review of level II, III and IV studies, Level IV.

How do massive immobile rotator cuff tears behave after arthroscopic interval slides? Comparison with mobile tears.

PURPOSE: the aim of this study was to compare clinical outcomes of contracted immobile massive rotator cuff tears mobilised through an arthroscopic interval slide technique versus massive mobile cuff tears directly repaired without any mobilisation. METHODS: twenty-five patients who underwent arthroscopic repair for massive rotator cuff tears with a minimum of 18 months follow-up were included. The patients were retrospectively divided into two groups. In group 1, a single or double interval slide was performed to achieve adequate tendon mobilisation. In group 2 (control group), massive rotator cuff tears were arthroscopically repaired without any additional release. Patients were evaluated with validated outcomes scores: subjective and objective Constant score, a Visual Analogue Scale (VAS) for pain, and single Assessment Numeric Evaluation (SANE). RESULTS: the two groups were comparable in terms of age, gender and involvement of the dominant arm. The mean follow-up duration was 31 months in group 1 and 28 months in group 2 (p = 0.4). The two groups showed no significant differences in SANE and VAS results (group 1: SANE 77%, VAS 1.3; group 2: SANE 88%, VAS 1.6), or in total Constant score (group 1: 66.5 ± 11; group 2: 75 ± 14; p = 0.1) and subjective Constant score (Group 1: 31 ± 5; group 2: 30.8 ± 7; p = 0.9). A significant difference was found for the objective Constant score, which was higher in the control group (group 1: 35.5 ± 7; group 2: 44 ± 8; p = 0.009). CONCLUSIONS: Subjective clinical outcomes of arthroscopic repair with or without interval slides did not differ and were satisfactory. Objectively, immobile cuff tears showed inferior results. The use of interval slides might be considered a first step or an alternative to more invasive procedures for low demanding patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Improved visualization of the 70° arthroscope in the treatment of talar osteochondral defects.

Osteochondral defects (OCDs) of the talus are a common cause of residual pain after ankle injuries. When conservative treatment fails, arthroscopic debridement combined with drilling/microfracturing of the lesion (bone marrow stimulation [BMS] procedures) has been shown to provide good to excellent outcomes. Not uncommonly, talar OCDs involve the borders of the talar dome. These uncontained lesions are sometimes difficult to visualize with the 30° arthroscope, with potential negative effect on the clinical outcome of an arthroscopic BMS procedure. The use of the 70° arthroscope has been described for a multitude of common knee, shoulder, elbow, and hip procedures. The purpose of this article is to show the usefulness of the 70° arthroscope in arthroscopic BMS procedures, pointing out which kinds of talar OCDs can benefit most from its use.

Optimization of portal placement for endoscopic calcaneoplasty.

PURPOSE: The purpose of our study was to determine an anatomic landmark to help locate portals in endoscopic calcaneoplasty. METHODS: The device for optimal portal placement (DOPP) was developed to measure the distance from the distal fibula tip to the calcaneus (DFC) in 28 volunteers to determine the location of the posterosuperior calcaneal border in relation to this line. RESULTS: The DOPP showed an interobserver reliability of 0.99 (95% confidence interval, 0.97 to 0.99). We found that portals should be placed at a mean of 15 mm (SD, 4.5 mm) distal to the tip of the fibula in patients with flat feet, at a mean of 20 mm (SD, 4.8 mm) in normal feet, and at a mean of 22 mm (SD, 5.4 mm) in cavus feet. The difference in the DFC within the 3 different foot type groups was significant (P < .05). CONCLUSIONS: The DOPP was shown to be highly reliable in measuring the DFC (intraclass coefficient, 0.99). A numeric distance scale for use in all different foot morphologies could not be constructed. There is a direct relation between portal location and foot morphology (P < .05): in flat feet the portal location is significantly more proximal (15 mm) to the tip of the fibula when compared with cavus feet (22 mm). CLINICAL RELEVANCE: These results may help with portal placement in endoscopic calcaneoplasty for all different foot morphologies.