Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue.

PURPOSE: Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants. METHODS: 64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test. RESULT: Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found. CONCLUSION: Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

Persistent Pain After Operative Treatment for Chronic Lateral Ankle Instability.

A high frequency of associated injuries is seen in patients with chronic lateral ankle instability. Comorbidities include intraarticular pathologies (osteochondral lesion, soft tissue or bony impingement syndrome, loose body, synovitis, etc.), peroneal tendon pathologies, neural injuries, and other extraarticular pathologies. Surgeons should have a high index of suspicion for these associated pathologies before operative intervention, correlate with clinical findings, and plan the treatment. Despite the restoration of ankle stability following ligament repair or reconstruction surgery, postoperative residual pain, which can negatively affect clinical outcomes and patient satisfaction, is highly prevalent (13-35%). The aim of this review was to discuss the causes of persistent pain after operative treatment for chronic lateral ankle instability.

Comparison of the Modified Broström Procedure for Chronic Lateral Ankle Instability With and Without Subfibular Ossicle.

BACKGROUND: Subfibular ossicles are frequently found in patients with chronic lateral ankle instability (CLAI). However, there is a lack of consensus about the optimal surgical treatment for CLAI with subfibular ossicle. PURPOSE: To evaluate the clinical and radiographic outcomes of the modified Broström procedure with subfibular ossicle excision compared with the same procedure for CLAI without subfibular ossicle. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Ninety-six patients (96 ankles) treated with the modified Broström procedure using bone tunnel and suture anchor techniques for CLAI constituted the study cohort. The 96 ankles were divided into 2 groups with and without subfibular ossicles. The ossicle group (42 ankles) and nonossicle group (54 ankles) consisted of patients with a mean age of 26.6 and 30.3 years, respectively, at the time of surgery with a mean follow-up duration of 63.7 and 62.1 months, respectively. Subfibular ossicles were excised in the ossicle group. RESULTS: Mean Karlsson scores improved from 55.2 to 95.3 in the ossicle group and from 56.4 to 94.8 in the nonossicle group at final follow-up. Mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores also improved from 63.3 to 95.9 in the ossicle group and from 62.8 to 95.1 in the nonossicle group at final follow-up. Mean talar tilt angles were 14.0° in the ossicle group and 12.2° in the nonossicle group preoperatively and 7.6° and 6.8° at the final follow-up, respectively. Mean anterior talar translations in the ossicle group and nonossicle groups improved from 9.3 and 9.4 mm preoperatively to 5.8 and 5.7 mm at final follow-up, respectively. No significant differences were found between the 2 groups in terms of Karlsson score, AOFAS score, talar tilt angle, and anterior talar translation at final follow-up (P > .05). CONCLUSION: The modified Broström procedure with subfibular ossicle excision provided similarly good clinical and radiographic outcomes compared with the same procedure without subfibular ossicle excision. Accordingly, the study results suggest that these procedures appear to be effective and reliable method for the treatment of CLAI with subfibular ossicle.

Gender Differences in Outcome After Modified Broström Procedure for Chronic Lateral Ankle Instability.

BACKGROUND: The modified Broström procedure is commonly used for anatomic repair of chronic lateral ankle instability. However, no studies have compared outcomes of gender-based differences after the modified Broström procedure. We compared outcomes of the modified Broström procedure in men and women. METHODS: A total of 155 patients (155 ankles) treated with the modified Broström procedure for chronic lateral ankle instability constituted the study cohort. The 155 ankles were divided into 2 groups: a men's group (94 ankles) and a women's group (61 ankles). The Karlsson score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, talar tilt, and anterior talar translation were used to evaluate clinical and radiographic outcomes. The mean follow-up duration was 42.8 months (range, 24-101). RESULTS: Mean preoperative Karlsson scores were 53.6 points (39-65) in the men's group and 54.9 points (39-65) in the women's group, and these improved to 93.2 (72-100) and 92.2 (80-100), respectively, at the final follow-up. Mean preoperative AOFAS ankle-hindfoot scores were 62.4 points (44-79) in men and 63.6 points (49-77) in women and 93.7 (72-100) and 92.3 (79-100), respectively, at the final follow-up. Mean preoperative talar tilt angles decreased from 11.9 degrees (2.5-27.5) in men and 11.4 degrees (0.9-24.7) in women to 6.0 (1.0-11.5) and 6.0 (2.3-11.9), respectively, at the final follow-up. Mean preoperative anterior talar translation in men and women improved from 8.6 mm (5.1-14.6) and 8.7 mm (2.3-11.9) to 6.0 (4.3-8.7) and 5.8 (3.3-9.9), respectively, at the final follow-up. No significant differences were found between men and women in terms of Karlsson scores, AOFAS scores, talar tilt angle, and anterior talar translation. CONCLUSIONS: The modified Broström procedure showed similar good functional and radiographic outcomes in men and women. These results suggest that the modified Broström procedure is effective and reliable for treating chronic lateral ankle instability regardless of gender. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

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.

Comparison of bone tunnel and suture anchor techniques in the modified Broström procedure for chronic lateral ankle instability.

BACKGROUND: The modified Broström procedure is frequently used to treat chronic lateral ankle instability. There are 2 common methods of the modified Broström procedure, which are the bone tunnel and suture anchor techniques. PURPOSE: To compare the clinical outcomes of the modified Broström procedure using the bone tunnel and suture anchor techniques. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Eighty-one patients (81 ankles) treated with the modified Broström procedure for chronic lateral ankle instability constituted the study cohort. The 81 ankles were divided into 2 groups, namely, a bone tunnel technique (BT group; 40 ankles) and a suture anchor technique (SA group; 41 ankles). The Karlsson score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, anterior talar translation, and talar tilt angle were used to evaluate clinical and radiographic outcomes. The BT group consisted of 32 men and 8 women with a mean age of 34.8 years at surgery and a mean follow-up duration of 34.2 months. The SA group consisted of 33 men and 8 women with a mean age of 33.3 years at surgery and a mean follow-up duration of 32.8 months. RESULTS: Mean Karlsson scores improved significantly from 57.0 points preoperatively to 94.9 points at final follow-up in the BT group and from 59.9 points preoperatively to 96.4 points at final follow-up in the SA group. Mean AOFAS scores also improved from 64.2 points preoperatively to 97.8 points at final follow-up in the BT group and from 70.3 points preoperatively to 97.4 points at final follow-up in the SA group. Mean anterior talar translations in the BT group and SA group improved from 9.0 mm and 9.2 mm preoperatively to 6.5 mm and 6.8 mm at final follow-up, respectively. Mean talar tilt angles were 12.0° in the BT group and 12.5° in the SA group preoperatively and 8.8° at final follow-up for both groups. No significant differences were found between the 2 groups in terms of the Karlsson score, AOFAS score, anterior talar translation, and talar tilt angle. CONCLUSION: The bone tunnel and suture anchor techniques of the modified Broström procedure showed similar good functional and radiographic outcomes. Both techniques appear to be effective and reliable methods for the treatment of chronic lateral ankle instability.

The effect of ossicle resection in the lateral ligament repair for treatment of chronic lateral ankle instability.

BACKGROUND: The management of an ossicle or avulsion fragment of the fibular tip in chronic lateral ankle instability is an open question. Some authors maintain the necessity of osteosynthesis for reconstruction of the lateral ligamentous structure if the fragment is large. We hypothesized that the modified Broström procedure with resection of the ossicle would result in good outcomes compared to that of the same procedure for chronic lateral instability patients without ossicle. METHODS: Between December 2004 and December 2010, 102 patients underwent the modified Broström procedure for chronic lateral instability. Of these, 82 patients (86 ankles) were available for this study. Forty ankles had ossicles at the fibular tip (group O), 46 had no ossicle (group N). The average follow-up period was 33 months in group O and 37 months in group N. Irrespective of size, if there were ossicles we resected all fragments and performed the modified Broström procedure. To analyze the surgical outcome, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot pain and function scales and Karlsson scores were compared between the 2 groups preoperatively and postoperatively. RESULTS: Preoperative scores in the 2 groups showed no significant difference, except for AOFAS pain score. There was no significant difference in postoperative AOFAS pain and function score between the groups. Postoperative Karlsson score was significantly higher in group O than in group N (P = .001). Group O was divided into 2 subgroups by the largest diameter of the ossicle (< 10 mm and ≥ 10 mm); there was no significant difference in surgical outcomes. CONCLUSIONS: In the treatment of chronic lateral instability of ankle, if there are ossicles on the fibular tip, osteosynthesis of the ossicles may not be necessary, even if the size is considerable. Modified Broström procedure after resection of the ossicle was successful. LEVEL OF EVIDENCE: Level III, retrospective case series.

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.

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 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.

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.

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.