Balance Error Scoring System in the assessment of chronic ankle stability: A systematic review and meta-analysis.

OBJECTIVE: Chronic ankle instability (CAI) is a common musculoskeletal injury associated with static balance deficits. The Balance Error Scoring System (BESS) is commonly used to assess static balance in individuals with CAI. However, the sensitivity of BESS in detecting balance deficits in CAI is unknown. This study compared BESS performance between people with CAI and controls and investigated which stances most effectively identified balance deficits in individuals with CAI. LITERATURE SURVEY: Seven electronic databases (Web of Science, CINAHL, Embase, PubMed, Scopus, SPORTDiscus, and Cochrane Library) were searched from July 13, 2023, to September 10, 2023, using the ankle instability and balance related terms as keywords to search original studies and perform a systematic review. METHODS: Studies that compared BESS scores between individuals with CAI and healthy controls were systematically identified. Extracted data included study characteristics, participant demographics, and assessment details. The risk of bias was assessed using the Newcastle-Ottawa Scale. The standardized mean difference (SMD) and 95% confidence interval (CI) were used as effect sizes to compare groups for the BESS components used to assess CAI. RESULTS: Six studies met the eligibility criteria. The double-leg foam stance yielded an SMD of -0.02 (95% CI: -0.32 to 0.29), with an I2 value of 3.5%. Significant differences between groups were noted in the single foam (SMD = 0.89; 95% CI: 0.33-1.45; I2 = 78.3%) and single firm (SMD = 0.62; 95% CI: 0.14-1.10; I2 = 72.1%) performances, although both demonstrated high heterogeneity. Conversely, the tandem foam (SMD = 0.77; 95% CI: 0.51-1.02; I2 = 0.0%) and tandem firm (SMD = 0.38; 95% CI: 0.11-0.68; I2 = 23.8%) performances showed small to moderate between-group differences with considerably lower heterogeneity. CONCLUSION: This review indicates that tandem stances on foam and firm surfaces in the BESS are reliable indicators of static balance deficits in individuals with CAI.

A composite PET-matrix patch enhances tendon regeneration and tendon-to-bone integration for bridging repair of the chronic massive rotator cuff tears in a rabbit model.

In recent years, bridging repair has emerged as an effective approach for the treatment of massive rotator cuff tears (MRCTs). The objective of this study was to develop a composite patch that combines superior mechanical strength and biocompatibility and evaluate its potential for enhancing the outcomes of bridging repair for MRCTs. The composite patch, referred to as the PET-matrix patch (PM), was fabricated by immersing a plain-woven PET patch in decellularized matrix gel and utilizing the freeze-drying technique. The results demonstrated that the PM has reliable mechanical properties, with a maximum failure load of up to 480 N. The decellularized matrix sponge (DMS), present on the surface of the PM, displayed a loose and porous structure, with an average pore size of 62.51 µm and a porosity of 95.43%. In vitro experiments showed significant elongation of tenocytes on the DMS, with cells spanning across multiple pores and extending multiple protrusions as observed on SEM images. In contrast, tenocytes on the PET patch appeared smaller in size and lacked significant elongation. Additionally, the DMS facilitated the proliferation, migration and differentiation of tenocytes. In a rabbit model of chronic MRCTs, the PM group showed superior outcomes compared to the PET group at 4, 8 and 12 weeks after bridging repair. The PM group displayed significantly higher tendon maturing score, larger collagen diameter in the regenerated tendon and improved tendon-to-bone healing scores compared to the PET group (P < 0.05). Moreover, the maximum failure load of the tendon-bone complex in the PM group was significantly higher than that in the PET group (P < 0.05). In summary, the PM possesses reliable mechanical properties and excellent cytocompatibility, which can significantly improve the outcomes of bridging repair for chronic MRCTs in rabbits. Therefore, it holds great potential for clinical applications.

Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair.

PURPOSE: The aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization. METHODS: CAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up. RESULTS: A total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups. CONCLUSION: Elastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization. STUDY DESIGN: Cohort study; Level of evidence, 3.

Causal Relationships of Ligamentous Injuries in the Knee on Corticospinal Tract Structure: A Mendelian Randomization Analysis.

BACKGROUND: The association between ligamentous knee injuries and corticospinal tract (CST) structure has attracted attention; however, any causal relationship remains uncertain. We performed Mendelian randomization (MR) analysis to identify the causal effects of ligamentous knee injuries on the CST. HYPOTHESIS: Ligamentous knee injuries impair CST microstructure (ie, by reducing fractional anisotropy [FA] and increasing mean diffusivity [MD]). STUDY DESIGN: MR analysis. LEVEL OF EVIDENCE: Level 2. METHODS: MR uses genetic variants as instrumental variables to infer causal relationships between exposures and outcomes. Summary data for ligamentous injuries in knee and CST structure were obtained from genome-wide association study datasets. Significant and independent (5 × 10-6; r2 < 0.001; 10,000 kb) single-nucleotide polymorphisms were extracted for MR analysis. Three methods for MR analysis were used (hypothesis-driven 1-tailed inverse variance weighted, MR-Egger, and weighted median), and sensitivity analyses were conducted to test reliability and stability. RESULTS: Results from 3 MR methods consistently demonstrated that ligamentous knee injuries increased MD of the right CST (ß, 0.063; 90% CI, 0.003-0.123; P = 0.04), and weak statistical significance suggested increased MD of the left CST (ß, 0.060; 90% CI, -0.002 to -0.121; P = 0.05). However, no significant causal relationships were observed in CST FA, and no significant pleiotropy or heterogeneity was observed. Sensitivity analysis utilizing 2-tailed tests had no significant associations between ligamentous knee injuries and changes in CST structure. CONCLUSION: There is statistically weak genetic evidence that corticospinal pathway abnormalities may evolve after ligamentous knee injuries, which manifests as abnormally organized neurites. CLINICAL RELEVANCE: Ligamentous knee injuries require attention not only to damage to the structure of the knee joint itself but also to the process of maladaptive neuroplasticity that leads to structural and functional changes of the CST; novel interventions that target the corticospinal pathway may provide subsequent treatment of ligamentous knee injuries.

Clinical Features Post Anterior Cruciate Ligament Reconstruction Associated with Structural Alterations in Corticospinal Tract.

CONTEXT: Structural evidence for corticospinal tract (CST) abnormality between patients with ACLR and healthy controls, and the relationships between CST structure and clinical features of the patients (e.g., objective sensorimotor outcomes, postoperative duration) are lacking. OBJECTIVES: To investigate whether the structural features of CST 1) differ between patients with ACLR and healthy controls, and 2) were associated with clinical features in patients following ACLR. DESIGN: Cross-sectional study. SETTING: Sports medicine laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-six patients who had undergone ACLR and twenty-six healthy controls were enrolled in this cross-sectional investigation. MAIN OUTCOME MEASURE(S): Using the CST as the region of interest, we performed diffusion tensor imaging to measure the microstructure of white matter tracts. Between-group comparisons and correlation analyses with clinical features in patients with ACLR were performed. RESULTS: The patients with ACLR showed significant, moderate lower fractional anisotropy (FA, Cohen's d = -0.666, 95% CIs -1.221 to -0.104), lower axial diffusivity (AD, Cohen's d = -0.526, 95% CIs -1.077 to 0.030), and higher radial diffusivity (RD, Cohen's d = 0.514, 95% CIs -0.042 to 1.064) when compared to that of healthy controls, with the RD values being significantly correlated with the postoperative duration (r = 0.623, p < 0.001) after controlling the age, sex, and BMI in patients with ACLR. CONCLUSIONS: This study revealed that patients with ACLR have impaired integrity (lower FA values and higher RD values) in the CST contralateral to the ACLR injured limb in comparison with healthy controls. Decreased integrity (higher RD) of the CST in patients was significantly associated with longer postoperative duration, which hinted that impaired structural integrity of the CST may be a maladaptive process of neuroplasticity in ACLR.

Predictive Modeling for Functional Outcomes After All-Inside Arthroscopic Anterior Talofibular Ligament Repair of Chronic Ankle Instability.

BACKGROUND: Arthroscopic anterior talofibular ligament repair (AATFLR) is a surgical strategy to treat chronic ankle instability (CAI) patients. This study identified risk factors that influenced the functional outcomes of AATFLR for CAI and developed prognostic nomogram for predicting functional outcomes in future AATFLR cases. METHODS: Patients undergoing AATFLR from January 2016 to June 2022 with at least 10 months of follow-up were included in the study. The Karlsson Ankle Functional Score (KAFS) was evaluated preoperatively and at last follow-up visit. A total of 15 potential predictors including age, sex, body mass index, side affected, time from injury to surgery, sports-related injury, osteophyte, loose bodies, distal tibiofibular syndesmosis, ATFL avulsion fracture, Outerbridge classification of osteochondral lesions, postoperative immobilization method, ambulation time, walking time, and follow-up time, were recorded. We first used univariate binary logistic regression analysis to select the potential significant prognostic features, which were then subjected to the least absolute shrinkage and selection operator (LASSO) regression algorithm for final feature selection. A nomogram based on the regression model was developed to estimate the functional outcomes of patients. Models were validated internally using bootstrapping and externally by calculating their performance on a validation cohort. RESULTS: Overall, 200 ankles fit inclusion criteria. Of these 200, a total of 185 (92.5%) ankles were eligible and divided into development (n = 121) and validation (n = 64) cohorts. Four predictors were ultimately included in the prognostic nomogram model: age, sex, sports-related injury, and postoperative immobilization method. CONCLUSION: We found in our cohort that the significant predictors of poorer functional outcomes of AATFLR were postoperative immobilization with lower-leg cast, female sex, non-sports-related ankle sprain, and increasing age. Prognostic nomograms were created.

Spatiotemporal Observation of Monosodium Urate Crystals Deposition in Synovial Organoids Using Label-Free Stimulated Raman Scattering.

Gout, a common form of arthritis, is characterized by the deposition of monosodium urate (MSU) crystals in joints. MSU deposition in synovial tissues would initiate arthritis flares and recurrence, causing irreversible joint damage. However, the dynamic deposition of MSU crystals in tissues lacks experimental observation. In this study, we used chemical-specific, label-free stimulated Raman scattering (SRS) microscopy to investigate the spatiotemporal deposition and morphological characteristics of MSU crystals in human synovial organoids. Our findings revealed a critical 12-h window for MSU deposition in the lining layer of gouty synovium. Moreover, distinctive inflammatory reactions of the lining and sublining synovial layers in gout using SRS microscopy were further verified by immunofluorescence. Importantly, we identified a crucial proinflammatory role of sublining fibroblast-like synoviocytes, indicating a need for targeted medication treatment on these cells. Our work contributes to the fundamental understanding of MSU-based diseases and offers valuable insights for the future development of targeted gout therapies.

Investigation into the effect of deltoid ligament injury on rotational ankle instability using a three-dimensional ankle finite element model.

Background: Injury to the lateral collateral ligament of the ankle may cause ankle instability and, when combined with deltoid ligament (DL) injury, may lead to a more complex situation known as rotational ankle instability (RAI). It is unclear how DL rupture interferes with the mechanical function of an ankle joint with RAI. Purpose: To study the influence of DL injury on the biomechanical function of the ankle joint. Methods: A comprehensive finite element model of an ankle joint, incorporating detailed ligaments, was developed from MRI scans of an adult female. A range of ligament injury scenarios were simulated in the ankle joint model, which was then subjected to a static standing load of 300 N and a 1.5 Nm internal and external rotation torque. The analysis focused on comparing the distribution and peak values of von Mises stress in the articular cartilages of both the tibia and talus and measuring the talus rotation angle and contact area of the talocrural joint. Results: The dimensions and location of insertion points of ligaments in the finite element ankle model were adopted from previous anatomical research and dissection studies. The anterior drawer distance in the finite element model was within 6.5% of the anatomical range, and the talus tilt angle was within 3% of anatomical results. During static standing, a combined rupture of the anterior talofibular ligament (ATFL) and anterior tibiotalar ligament (ATTL) generates new stress concentrations on the talus cartilage, which markedly increases the joint contact area and stress on the cartilage. During static standing with external rotation, the anterior talofibular ligament and anterior tibiotalar ligament ruptured the ankle's rotational angle by 21.8% compared to an intact joint. In contrast, static standing with internal rotation led to a similar increase in stress and a nearly 2.5 times increase in the talus rotational angle. Conclusion: Injury to the DL altered the stress distribution in the tibiotalar joint and increased the talus rotation angle when subjected to a rotational torque, which may increase the risk of RAI. When treating RAI, it is essential to address not only multi-band DL injuries but also single-band deep DL injuries, especially those affecting the ATTL.

Histologic and biomechanical comparison of fascia lata autograft, acellular dermal xenograft, and synthetic patch for bridging massive rotator cuff tear in a rabbit model.

Background: Bridging repair has emerged as a promising and reliable treatment strategy for the massive rotator cuff tears (MRCTs). However, there remains a lack of evidence on which bridging graft provides the better repair results, and a dearth of animal studies comparing bridging repairs with different grafts. The purpose of this study was to evaluate the histological and biomechanical outcomes of commonly used grafts (autologous fascia lata (FL), acellular dermal matrix graft (ADM), and polyethylene terephthalate (PET) patch). Methods: A total of 66 male New Zealand White Rabbits were used to mimic a model of unilateral chronic MRCTs. The rabbits were randomly divided into three groups: (1) FL group, which underwent bridging repair with autologous FL; (2) ADM group, which underwent bridging with ADM; and (3) PET group, which underwent bridging with PET patch. Tissue samples were collected and subjected to histological analysis using Hematoxylin and eosin, Picrosirius red, Safranin O/Fast green staining, and Immunostaining. Collagen diameter and fibril density in the regenerated tendon was analyzed with transmission electron microscopy (TEM). Additionally, biomechanical tests were performed at 6 and 12 weeks after repair. Results: The regenerated tendon successfully reattached to the footprint in all experimental groups. At 6 weeks after repair, the FL group had a significantly higher Modified Tendon Histological Evaluation (MTHE) score at the regenerated tendon than the PET group (13.2 ± 1.64 vs 9.6 ± 1.95, respectively; P = 0.038). The picrosirius red staining results showed that the FL group had a significantly higher type I collagen content than the ADM and PET groups at 6 weeks, and this difference was sustained with the PET group at 12 weeks (P < 0.05). Immunofluorescence analysis against CD68 indicated that the number of macrophage infiltrates was significantly lower in the FL group than in the ADM and PET groups (P < 0.05). At 12 weeks after repair, the area of Safranin O metachromasia was significant greater in ADM group than that in the PET group (P = 0.01). The FL group showed a significantly larger collagen diameter in the regenerated tendon than the PET group (P < 0.05), as indicated by TEM results. Furthermore, the FL group resulted in a greater failure load (at 6 weeks; 118.40 ± 16.70 N vs 93.75 ± 9.06 N, respectively; P = 0.019) and elastic modulus (at 6 weeks; 12.28 ± 1.94 MPa vs 9.58 ± 0.79 MPa, respectively; P = 0.024; at 12 weeks; 15.02 ± 2.36 MPa vs 11.63 ± 1.20 MPa, respectively; P = 0.032) than the ADM group. Conclusions: This study demonstrated that all three grafts could successfully bridging chronic MRCTs in a rabbit model. However, autologous FL promoted tendon regeneration and maturation, and enhanced the tensile properties of the tendon-to-bone complex when compared with ADM and PET grafts.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines.

BACKGROUND: Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes. METHODS: A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines. RESULTS: Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol. CONCLUSION: Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Rehabilitation increases cortical activation during single-leg stance in patients with chronic ankle instability.

Background: Chronic ankle instability (CAI) has been considered a neurophysiological disease, having as symptoms dysfunction in somatosensory and motor system excitability. Rehabilitation has been considered an effective treatment for CAI. However, few studies have explored the effects of rehabilitation on neuroplasticity in the CAI population. Objective: The purpose of this study was to investigate the effects of rehabilitation on cortical activities for postural control in CAI patients and to find the correlation between the change in cortical activities and patient-reported outcomes (PROs). Methods: Thirteen participants with CAI (6 female, 7 male, age = 33.8 ± 7.7 years, BMI = 24.7 ± 4.9 kg/m2) received a home exercise program for about 40 min per day, four days per week and six weeks, including ankle range-of-motion exercise, muscle strengthening, and balance activities. Cortical activation, PROs and Y-balance test outcomes were assessed and compared before and after rehabilitation. Cortical activation was detected via Functional near-infrared spectroscopy (fNIRS) while the participants performed single-leg stance tasks. Results: The participants had better PROs and Y balance test outcomes after rehabilitation. Greater cortical activation was observed in the primary somatosensory cortex (S1, d = 0.66, p = 0.035), the superior temporal gyrus (STG, d = 1.06, p = 0.002) and the middle temporal gyrus (MTG, d = 0.66, p = 0.035) in CAI patients after rehabilitation. Moreover, significant positive correlations were observed between the recovery of ankle symptoms and the change of cortical activation in S1 (r = 0.74, p = 0.005) and STG (r = 0.72, p = 0.007) respectively. Conclusion: The current study reveals that six weeks of rehabilitation can cause greater cortical activation in S1, STG and MTG. This increase in cortical activation suggested a better ability to perceive somatosensory stimuli and may have a compensatory role in function improvement.

Insufficient recovery of proprioception in chronic ankle instability after surgical restabilization: A systematic review.

Surgical repair or reconstruction of the lateral ligaments for patients with chronic ankle instability (CAI) could, logically, restore the proprioception of ankle through retensing receptors. To validate this hypothesis, seven databases were systematically searched, and thirteen studies comprising a total of 347 patients with CAI were included. Although five studies reported improved proprioceptive outcomes after surgeries, the other five studies with between-limb/group comparisons reported residual deficits at final follow-up, which does not consistently support proprioceptive recovery after existing surgical restabilization for CAI. More controlled studies are needed to provide evidence-based protocols to improve proprioceptive recovery after ankle restabilization for CAI.

Postural Control Deficits During Static Single-leg Stance in Chronic Ankle Instability: A Systematic Review and Meta-Analysis.

CONTEXT: Postural control deficits arising from injured ankles are central to chronic ankle instability (CAI) and its persistent symptoms. This is usually measured by recording the center of pressure (CoP) trajectory during static single-leg stance using a stable force plate. However, existing studies have produced conflicting results on whether this mode of measurement adequately reveals the postural deficits in CAI. OBJECTIVE: To determine whether postural control during static single-leg stance is impaired in CAI patients when compared with uninjured healthy controls. DATA SOURCES: Literature databases, PubMed, Embase, Web of Science, Cochrane Library, Scopus, CINAHL, and SPORTDiscus, were searched from inception to April 1, 2022, using ankle-, injury-, and posture-related terms. STUDY SELECTION: Two authors independently performed the step-by-step screening of article titles, abstracts, and full texts to select peer-reviewed studies investigating CoP trajectory during static single-leg stance using a stable force plate in CAI patients and healthy controls. A total of 13,637 studies were reviewed, and 38 studies (0.003%) met the selection criteria. STUDY DESIGN: Meta-analyses of descriptive epidemiological study. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: CoP parameters, sway directions, visual condition, and numerical data (means and standard deviations) were extracted. RESULTS: The injured ankles of CAI patients had higher standard deviations of sway amplitude in both anterior-posterior and medial-lateral directions (standardized mean difference [SMD] = 0.36 and 0.31, respectively) under conditions of open eyes than controls. Higher mean sway velocity in anterior-posterior, medial-lateral, and total directions (SMD = 0.41, 0.37, and 0.45, respectively) with closed eyes was also found. CONCLUSION: CAI patients had deficits of postural control during static single-leg stance, and these deficits were identified by the CoP trajectory. Further methodological explorations of CoP parameters and corresponding test conditions are required to enhance the sensitivity and reliability of postural deficit assessments in CAI using force plates.

Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury.

BACKGROUND: Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE: To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS: One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS: Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION: BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.

Prevalence and Injury Patterns of CFL Injury in Chronic Lateral Ankle Instability: An Observational Cross-Sectional Study Using Ultrasound.

The purpose of this paper is to assess the prevalence and injury patterns of the calcaneofibular ligament (CFL) in chronic lateral ankle instability (CAI) patients using ultrasound imaging. This retrospective study included 938 ankle ultrasound images from January 2016 to May 2018. The patients' demographic data and the injury pattern classified by the injury location and the remnant quality were recorded and correlated using t tests, Fisher's exact tests, and post hoc tests accordingly. Of the 938 CAI patients, CFL injury was found in 408/938 (44%). Among the 408 anterior talofibular ligament (ATFL) and CFL complex injury patients, 71/408 (17%) presented with a completely absorbed ATFL, whereas 13/71 (18%) presented with an absorbed CFL. The total CFL absorption proportion in all patients was relatively low (30/938 = 3%). Post hoc tests indicated a negative association between thickened ATFLs and complex injuries. In addition, a positive association existed between absorbed ATFLs and complex injuries as well as absorbed ATFLs and absorbed CFLs. Thus, the results indicated that total tearing and absorption injury patterns of the CFL in CAI are not common. Even when the ATFL is absorbed, only approximately one-fifth (13/71 = 18%) of CFLs require reconstruction, suggesting that it is unnecessary to routinely repair or reconstruct CFLs in all lateral ligament surgeries.

In Vivo Characterization of Cerebellar Peduncles in Chronic Ankle Instability: A Single and Multishell Diffusion-Weighted Imaging Study.

BACKGROUND: Ankle sprain causes proprioceptor injuries and prolonged joint deafferentation, which might lead to maladaptive neuroplasticity in patients with chronic ankle instability (CAI), especially in the cerebellum. Previous studies have indicated the impairment of superior cerebellar peduncle (SCP), but the inferior cerebellar peduncle (ICP) and middle cerebellar peduncle (MCP) have not been fully analyzed. HYPOTHESIS: The cerebellar peduncles of participants with CAI would have altered fractional anisotropy (FA) and orientation dispersion index (ODI) in comparison with healthy controls without ankle injury history. In addition, FA and ODI would be correlated with the duration or severity of the sensorimotor deficits in CAI. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: A group of 27 participants with CAI and 26 healthy controls underwent diffusion-weighted imaging scanning, with the cerebellar peduncles as the regions of interest. The measures obtained by single-shell diffusion tensor imaging and the multishell neurite orientation dispersion and density imaging were used. Correlation analyses were performed to examine the potential relationship between the FA/ODI and both the normalized Y-balance scores and the durations of ankle instability. RESULTS: The ipsilateral ICP of the injured ankle in participants with CAI showed significantly lower FA (Cohen d 95% CI, -1.33 to -0.21; P = 0.04) and marginally significant higher ODI (Cohen d 95% CI, 0.10 to 1.20, P = 0.08) when compared with the same measures in the control group, with the ODI being positively correlated with the duration of ankle instability (r = 0.42, P = 0.03). CONCLUSION: The ICP in participants with CAI exhibited impaired integrity and a trend of abnormally organized neurites in comparison with a healthy control group. CLINICAL RELEVANCE: The impairments of ICP might be an ongoing part of the pathological process of CAI, having the potential to become a target for the diagnostic evaluation of this clinical entity.

Satisfactory outcomes from the double-row fixation procedure for ankle lateral ligaments injury with os subfibulare.

Background: Ossicles of avulsed fractures of the lateral malleolus can result in pain or chronic ankle instability. The purpose of this study was to evaluate and compare the arthroscopic double-row fixation procedure with anatomic ankle lateral ligaments reconstruction for the treatment of ankle lateral ligaments injury with os subfibulare. Methods: This retrospective study included 38 patients with ankle lateral ligaments injury with concomitant os subfibulare who were treated between July 2016 and November 2021. The patients were divided into a double-row fixation group (n = 19) and an ankle lateral ligaments reconstruction group (n = 19). The Karlsson and Peterson Scoring System for Ankle Function (KAFS), American Orthopedic Foot and Ankle Society (AOFAS) score, Tegner score, visual analog scale (VAS), and anterior drawer test (ADT) were obtained preoperatively and at the last post-operative follow-up. Magnetic resonance imaging (MRI) was also performed at the last post-operative follow-up. Results: The KAFS, AOFAS, VAS, and Tegner scores increased significantly after the surgery. Furthermore, the pre- and post-operative functional scores were comparable between the two groups. The ADT was negative in all participants post-operatively. There were no significant differences between the double-row fixation and ligaments reconstruction groups regarding the proportions of patients who achieved a minimally clinically important difference (MCID) in KAFS, AOFAS, and Tegner scores. There was no significant difference in T2 mapping values for the tibial and talar side post-operatively between the two groups. Moreover, there were no significant differences in functional scores post-operatively between bony fusion and non-fusion patients in the double fixation group. Conclusion: The double-row fixation procedure provided similar satisfactory clinical outcomes when compared with lateral ligaments reconstruction for the treatment of ankle lateral ligaments injury with os subfibulare over a short follow-up duration.

A biomechanical comparison of the double-row suture fixation and compression screw techniques in the treatment of lateral malleolar avulsion fracture.

Background: Avulsion fractures of fibula occur with ankle sprains. The purpose of this study was to compare the biomechanical characteristics of double-row suture versus compression screw techniques in treatment of lateral malleolar avulsion fracturelarger than 10 mm in size, which is typically not associated with an anterior talofibular ligament injury. Methods: We simulated lateral malleolus avulsion fractures in six matched pairs of 12 human cadaveric ankles. These were then randomly divided into two groups: a double-row fixation group and a compression screw group. Biomechanical testing was performed after surgical fixation. The foot was rotated from the neutral position toward inversion at a rate of 1°/s until 12.5 N-m or structural failure was reached. The final rotation torque, rotation angle, stiffness, and displacement of the ossicles were recorded. Results: No significant difference was found in the final rotation torque (7.60 ± 3.70 vs 7.23 ± 2.06 N-m, p = 0.87), rotation angle (43.61 ± 14.77° vs 40.93 ± 10.94°, p = 0.56), stiffness (0.19 ± 0.08 vs 0.13 ± 0.07, p = 0.33), or displacement (6.11 ± 5.23 vs 7.09 ± 5.93 mm, p = 0.77) between the two groups. Conclusions: The stability of the double-row suture fixation was equivalent to compression screw fixation in treating a lateral malleolar avulsion fracture larger than 10 mm in size with ligament injury, as determined by our biomechanical testing.

Safe Talar Tunnel Placement During Reconstruction of the Deep Layer of the Deltoid Ligament: A Comparison of 4 Different Anatomic Landmarks on the Lateral Malleolus.

Background: Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair. Purpose: To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL). Study Design: Descriptive laboratory study. Methods: A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels. Results: For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm). Conclusion: Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction. Clinical Relevance: Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction.

Thin and Plain Supplementary Motor Area in Chronic Ankle Instability: A Volume and Surface-based Morphometric Study.

CONTEXT: The supplementary motor area (SMA) is involved in the functional deficits of chronic ankle instability (CAI), but the structural basis of its abnormalities remains unclear. OBJECTIVE: To determine the differences in volume and surface-based morphological features of SMA between patients with CAI and healthy controls, and their relationship with the clinical features of CAI. DESIGN: Cross-sectional study. SETTING: Sports medicine laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 32 CAI patients (10 females; age: 32.46 ± 7.51 years) and 31 healthy controls (12 females; age: 29.70 ± 8.07 years) participated in this study. MAIN OUTCOME MEASURE(S): Participants perform T1 structural magnetic resonance imaging and calculate volume and surface-based morphological features of SMA subregions. These included anterior and posterior subdivisions of Brodmann's area 6 m (6 ma/6 mp), and supplementary and cingulate eye fields. Between-group comparisons and correlation analysis with clinical features of CAI were performed. RESULTS: Moderately thinner 6 mp (Cohen's d = -0.61) and moderately plainer 6 ma (Cohen's d = -0.70) were observed in patients compared with controls. Before and after regressing out the covariates, the thinner 6 mp was correlated with the lower foot and ankle ability measure scores of daily activities (r-before=0.400, r-after = 0.449). CONCLUSIONS: Patients with CAI had a thinner posterior subdivision (motor-output site) and a plainer anterior subdivision (motor-planning site) of SMA than that of controls. The thin motor-output site of the SMA is associated with ankle dysfunction in patients. These morphologic evidence of maladaptive neuroplasticity in SMA might promote more targeted rehabilitation of CAI.