Results of Anatomical Arthroscopic Repair of Anterior Talofibular Ligament in Chronic Lateral Ankle Instability Patients.

BACKGROUND: To assess the clinical and functional outcomes of all-inside arthroscopic anatomical repair of anterior talofibular ligament (ATFL) for management of chronic lateral ankle instability (CLAI) in a considerable number of patients during medium-term follow-up. METHODS: A retrospective analytic study was performed on 100 patients with CLAI who presented between August 2015 and July 2020 (average age: 32.9 years; range: 16-54 years). All-inside arthroscopic ATFL direct repair was performed in all patients through 2 portals only with fixation using 2 knotless anchors. Associated intraarticular lesions were treated in the same procedure. Outcomes were assessed with pre- and postoperative visual analog scale (VAS), the ankle-hindfoot score of the American Orthopaedic Foot & Ankle Society (AOFAS), and the Karlsson Ankle Functional Score (KAFS). RESULTS: All patients were followed for 24-48 months. At the final follow-up, ankle pain had improved significantly. Both the ankle anterior drawer test and the ankle varus stress tests were negative. There was no loss of ankle range of motion compared with preoperative measures, and all patients returned to normal gait. The mean VAS score decreased to 0.39 ± 0.63, the AOFAS score increased to 95.17 ± 4.7, and the KAFS score increased to 95 ± 4.07. All the follow-up indexes significantly improved compared to those before surgery. CONCLUSION: At minimum 24-month follow-up, the all-inside arthroscopic ATFL repair used to treat CLAI was found to restore ankle stability and yield good clinical outcomes with a relatively low complication rate. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Biomechanical study of autograft anatomic reconstruction in lateral ankle instability. / Estudio biomecánico de la reconstrucción ligamentosa anatómica con autoinjerto en la inestabilidad lateral de tobillo.

INTRODUCTION: The purpose of this work is perform a biomechanical comparison of anatomic reconstruction of the anterior talofibular ligament (ATFL) with the intact ATFL. MATERIALS AND METHODS: We studied 18 fresh cadaveric ankles with intact ATFL. Each specimen was clinically assessed with the anterior drawer (AD) and varus tilt (VT) tests and the angular movement in the three spatial planes (axial, coronal and sagittal) was measured with an arthrometer using a sensor located in the talus. RESULTS: Statistically significant differences were found in the axial plane, between the intact ATFL versus the sectioned ATFL for AD test with p = 0.012, and for VT test with p = 0.013. Regarding the coronal plane, we also observed a statistically significant difference for VT test with p = 0.016. In the sagittal plane, there are no statistically significant differences in both maneuvers. No statistically significant differences were found when comparing the biomechanics of anatomic ligament reconstruction versus the intact ATFL. CONCLUSION: Autograft anatomic reconstruction of the ATFL showed biomechanical properties similar to those of the native ATFL, at the zero moment in a cadaveric model.

How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings.

INTRODUCTION: The posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages. METHODS: The fracture pattern of PM is classified according to Haraguchi or Bartonícek classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection. RESULTS: Posterolateral approach should be the election for Haraguchi I or III and Bartonícek 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartonícek 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartonícek 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach. CONCLUSION: To address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.

Arthroscopic posterior subtalar arthrodesis for salvage of posttraumatic arthritis following calcaneal fractures.

BACKGROUND: Subtalar arthrodesis is a treatment option for pain due to posttraumatic arthritis following calcaneal fractures. The goal of this study is to examine the results of arthroscopic subtalar arthrodesis for posttraumatic arthritis following calcaneal fractures. PATIENTS AND METHODS: We performed a retrospective case series reviewing 37 consecutive patients (36 male) treated for posttraumatic arthritis following calcaneal fractures by arthroscopic subtalar arthrodesis. The fractures were due to high-energy injuries in 81% of cases, and 12 fractures (32.4%) had been previously treated with internal fixation. Average follow-up was 57.5 months. RESULTS: Average American Orthopedic Foot and Ankle Society (AOFAS) scores significantly improved from 49.0 ± 10.9 points preoperatively to 76.0 ± 8.0 points at final follow-up. Average time to union was 12.5 weeks. Six patients (16.2%) suffered complications: superficial wound infection (2.7%), symptomatic hardware that warranted removal (5.4%) and nonunion (8.1%) presented nonunion. All three cases had prior internal fixation through an extensile lateral approach, and fused after a repeat surgery. CONCLUSION: Arthroscopic subtalar arthrodesis offers consistent improvement in cases of posttraumatic arthritis following calcaneal fractures, with a union rate similar to published series of open arthrodesis. We observed more nonunions in patients who had been treated previously with internal fixation. In spite of this, we continue to recommend arthroscopic subtalar arthrodesis, as it preserves the soft tissue envelope better than open techniques.

Anatomical Arthroscopic Graft Reconstruction of the Anterior Tibiofibular Ligament for Chronic Disruption of the Distal Syndesmosis.

Injuries of the distal tibiofibular syndesmosis are commonly overlooked or mismanaged, and chronic instability is a debilitating condition leading to premature joint degeneration. Several methods of treatment have been described, mainly screw fixation, arthrodesis, or ligament reconstruction. Most clinical evidence is limited to case series, mainly screw fixation, and there is a general paucity of evidence regarding ligament reconstruction, which is considered to be more anatomic and to restore joint biomechanics. Most papers describe open techniques. We describe an original technique for all-inside anatomic arthroscopic graft reconstruction of the anterior-inferior tibiofibular ligament, which is simpler than other previously described reconstruction procedures. In addition to being performed through standard ankle arthroscopy portals, we believe this technique avoids potential complications.

Predicting syndesmotic injuries in ankle fractures: a new system based on the medial malleolar focus.

The early establishment of the diagnosis of a syndesmotic injury is essential for treatment selection. However, such injuries may not be apparent radiographically. Previous studies have attempted to describe correlations between medial malleolar fracture geometry and syndesmotic disruption. The main objective of this study was to create predictive models for assessing syndesmotic injuries based on an originally described angle, i.e., the medial crural-focal angle (MCFA). This study included 138 ankle fractures involving the medial malleolus. Any measure from the plain radiograph that could potentially lead to the suspicion of a syndesmotic disruption was recorded, and the newly described MCFA (formed by the main line of the medial malleolus fracture and a line perpendicular to the bearing surface of the tibial plafond) was also recorded. The inter- and intraobserver reliabilities were obtained using Krippendorff's alpha coefficients. To examine the predictive abilities of every parameter, several statistical methods were applied including logistic regression, an ad hoc clinical rule, and discriminant analysis. After variable selection, we obtained the best possible logistic model. The variables that were found to be statistically significant were the MCFA, the tibiofibular clear space (TFCS) and the type of injury in the Lauge-Hansen (L-H) classification. This model was tested by cross validation, which revealed a mean percentage of correctly classified patients of 88%. A simpler and more intuitive alternative model was sought that was based solely on the influences of the MCFA and the TFCS. Our study revealed that an absence of syndesmotic disruptions when the MCFA was under 60°, and there were no uninjured patients with tibiofibular clear space values over 6mm. Cross-validation revealed that the mean percentage of patients who were correctly classified with this model was 86%. The application of discriminant analysis to this combination of variables resulted in a function was able to correctly classify a mean of 84% of patients. In conclusion, three models that can predict syndesmotic injury using parameters from preoperative plain radiographs were obtained and validated. The MCFA measurement was in these models and found to be a reliable technique.