Treatment of lateral ankle ligament tears. Operative or conservative?

In lateral ankle ligament tears, the anterior talofibular ligament ruptures most commonly, often in conjunction with the calcaneofibular ligament. The posterior talofibular ligament is rarely affected. Associated injuries at the adjacent ligamentous structures or at the articular cartilage of the ankle commonly occur. The diagnosis is established clinically with the anterolateral drawer sign and an increased lateral talar tilt. Stress radiographs in two planes demonstrate talar tilt and anterior displacement of the talus, in comparison to the unaffected side. Magnetic resonance imaging provides an early diagnosis of concomitant injuries. Simple, acute lateral ankle ligament tears are treated non-operatively. Surgery is indicated in dislocated bone avulsions and in chondral or osteochondral fractures. A recurrent tear in an athletic patient should also be treated operatively. Athletic endeavours, the number of torn ligaments and patient age are no useful indicators for surgical treatment. Conservative treatment consist of oedema therapy, immobilization of the fibular ligaments with as little compromise of ankle joint function as possible, and rehabilitation with muscle strengthening and proprioception training. During surgery, the ligament stumps are reapproximated in anatomic position, reinforced with local tissue if necessary, and the articular surface is examined for concomitant injuries.     

Involvement of the inner malleolus and deltoid ligament in supination trauma of the ankle joint

Additional ligament ruptures or fractures of the medial side of the ankle joint accompanying the lateral ligament rupture are rare. These injuries are more often in traumas with pronation-eversion movements of the foot. In cases of lateral ligaments ruptures we only found in 2.8% and in 5.9% additional medial injuries. This is confirmed by different biomechanical experiments. Experimentally the delta ligament rupture could mostly be caused by pronation-eversion movements or by forced plantar flexion of the foot. The diagnosis of bony lesions of the medial malleolus might be easy by X-ray, but ligament lesions of the medial ankle joint can be diagnosed easily too be using the stress X-ray controlling the medial talar tilt as a sign of medial instability. Because the necessity of surgical treatment is less important than of the lateral ligaments we recommend this procedure in cases of bilateral instability or if dislocation is obvious.     

The syndrome of external ligament sprain in the horse

The treatment of acute complete (grade III) tears of the lateral ligaments of the ankle has generated much controversy in the medical literature. Functional treatment has become the standard treatment as it has been shown that there is no significant difference in long term results whatever the treatment (operative repair and cast, cast alone, or early controlled mobilization). Functional treatment includes only a short period of protection by tape bandage or brace and allows early weight-bearing. Major trauma with avulsion of bone and severe ligamentous damage on both medial and lateral sides of the ankle is however an indication for surgical treatment in the acute phase. Secondary operative reconstruction can be performed in case of persistent instability and laxity of the ankle. Secondary anatomic repair as proposed by Brodstr?m, Duquennoy et al. and Karlsson et al. has a high rate of success and avoids the potential morbidity of harvesting partially or totally the peroneus brevis or other tendon grafts. Evaluation of the injured ankle has improved and in selected patients ultrasonography, arthrography, magnetic resonance imaging or bone scintigraphy may be useful for further evaluation of the injury. The frequency of associated injuries has probably been underestimated. Although ankle sprain is often thought of as an injury involving only the lateral ankle ligaments, there are varied and multiple components to the common sprained ankle. This condition would perhaps more appropriately be designated as the sprained ankle syndrome.     

Deltoid ligament injuries: diagnosis and management

The medial ligaments of the ankle are injured more often than generally believed. Complete deltoid ligament tears are occasionally seen in association with lateral malleolar fractures or bimalleolar fractures. Chronic deltoid ligament insufficiency can be seen in several conditions, including posterior tibial tendon disorder, trauma- and sports-related deltoid disruptions, and valgus talar tilting in patients who have a history of triple arthrodesis or total ankle arthroplasty. This article focuses on the anatomy and function of the medial ligaments of the ankle and establishes a rationale for the diagnosis and treatment of incompetent deltoid ligament.     

Ligamentous avulsion of the ulnar collateral ligament of the thumb of a child

Ulnar collateral ligament ruptures of the metacarpophalangeal joint of the thumb in children are usually associated with epiphyseal fractures of the proximal phalanx and, less frequently, cartilaginous fragments from the metacarpal. Radiographs are often normal. We describe an isolated ligamentous avulsion of the ulnar collateral ligament from the thumb metacarpal, without a bony or cartilaginous fragment, in a skeletally immature 12-year-old boy.     

Lateral ligament injury of the ankle in children: Follow-up results of primary surgical treatment

Among 40 acutely injured ankles in children, surgery revealed a cartilaginous and/or bony fragment in 19, and an isolated rupture of the anterior talo-fibular ligament without any lesion of the bone or cartilage in another 17. In four ankles there was no ligament lesion. The lesions were surgically repaired. All ankles healed well and were painless and functionally stable at follow-up. In four ankles radiographs showed a small subfibular fragment, in which bony fusion had failed, but even these ankles were stable. Two other ankles gave a slightly positive sign in the clinical anterior drawer test as compared with the contralateral uninjured ankle, but there were no signs of functional instability nor were there any subjective complaints. Our results suggest that severe ankle sprains in children may cause isolated ruptures of the anterior talofibular ligament and frequently osteochondral lesions. We therefore advocate primary suture of ruptured lateral ligaments of the ankle in children.     

Avulsion of the distal triceps tendon with fracture of the radial head

We present a rare case of associated distal triceps tendon avulsion with radial head fracture; the lateral and medial collateral ligaments of the elbow were also ruptured. The patient underwent surgical procedure for the reinsertion of the triceps tendon using metallic anchors, radial head prosthetic replacement, and repair of the lateral collateral ligament. We believe this combined injury pattern of radial head fracture with triceps tendon rupture or avulsion should be considered according to the concept of the spectrum of elbow instability.     

Lateral instability of the ankle joint.

Acute lateral ankle ligament ruptures are successfully treated nonoperatively with physiotherapy, peroneal strengthening, and coordination training. About 10-20% of patients may develop functional instability despite adequate nonoperative treatment. Chronic functional instability is not always a severe disability, but reconstruction of the lateral ankle ligaments may be necessary for patients with high demands on ankle stability. More than 50 different surgical procedures for the treatment of chronic lateral ankle joint instability have been described. Most of these are tenodeses where one of the peroneus tendons is used, such as Evans, Watson-Jones, and Chrisman-Snook reconstructions. Good short-term results have been reported, but the long-term results after the Evans and Watson-Jones reconstructions are worse than anticipated. Anatomic ligament reconstruction with shortening, reinsertion, and imbrication of the elongated ligaments, a simple procedure with good long-term results, might be a better alternative than other more complex ligament reconstructions.     

Kollateralbandverletzungen der Fingergrundgelenke

Collateral ligament injuries of the metacarpal joints of the fingers are rare conditions. The injury should be diagnosed by clinical investigation and standard radiographs. Leading symptoms are local tenderness and joint instability. Instability is verified by clinical stress testing of the metacarpophalangeal joint in 90° of flexion. In Grade I injuries stability is preserved due to ligament attenuation or small partial tears. Grade II injuries show laxity with firm endpoint according to incomplete tear. In Grade III injuries instability without endpoint can be found as a result of complete tears. Radiographs may show avulsed bone fragments.In Grade I and II tears or non- displaced avulsion fragments treatment is conservative with buddy taping for 6 weeks. In case of persistent instability or grade III tears suturing or refixation of the ligament are performed. Small avulsion fragments are removed and the ligament is fixed to the bone. Greater avulsion fragments are fixed by suitable small implants. Adequate treatment will lead to reliable good results. Even in chronic tears reconstruction with local material or tendon transplants is usually successful.     

Syndesmosis injuries: acute,chronic, new techniques for failed management

A syndesmotic injury occurs through tearing, rupture, or bony avulsion of the syndesmotic ligament complex. The syndesmotic ligament complex consists of the anterior tibiofibular, the posterior tibiofibular, the transverse tibiofibular and the interosseous ligaments. Without these ligamentous restraints the distal tibiofibular joint (DTFJ) widens and can result in an asymmetric ankle mortise. Many cadaveric studies have been performed to evaluate the force required and amount of DTFJ displacement with progressive sectioning of the syndesmotic ligaments.     

The “Lateral Gutter Drive-Through” Sign: An Arthroscopic Indicator of Acute Femoral Avulsion of the Popliteus Tendon in Knee Joints

Acute avulsions of the popliteus tendon and the lateral collateral ligament of the femur (peel-off lesion) are common and can both be missed during preoperative assessment and later overlooked during surgery if not specifically sought out. Arthroscopic observation of the direct avulsion sign of the torn end of the popliteus tendon occurs less frequently in patients with acute and subacute injuries. This study describes an arthroscopic sign that detects these tears when they either involve only the popliteal tendon or include the lateral collateral ligament assessed from the lateral gutter of the joint. The “lateral gutter drive-through,” visualized during diagnostic arthroscopy, is described as entering of the arthroscope into the posterolateral compartment through the interval between the popliteal tendon and the lateral femoral condyle. A positive sign indicates (1) the presence of femoral avulsion tears of the popliteal tendon or concomitant lateral collateral ligament, (2) the presence of repairable posterolateral corner tears, and (3) the enablement of mini-open surgery for the repair of these avulsion tears with a recess or reattachment procedure. In addition, arthroscopic evaluation of the lateral compartment and preoperative magnetic resonance imaging assessment are used to eliminate the multiple-level injuries of the popliteus tendon and lateral collateral ligament.     

The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon

PURPOSE: Longitudinal split tears of the peroneus brevis tendon have been increasingly reported as a source of lateral ankle pain and disability. MR imaging is useful in identifying the appearance of longitudinal split tears of the peroneus brevis tendon to differentiate this entity from other causes of chronic lateral ankle pain. We observed variations in anatomy associated with these tears. MATERIALS AND METHODS: Twenty-two patients (eleven males, eleven females) were identified as having longitudinal split tears of the peroneus brevis tendon. These cases were reviewed retrospectively to evaluate for the following: shape of the peroneus brevis tendon, high signal in the peroneus brevis tendon, tendon subluxation, appearance of the superior peroneal retinaculum, presence of osseous changes in the ankle, lateral ankle ligaments, presence of a bony fibular spur, flattening of the peroneal groove of the fibula and presence of a peroneus quartus. A control group consisted of twenty ankles imaged for reasons other than lateral ankle pain. The same structures were assessed in this group. A Fisher's exact P-value was used to determine the significance of each finding in the two groups. RESULTS: Statistically significant associated findings were chevron shaped tendon (p = .0001), high signal in the peroneus brevis (p = .0017), bony changes (p = .0001), flat peroneal groove (p = .0001), abnormal lateral ligaments (p = .0004), and lateral fibular spur (p = .0006). CONCLUSIONS: MR imaging is useful in differentiating longitudinal split tears of the peroneus brevis tendon from other lateral ankle disorders. It can show the extent of the abnormality in the tendon and the associated findings of soft tissue and/or bone variations which must be addressed at the time of surgery.     

The stress-tenogram in the diagnosis of ruptures of the lateral ligament of the ankle.

The stress-tenogram is a radiological technique for the investigation of injuries to the lateral ligament of the ankle, and combines the information previously provided by inversion and anterior stress radiographs, and the peroneal tenogram. It is designed to differentiate between stable and unstable ankles, and between isolated ruptures of the anterior talofibular ligament and combined tears of the anterior talofibular and calcaneofibular ligaments. A high degree of diagnostic accuracy has been confirmed at operative repair in a group of thirty-two patients.     

Avulsion fractures of the medial and lateral malleoli of the ankle in cadavers: new radiographic projections for improved diagnosis

The malleolar attachment sites of the tibionavicular (TN), tibiocalcaneal (TC), posterior tibiotalar (PTT), anterior talofibular (ATF), and calcaneofibular (CF) ligaments of 3 cadaveric ankles were dissected. Standard and new radiographic projections of the ankle were obtained with the foot in different positions and various degrees of beam angulation. Simulated avulsion injuries related to these ligaments were created, and the visibility of these structures was assessed. Avulsion injuries of the TN ligament were better assessed in the plantar-flexed radiographs with lateral beam angulation. Standard projections were found to adequately depict avulsion fractures related to the TC and CF ligaments. Radiographs in external ankle rotation were best for evaluating injuries of the PTT ligament. Avulsion injuries related to the ATF ligament were best visualized in the plantar-flexed views with medial beam angulation. Modified radiographic projections of the ankle improve visualization of ligamentous structures of the malleoli and avulsion injuries related to those.     

Syndesmotic Internal Brace~(TM) for anatomic distal tibiofibular ligament augmentation

Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the Tight Rope~?system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 Tight Ropes~?. Therefore, we developed a new syndesmotic Internal Brace~(TM) technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The Internal Brace~(TM) technique was developed by Gordon Mackay from Scotland in 2012 using Swive Locks~? for knotless aperture fixation of a Fiber Tape~? at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern,patients can either be treated by the new syndesmotic Internal Brace~(TM) technique alone as a single anterior stabilization, or in combination with one posteriorly directed Tight Rope~? as a double stabilization, or in combination with one Tight Rope~? and a posterolateral malleolar screw fixation as a triple stabilization. Moreover,the syndesmotic Internal Brace~(TM) technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an Internal Brace~(TM) after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic Internal Brace~(TM) technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.     

Complex instability of the anterior knee

Complex knee instability involves the anterior cruciate ligament (ACL) and one or more major stabilizers of the knee [medial collateral ligament (MCL), lateral collateral ligament (LCL), posterior cruciate ligament (PCL)]. The medial side has a high healing potential and does not need operative treatment in most cases if ACL reconstruction is performed. Reconstruction of the medial ligament complex is indicated in gross instability of the medial meniscus fixation, dislocation of the MCL into the joint, and large dislocated bony avulsions. Injuries on the lateral side do not heal spontaneously and require acute operative treatment (first 2 weeks). Frank knee dislocations and gross multiligament injuries should be reduced acutely, and the integrity of the vascular structures must be examined closely. In a European multicenter study, operative treatment with reconstruction of both cruciate ligaments and functional rehabilitation gave better results than conservative treatment with immobilization of the joint.     

Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle

The Chrisman-Snook procedure for instability of the lateral ankle ligaments, first described in 1969, reconstructs the anterior talofibular ligament and the calcaneofibular ligament using one-half of the peroneus brevis tendon, routed through tunnels in the fibula and calcaneus. In the present long-term evaluation of the results of this procedure, forty-eight of sixty ankles, in fifty-seven patients, were assessed after a mean follow-up of ten years (range, four to twenty-four years). The results were excellent in thirty-eight ankles, good in seven, fair in two, and poor in one. The two ankles with a fair result were improved but still had some persistent instability, while the ankle with a poor result (no improvement) was in a patient with generalized ligament laxity. All three patients with a fair or poor result had had a severe reinjury to the ankle. Based on the findings in this study, we concluded that this procedure will restore good long-term function in a high percentage of patients who are disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments.     

The two-level ulnar collateral ligament injury of the metacarpophalangeal joint of the thumb

Ulnar collateral ligament injuries of the thumb may present as avulsion fractures of the bone or as ligamentous tears. Displaced fracture fragments or Stener lesions demand operative management. Occasionally, both fracture and ligamentous tears may occur simultaneously, and the management of the ligamentous aspect may be overlooked in cases with undisplaced fractures leading to failure of non-operative treatment. It is important in cases with a relatively undisplaced fracture fragment to exclude a simultaneous ligamentous tear and Stener lesion by careful clinical examination and by examining the radiographs for telltale displaced flecks of bone.     

Methoden und Ergebnisse der lateralen Bandplastik des oberen Sprunggelenkes

A review is given about common techniques for plastic repair of the lateral ligament of the upper ankle joint. Own experiences are presented. Indications for plastic repair are: old injury of the ligaments with clinical symptoms; fresh lesions of the ligament; if the tissue of the articular capsule or of the ligament are completely destroyed or if during surgery a chronic insufficieny of the ligaments becomes evident. Contraindications against plastic repair are: a marked arthrosis of the ankle joint, a permanent valgar displacement of the talus, old age and a high risk for surgery. The results of 13 plastic operations of the lateral ligament could be classified as “very good” in ten cases and as “good” in three cases (evaluation according to Marti). In seven cases a modified technique of Watson-Jones has been used, twice Weber’s method and in four cases a direct ligament plastic. Those procedures are favoured which come close to the original anatomy, are easy to perform without destroying functional structures and which do not cause an unnecessary restriction of movement.     

Treatment of recurrent desmorrhexis. Results of a prospective, randomized study

Previous studies concerning ruptures of the lateral ligaments of the ankle dealt with acute first ruptures. There are a few articles about chronic instability of the ankle but no prospective investigations have been reported concerning the treatment of recurrent ruptures. Good results were obtained following after non-operative treatment of acute ruptures of the fibular ligaments of the ankle joint. This prospectively randomized study was commenced to test whether recidivations of the rupture of the lateral ligaments can also be treated non-operatively or if they are in need of operative repair. The second question to be answered was whether these injuries should be treated differently depending on the treatment of the first rupture. From December 1986 to November 1989, 109 patients with a recidivation of a rupture of the ankle joint lateral ligaments were included in this prospective trial at the Department of Trauma Surgery, Hannover Medical School. They were divided into two groups depending on the therapy used to treat the first injury: The relapse was classified as a second-stage-rupture in cases where treatment of the first ligament rupture did not involve an operation and as a rerupture if the initial rupture was surgically repaired. Half of each group was treated randomly either with surgical ligament repair or without. A total of 100 patients (92%) at an average age of 24 years (11 to 49 years) was seen for follow-up examination one year after the relapse: The follow-up included the patient's subjective assessment, a clinical examination, and stress radiography. A 70 point score was used for evaluation of the total result. Two wound infections requiring reoperation were observed in the operative treatment groups. The follow-up examination revealed better results in both operative treatment groups (A and C), which was statistically significant (P < 0.05). Patients with a second-stage-rupture showed a significantly higher (P < 0.001) stability by stress radiography after surgical treatment (group A) in contrast to non-operative treatment (group B). In addition, the subjective and clinical results indicated a tendency towards better results which were not statistically significant (P < 0.09 and P < 0.07). In cases of rerupture the patient's subjective assessment revealed significantly more (P < 0.05) complaints after non-operative treatment (group D). Clinical results were comparable, and radiologic assessment showed a tendency towards higher joint stability after surgical treatment (group C), although it was not statistically significant (P < 0.07). Based on the results presented, the authors recommend the surgical repair of ankle joint ligaments in cases of second-stage- or rerupture.