Reconstruction of the lateral ankle ligaments with bone-patellar tendon graft in patients with chronic ankle instability: a preliminary report

BACKGROUND: Unsatisfactory long-term results have been reported after use of a Brostr?m repair for patients with chronic ankle ligament insufficiency. HYPOTHESIS: Repair or reconstruction of both the anterior talofibular and calcaneofibular ligaments is essential for normal kinematics of the ankle-hindfoot. STUDY DESIGN: Case series. METHODS: Thirteen patients with chronic instability of the ankle were found at operation to have injuries of both the anterior talofibular and calcaneofibular ligaments, with a lack of healthy ligament margins suitable for suturing. Reconstruction of the ligaments was performed with bone-patellar tendon graft. The score devised by Good et al. was used to assess the patients' clinical condition before the operation and at final follow-up. RESULTS: Before the operation, six patients had a grade 3 clinical condition and seven had a grade 4 condition. At a mean follow-up of 26.5 months, all patients had a grade 1 condition. The average talar tilt of the patients was improved from 18.4 degrees +/- 5.5 degrees to 4.9 degrees +/- 2.6 degrees, and the average anterior drawer sign was improved from 9.1 +/- 2.6 mm to 5.8 +/- 1.6 mm. CONCLUSION: In cases of combined injuries, short-term results of reconstruction of the anterior talofibular and calcaneofibular ligaments using bone-split patellar tendon graft were good, with a low frequency of complications.     

Graded stress radiography in acute injury to the lateral ligaments of the ankle

The diagnostic accuracy of graded stress radiography in 26 patients with acute injury to the lateral ankle ligaments has been compared with findings at arthrography and surgery. Measuring talar tilt angles and anterior talar displacement over a range of pressures applied to the distal tibia using a commercially available stress device allows diagnostic distinction between isolated anterior talofibular ligament injury and a combined lesion that involves the calcaneofibular ligament. The results compare well with arthrographic and surgical findings.     

Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study

The modified Brostrom procedure is commonly recommended for reconstruction of the anterior talofibular ligament (ATF) and calcaneofibular ligament (CF) with an advancement of the inferior retinaculum. However, some surgeons perform the modified Bostrom procedure with an semi-single ATF ligament reconstruction and advancement of the inferior retinaculum for simplicity. This study evaluated the initial stability of the modified Brostrom procedure and compared a two ligaments (ATF + CF) reconstruction group with a semi-single ligament (ATF) reconstruction group. Sixteen paired fresh frozen cadaveric ankle joints were used in this study. The ankle joint laxity was measured on the plane radiographs with 150 N anterior drawer force and 150 N varus stress force. The anterior displacement distances and varus tilt angles were measured before and after cutting the ATF and CF ligaments. A two ligaments (ATF + CF) reconstruction with an advancement of the inferior retinaculum was performed on eight left cadaveric ankles, and an semi-single ligament (ATF) reconstruction with an advancement of the inferior retinaculum was performed on eight right cadaveric ankles. The ankle instability was rechecked after surgery. The decreases in instability of the ankle after surgery were measured and the difference in the decrease was compared using a Mann-Whitney U test. The mean decreases in anterior displacement were 3.4 and 4.0 mm in the two ligaments reconstruction and semi-single ligament reconstruction groups, respectively. There was no significant difference between the two groups (P = 0.489). The mean decreases in the varus tilt angle in the two ligaments reconstruction and semi-single ligament reconstruction groups were 12.6 degrees and 12.2 degrees , respectively. There was no significant difference between the two groups (P = 0.399). In this cadaveric study, a substantial level of initial stability can be obtained using an anatomical reconstruction of the anterior talofibular ligament only and reinforcement with the inferior retinaculum. The modified Brostrom procedure with a semi-single ligament (Anterior talofibular ligament) reconstruction with an advancement of the inferior retinaculum can provide as much initial stability as the two ligaments (Anterior talofibular ligament and calcaneofibular ligament) reconstruction procedure.     

Reconstruction of the lateral ankle ligaments. A biomechanical analysis.

The purpose of this study was to perform a biomechanical analysis of several commonly performed operative procedures used to stabilize the lateral ankle. We performed the Evans, Watson-Jones, and Chrisman-Snook procedures on 15 cadaveric ankles and tested the ankles for stability, motion, and isometry of graft placement. The Evans procedure allowed increased anterior displacement, internal rotation, and tilt of the talus when compared to ankles with intact ligaments. Subtalar joint motion was restricted by the Evans procedure. The Watson-Jones procedure controlled internal rotation and anterior displacement of the talus, but was less effective in controlling talar tilt and also restricted subtalar joint motion. The Chrisman-Snook procedure allowed increased internal rotation and anterior displacement of the talus when compared to ankles with intact ligaments. The procedure was effective in limiting talar tilt, but restricted subtalar joint motion. Based on the biomechanical data obtained, we devised a lateral ankle reconstruction with bone tunnels that reproduce the anatomic orientation of both the anterior talofibular and calcaneofibular ligaments. This ankle ligament reconstruction resists anterior displacement, internal rotation, and talar tilt without restricting subtalar joint motion. Clinical relevance: We found considerable mechanical differences among the more commonly performed lateral ankle reconstructions. It is possible to locate bone tunnels and graft placement so that a more anatomic configuration is achieved.     

Strain measurement in lateral ankle ligaments

We measured strain in the lateral ligaments of 10 human cadaver ankles while moving the ankle joint and applying stress in a variety of ways. We studied the anterior talofibular, calcaneofibular, posterior talofibular, anterior tibiofibular, and posterior tibiofibular ligaments. Strain measurements in the ligaments were recorded continuously while the ankle was moved from dorsiflexion into plantar flexion. We then repeated measurements while applying inversion, eversion, internal rotation, and external rotation forces. Strain in the anterior talofibular ligament increased when the ankle was moved into greater degrees of plantar flexion, internal rotation, and inversion. Strain in the calcaneofibular ligament increased as the talus was dorsiflexed and inverted. These findings support the concept that the anterior talofibular and calcaneofibular ligaments function together at all positions of ankle flexion to provide lateral ankle stability. We measured maximum strain in the posterior talofibular ligament when the ankle was dorsiflexed and externally rotated. The strain in the anterior and posterior tibiofibular ligaments increased when the ankle was dorsiflexed. External rotation increased strain in the anterior tibiofibular ligament and decreased strain in the posterior tibiofibular ligament. Based upon strain measurements in the lateral ankle ligaments in various ankle joint positions, we believe the anterior talofibular ligament is most likely to tear if the ankle is inverted in plantar flexion and internally rotated. Theoretically, the calcaneofibular ligament tears primarily in inversion if the ankle is dorsiflexed; the anterior tibiofibular ligament tears in dorsiflexion, especially if combined with external rotation; and the posterior tibiofibular ligament tears with extreme dorsiflexion.     

Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study

The normal anatomy of the lateral ankle and subtalar ligaments seen at magnetic resonance (MR) imaging was studied in four cadaver ankles. Sixteen ankles of 11 healthy volunteers were imaged with four different MR imaging protocols to optimize technique. The anterior talofibular ligament was identified in 100% of the ankles of the volunteers in the axial plane, the calcaneofibular ligament in 81% of the ankles in the coronal plane, the cervical ligament in 69% of the ankles in the coronal plane and in 88% of the ankles in the sagittal plane, and the talocalcaneal ligament in 56% of the ankles in the coronal plane and in 62% of the ankles in the sagittal plane. It is concluded that thin-section (1-3-mm) MR imaging techniques, especially the one in which data are acquired with three-dimensional Fourier transform, are best for visualization of the ligaments. These techniques may play a role in the evaluation of patients with chronic ankle pain and instability.     

慢性踝关节外侧不稳定的手术治疗

报告了１５例慢性踝关节外侧不稳定的病例。结果表明，跟腓韧带、距腓前韧带松弛引起踝关节反复扭伤、疼痛，提示外踝关节不稳定，距骨斜角超过５°则提示外踝韧带断裂。介绍了一种修补外踝韧带的手术方法，术后效果较佳。     

Clinical association of acute lateral ankle sprain with syndesmotic involvement: a stress radiography and magnetic resonance imaging study

BACKGROUND: Information concerning the clinical association between syndesmosis injury and grade of lateral ankle ligament damage would aid in the diagnosis and treatment of ankle sprains. HYPOTHESIS: Evaluation of lateral ligament injury in terms of percentage tear of both the anterior talofibular and calcaneofibular ligaments can provide information on the extent of syndesmotic involvement. STUDY DESIGN: Prospective cohort study. METHODS: Twenty-five patients volunteered to have magnetic resonance imaging examinations performed and 21 volunteered to undergo graded stress radiographs. Talar tilt angles were measured from radiographs taken with 0, 6, 9, 12, and 15 daN of force applied medially just above the ankle joint, and the percentage of ligament tear and grade of injury were determined. Scans were obtained with the foot in neutral and plantar flexion to image the anterior talofibular and calcaneofibular ligaments. RESULTS: Grades of lateral ligament injury determined by magnetic resonance imaging and graded stress radiography were the same. The extent of syndesmotic injury could be assessed for all patients. CONCLUSIONS: Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage, but the more severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments. The inverse correlation can be explained on the basis of the difference between the mechanisms that precipitate these injuries.     

Diagnostic value of stress radiography in lesions of the lateral ligaments of the ankle

The diagnostic accuracy of inversion and anterior stress radiography in rupture of the lateral ligaments of the ankle joint was assessed in 56 patients undergoing surgery. In inversion stress radiography, 58 per cent of the patients with confirmed rupture of the lateral ligaments of the ankle had a talar tilt of 10 degrees or more, allowing a predictive value of a positive test of 94 per cent. In anterior stress radiography, 53 per cent of the patients had a posterior tibiotalar distance of 9 mm or more, allowing a predictive value of a positive test of 81 per cent. In measurements of talar tilt and anterior displacement of the talus values higher than normal in the injured ankle may be a sign of a rupture of the lateral ligament.     

Relationship between stress ankle radiographs and injured ligaments on MRI

Objective

This study was performed to investigate the relationship between the injured lateral ankle ligaments on MRI and stress ankle radiographs.

Materials and methods

Two hundred and twenty-nine consecutive patients (mean age 35.5 years, SD 14.6 years; 136 males and 93 females) that underwent ankle stress radiographs and MRI for lateral ankle instability were included. Tibiotalar tilt angle and anterior translation of talus were measured on stress ankle radiographs. Degree of lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and deltoid ligament injuries were evaluated and scored as intact (0), partial injury (1), and complete injury (2) on MR images. Effusion of ankle joint was also recorded. The effects of gender, age, injuries of ligaments, and ankle joint effusion on stress radiographs were statistically analyzed.

Results

Gender (p?=?0.010), age (p?=?0.020), and anterior talofibular ligament (ATFL) injury (p?<?0.001) were the factors significantly affecting tibiotalar tilt angle. Posterior talofibular ligament (PTFL) injury (p?=?0.014) was found to be the only significant factor affecting the anterior translation on the anterior drawer radiographs.

Conclusions

ATFL injury and PTFL injury on MRI significantly affected tibiotalar tilt angle and anterior drawer on stress radiographs. Other factors, such as age and gender, need to be considered in evaluating radiographic lateral ankle instability.     

Surgical treatment of lateral ankle instability syndrome

Lateral ankle instability syndrome is defined by pain and instability caused by ligament laxity. Anterior talofibular ligament laxity, with or without calcaneofibular laxity and other abnormalities, is often present in conjunction with peroneus brevis tendon tears, abnormal ligament placement, tibialis posterior tendon tears, osteochondritis dissecans, arthritis, synovitis, loose bodies, and tarsal coalition. Surgical reconstructions were performed on 43 ankles using a split peroneus brevis tendon graft routed through osseous tunnels in the talus, fibula, and calcaneus and resutured to the reconstructed anterior talofibular and calcaneofibular ligaments. The tunnel locations, transfer routes, and tendon reinforcement were modifications based on the Elmslie procedure. Good and excellent results were achieved in 91% of the patients. Ninety-eight percent of the patients achieved stability. Followup was from 9 months to 11 years. Twenty-one patients had preoperative and intraoperative findings that required additional procedures. Thorough evaluation of patients with lateral ankle instability syndrome increases the frequency of finding associated abnormalities, which if left uncorrected, may adversely affect the outcome of surgery.     

Bandverletzungen des Sprunggelenks

The diagnosis of lateral collateral ankle ligament trauma is based on patient history, clinical examination and clinical stress tests. If the clinical stress test is positive, stress radiography can be performed. There is, however, no consensus about the usefulness of stress radiography in acute ankle sprain, and in particular about the cut-off talar tilt angle beyond which a two-ligament rupture would be certain, ranging from 5 degrees to 30 degrees. Today, magnetic resonance imaging (MRI) is not used in this area, although it does allow controlled positioning of the foot and defined section visualization of injured lateral collateral ankle ligaments. In acute and chronic sinus tarsi injuries, MRI forms the established basis for diagnostic imaging, and can provide a definitive answer in most cases. MRI is also the method of choice for chronic posttraumatic pain with anterolateral impingement after rupture of the anterior talofibular ligament. Generally, for the evaluation of acute ankle injuries, MRI has developed to be the most important second-step procedure when projection radiology is non-diagnostic.     

运动员及演员踝外侧韧带断裂

文章介绍了踝外侧韧带断裂的检查方法,对距腓前与跟腓韧带全断裂者需手术治疗,术后能恢复训练。     

Lateral ankle ligaments: MR arthrography with anatomic correlation in cadavers

Objective

The purpose of our study was to use magnetic resonance (MR) imaging and MR arthrography to demonstrate the anatomy of the lateral ankle ligaments using standard and oblique imaging planes in cadavers.

Material and methods

MR imaging of ten cadaveric ankles was performed before and after intra-articular administration of contrast solution. Proton-density MR images were acquired in standard and oblique imaging planes. MR imaging was correlated with anatomic sections. Measurements using oblique imaging planes were obtained to characterize the morphology of the lateral ligaments.

Results

The anterior talofibular ligament (ATFL) had a variable number of bands in all specimens, separated by fat signal oriented obliquely parallel to the long axis of the ligament. The fibular attachment of ATFL was located in close proximity to the fibular attachment of the distal band of the anterior tibiofibular ligament (AITFL). The angle formed by the calcaneofibular ligament (CFL) and the fibular shaft varied with different ankle positions. Special axial oblique plane best demonstrated the CFL. The posterior talofibular ligament (PTFL) was multi-fasciculated in appearance. Dorsiflexion of the ankle joint helped elongate the PTFL and best depicted this ligament in its entirety in the axial plane.

Conclusion

Oblique imaging planes parallel to the long axis of the individual ligaments may improve visualization of the anatomy of the lateral ankle ligaments. The orientation of the lateral ankle ligaments is affected by the position of the talocrural and subtalar joints. Understanding the morphology of the lateral ankle ligaments can help radiologists diagnose abnormalities of these ligaments.     

Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws

Purpose

The purpose of this study was to evaluate the functional and radiographic outcomes of a novel surgical technique devised to treat chronic lateral ankle instability. The technique involves direct repair of the anterior talofibular ligament and anatomic reconstructions of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using a free semitendinosus tendon allograft and interference screws.

Methods

This retrospective study involved a review of the records of 27 patients (28 ankles) with chronic lateral ankle instability treated from 2007 to 2009. VAS pain scores, AOFAS scores, Karlsson–Peterson ankle scores (24 ankles), and patient satisfaction were evaluated at median of 19 (12–26)?months postoperatively. Radiographically, talar tilt angles and anterior talar translation were assessed in pre- and postoperative ankle stress views.

Results

Median patient age at surgery was 36.5 (16–57)?years. Median VAS pain score decreased from 6 (3–9) to 2 (0–4) (P?P?P?P?Conclusions The described technique, which involves anatomic reconstruction of the ATFL and CFL using the semitendinosus tendon and interference screws with direct repair of the capsule, is a viable option for treating lateral ankle instability with stable tendon fixation and provides satisfactory clinical outcomes.

Level of evidence

Case-series, Level IV.     

Acute ankle injury and chronic lateral instability in the athlete

Ankle injuries occur frequently in sports. The lateral ligamentous complex, specifically the anterior talofibular and calcaneofibular ligaments, are most commonly injured. In acute lateral ligament injuries, a functional ankle rehabilitation program is the mainstay of treatment. Chronic ankle instability develops in a minority of patients. Surgical procedures are broadly classified into anatomic ligament repairs versus reconstructive tenodeses. Commonly performed techniques include the Brostrom-Gould procedure,the modified Brostrum-Evans procedure, and the Chrisman-Snook procedure.     

Anatomie und Kinematik der Sprunggelenke des Menschen

In the ankle (talocrural) joint, the lower end of the tibia and fibula embrace the trochlea tali. Thus, an approximately uniaxial joint is formed which permits dorsiflexion and plantarflexion of the foot against the leg. Due to the geometry of the trochlea tali, conjunct lateral rotation of the fibula against the tibia occurs at the tibiofibular articulations synchronously with active dorsiflexion at the ankle joint. Movements at the talocrural joints are mainly limited by the opposing muscles as well as by strong collateral ligaments. Talus and calcaneus form a functional unit connected by posterior and anterior articulations. The posterior articulation is the subtalar (talocalcaneal) joint; in the anterior articulation, talar facets of the calcaneus together with the posterior surface of the navicular and the superior fibrocartilaginous surface of the plantar calcaneonavicular ligament form a concavity for the talar head. Thus, the talocalcaneonavicular joint is a compound and--like the subtalar joint--a multiaxial articulation. On the weight-bearing foot, the distal tarsus and metatarsus are pronated and supinated against the talus in order to maintain plantigrade contact. When the foot is off the ground, these movements are modified to eversion and inversion, also involving the calcaneocuboid joint. In addition, movements between the calcaneus and cuboid also occur during pronative or supinative changes between the fore- and hindfoot. Limitation of movements is due to leg muscles as well as strong ligaments. Finally, the cuneonavicular, cuboideonavicular, intercuneiform and cuneocuboid joints permit some additional alterations of the loaded foot in contact with the ground.     

Injuries of the lateral ankle ligaments: classification with tenography and arthrography

To assess the value of tenography of the peroneal tendon sheaths and of arthrography of the tibiotalar joint for the diagnosis and classification of recent ruptures of the lateral ankle ligaments, the authors performed a prospective study on 108 patients with inversion trauma of the ankle. All patients underwent tenography. Arthrography was performed if results of tenography were negative. All patients with positive tenographic or arthrographic results underwent surgery. Tenography proved to be reliable in the diagnosis of injuries of the calcaneofibular ligament (sensitivity, 88%; specificity, 87%-94%). The positive predictive value of tenography in combination with arthrography was 100% for the diagnosis of lateral ligament ruptures. The authors conclude that a combination of arthrography and tenography is a reliable method for diagnosing recent ruptures of the lateral ankle ligaments and for differentiating between isolated ruptures of the talofibular ligament and combined lesions of both the talofibular and the calcaneofibular ligaments.     

Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers.

Findings at high-resolution magnetic resonance (MR) imaging of the lateral and medial collateral ligaments of the ankle were compared with findings in anatomic sections from cadavers. MR imaging of six cadaveric feet was performed with a newly developed local gradient coil and axial and coronal T1-weighted spin-echo sequences. Axial imaging provided optimum views of the anterior and posterior talofibular ligaments, the deep layers of the medial collateral ligament, and the tibionavicular ligament. Coronal imaging allowed complete visualization of the calcaneofibular, posterior talofibular, tibiocalcaneal, and posterior tibiotalar ligaments. In both imaging planes, differentiation of the deep and superficial layers of the medial collateral ligament was possible. Differentiation between the syndesmotic complex and the lateral collateral ligament was accomplished easily; in particular, differentiation of the posterior tibiofibular ligament from the posterior talofibular ligament was not difficult because of the differing insertions of these ligaments. The inhomogeneous appearance of the medial collateral ligament and the posterior talofibular ligament on MR images correlated with areas of fatty tissue on corresponding microscopic sections. High-resolution MR imaging with a newly developed local gradient coil allows excellent visualization of the lateral and medial collateral ligaments of the ankle.     

Single-leg postural equilibrium test

The ability to balance on one leg was tested in 29 patients with chronic posttraumatic functional instability of the ankle joint prior to operative exploration of the lateral ligaments of the ankle joint. The results were recorded in seconds and were compared with a control group without functional instability. Patients with ruptured calcaneofibular ligament had a significantly reduced test result compared with patients with uninjured calcaneofibular ligament. Isolated damage to the anterior talofibular ligament did not affect the test result. The patients had a significantly reduced test result on the affected leg, as compared with the unaffected leg and the control group. The single-leg postural equilibrium test is a simple clinical test that is easily used in the objective evaluation of functional instability of the ankle. In chronic functional and mechanical instability, this test seems useful in differentiating between injured and uninjured calcaneofibular ligament.