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.     

Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study

Purpose

The purpose of this study was to evaluate a step-by-step approach to endoscopic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL).

Methods

Fourteen lower extremity cadaveric specimens were used. Four standard portals were defined and used. A step-by-step approach using several anatomical landmarks was used to reconstruct the ATFL and CFL. The feasibility of visualising the anatomical landmarks and both ligaments and their footprints was assessed. Both ligaments were reconstructed using a gracilis graft fixed in bone tunnels. The lateral side of the ankle was completely exposed and dissected. The specimen was assessed for clinical stability of the reconstruction and damage to the surrounding anatomical structures. The distance between the centre of the tunnel and the anatomical insertions of the ligaments was measured. The distance between the portals and the nerves was measured.

Results

The step-by-step approach allowed a good visualisation of the entire course of the ATFL and CFL. An endoscopic reconstruction of both ligaments was performed, and good stability was obtained. The measurements revealed a good positioning of the reconstructed ligament insertions with a maximal error of 2 mm in most specimens. Anatomical dissection revealed no damage to the surrounding anatomical structures that were at risk. The average distance to the superficial peroneal nerve was 11.9 ± 5.3 mm (standard deviation), and the average distance to the sural nerve was 17.4 ± 3.2 mm (standard deviation). A safe zone was defined with regard to the surrounding nerves.

Conclusion

The described technique, which involves an anatomical endoscopic reconstruction of the ATFL and CFL, using a gracilis graft, is a viable option to treat lateral ankle instability. This technique is reproducible and safe with regard to the surrounding anatomical structures.

     

New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test,stress radiography and stress ultrasound

Purpose

To diagnose chronic ankle instability, clinicians frequently use manual anterior drawer test and stress radiography. However, both exams can yield incorrect results and do not reveal the extent of ankle instability. The use of stress ultrasound during a manual anterior drawer stress procedure might enable the diagnosis of chronic ankle instability.

Methods

Seventy-three patients with chronic ankle pain or laxity after remote ankle sprain were included. The study population included 41 males and 32 females. The mean age of the patients at the time of the operation was 29 years. A standardized physical examination (manual anterior drawer test), stress radiography and stress ultrasonography were performed to assess the anterior talofibular ligament (ATFL). Ultrasound images were taken in the resting position and the maximal anterior drawer position. The statistical significance of stress ultrasound among the three groups according to manual anterior drawer test and a specific degree (5 mm) of anterior translation of stress radiography were analysed. Correlation coefficients between stress ultrasound, stress radiography and manual anterior drawer test were calculated.

Results

There was a significant difference for ATFL length (ATFL stress) and ATFL ratio (ATFL stress/ATFL resting) among the three groups (both p < 0.001). However, there was no significant difference for anterior translation of stress radiography among three groups according to manual anterior drawer test (p = 0.159). There was a significant difference for ATFL length (ATFL stress) and ATFL ratio between two groups with 5-mm anterior translation of stress radiography (p = 0.002 and p = 0.011, respectively). The mean value of grade of manual anterior drawer test between the two groups also differed (p = 0.021). There was a moderately positive linear relationship between stress ultrasound and manual anterior drawer test. Also, there was a positive linear relationship between stress ultrasound and stress radiography.

Conclusion

The results suggest that the value of ATFL length (ATFL stress) and ATFL ratio of stress ultrasound could be used for diagnosis of chronic ankle instability in addition to manual anterior drawer test and stress radiography.

Level of evidence

III.     

Assessment of the feasibility of arthroscopic visualization of the lateral ligament of the ankle: a cadaveric study

Purpose

An anatomical study was performed to assess the feasibility of arthroscopic visualization of the lateral ligaments of the ankle.

Methods

The fibular, talar and calcanear insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) were identified by standard arthroscopy portals. After dissection of the ATFL and CFL, bone tunnels were created at the estimated centres of their footprints. Dissection was then performed to identify the footprints and their position in relation to bony landmarks. The distance from the real centre of the footprint to the corresponding tunnel entrance was measured.

Results

Fourteen fresh frozen ankles were included. The ATFL and CFL were identified in all cases. The centre of the fibular ATFL footprint was found to be 16.1 ± 3.5 mm from the tip of the fibula, and the talar footprint was 18.4 ± 2.8 mm from the apex of the lateral talar process. The centre of the fibular CFL footprint was 4.2 ± 0.8 mm from the tip of the fibula, and the calcaneal footprint was 18.4 ± 2.5 mm from the fibular process of the calcaneum. The fibular tunnel was 2.9 ± 3 mm proximally from the centre of the ATFL fibular footprint, the talar tunnel was 4.4 ± 3.2 mm proximally from the centre of the talar footprint, and the calcaneal tunnel was 3.3 ± 2.8 mm too anterior from the CFL calcaneal footprint. No iatrogenic lesions were noted.

Conclusion

Arthroscopic identification of the ATFL, CFL and their corresponding footprints can be considered safe and reliable. Tunnels entrances, in preparation for arthroscopic ligament reconstruction, are precisely positioned. Arthroscopic anatomical ligament reconstruction is a feasible option.

     

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.     

Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL

Purpose

Current methods of anterior talofibular ligament (ATFL) reconstruction fail to restore the stability of the native ATFL. Therefore, augmented anatomic ATFL reconstruction gained popularity in patients with attenuated tissue and additional stress on the lateral ankle ligament complex. The aim of the present study was to evaluate the biomechanical stability of the InternalBrace^® (Arthrex Inc., Naples, FL, USA), a tape augmentation designed to augment the traditional Broström procedure.

Methods

Twelve (12) fresh-frozen human anatomic lower leg specimens were randomized into two groups: a native ATFL (ATFL) and a tape augmentation group (IB). Dual-energy X-ray absorptiometry (DEXA) scans were carried out to determine bone mineral density (BMD) of the specimens. The ligaments were stressed by internally rotating the tibia against the inverted fixated hindfoot. Torque at failure (Nm) and angle at failure (°) were recorded.

Results

The ATFL group failed at an angle of 33 ± 10°. In the IB group, construct failure occurred at an angle of 46 ± 16°. Failure torque reached 8.3 ± 4.5 Nm in the ATFL group, whereas the IB group achieved 11.2 ± 7.1 Nm. There was no correlation between angle at ATFL or IB construct failure or torque at failure, respectively, and BMD for both groups.

Conclusion

This study reveals that tape augmentation for ATFL reconstruction shows similar biomechanical stability compared to an intact native ATFL in terms of torque at failure and angle at failure. BMD did not influence the construct stability. Tape augmentation proved an enhanced initial stability in ATFL reconstruction which may allow for an accelerated rehabilitation process.

Level of evidence

II.

     

Management of acute lateral ankle ligament injury in the athlete

Purpose

Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries with special emphasis on a rationale for treatment of these injuries in athletes.

Methods

A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed.

Results

It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7–10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot.

Conclusion

Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4–5 days to reduce pain and swelling. Initially, 10–14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.

Level of evidence

IV.     

Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability

Purpose

To incorporate a diagnostic technique for measuring subtalar motion, namely “talar rotation”, into the manual supination-anterior drawer stress radiographs for evaluation of the severity of rotational instability, and to determine its clinical relevance.

Methods

Sixty-six patients with combined injuries of the anterior talofibular (ATFL) and calcaneofibular ligament (CFL) underwent three bilateral manual stress radiographs, and mean increments of anterior talar translation (mm), talar tilt (°), and talar rotation (%) in the injured ankle compared to the normal opposite side were measured with the technique. Intraobserver and interobserver reliability of each measure was assessed, and the difference in the degree of increments was compared according to the presence of additional cervical ligament insufficiency.

Results

Ankle stress radiographic intraobserver and interobserver agreement was ICC = 0.91 and 0.82 for talar rotation (%), ICC = 0.64 and 0.51 for anterior talar translation, and ICC = 0.78 and 0.71 for talar tilt angle, respectively. In group 2 including patients with combined injuries of the ATFL and CFL along with additional cervical ligament insufficiency, a significantly higher increment of talar rotation, mean 6.4 % (SD 3.4 %), was observed compared to that of talar rotation, mean 4.1 % (SD 2.7 %), in the other group (group 1) with an intact cervical ligament (p < 0.001).

Conclusions

A new comprehensive stress radiographic technique for diagnosis of chronic lateral ankle instability presented in this study might be a reliable and representable measurement tool to assess additional injury or instability of the subtalar joint.

Level of evidence

Prospective cohort study, Level II.

     

An alternative injection technique for performing MR ankle arthrography: the lateral mortise approach

Objectives

This study evaluates whether the recently described lateral mortise (LM) approach to therapeutic ankle injections can also be used to inject the ankle prior to magnetic resonance arthrography (MRA) without impairing the evaluation of the anterior talofibular ligament (ATFL).

Materials and methods

An IRB-approved, retrospective review of ankle MRAs performed using the LM approach between April 2009 and April 2011 was conducted. The MRAs were independently evaluated by three musculoskeletal radiologists for: ATFL assessment (well assessed, limited or unable to assess), amount of fluid in the anterolateral soft tissues (none to large), and capsular distention (underdistended to overdistended). Patient age, gender, fluoroscopy time, injection location, degree of ankle arthritis, and ankle joint narrowing on radiographs were recorded. Statistical analysis was performed using exact binomial confidence limits.

Results

Fifteen MRAs were successfully performed on 13 patients (mean age: 27 years, 11 male, 2 female). Mean fluoroscopic time was 39 s (range 9–108) and mean volume injected was 7 mL (range 5–9 mL). The ATFL was well assessed on all MRAs. A moderate to large amount of fluid was noted in the anterolateral soft tissues on 5 out of 15 MRAs. No ankle joints were underdistended, but 3 out of 15 were overdistended.

Conclusion

Since the ATFL is inferior to the location used for the LM injection, the interpretation of the ankle MRA, specifically ATFL evaluation, was not compromised in any patient. Therefore, the LM approach can be used as an alternative to the anteromedial approach for ankle MRA without sacrificing diagnostic quality.     

The dorsal pedis artery as a new distal landmark for extramedullary tibial alignment in total knee arthroplasty

Purpose

It is better to use multiple anatomical landmarks to reduce errors in component alignment in total knee arthroplasty. Therefore, it is worthwhile to find a new landmark that can be used as an addition to conventional ones. Herein, we assessed the dorsal pedis artery as a new distal landmark for extramedullary tibial alignment.

Methods

Fifty-two ankles in patients undergoing total knee arthroplasty and 10 ankles in normal controls were included. Color Doppler ultrasonography was used to locate the dorsal pedis artery at the level of the ankle joint. Conventional landmarks, including the tibialis anterior tendon, the extensor hallucis longus tendon, the extensor digitorum longus tendon, and the malleolar centre, were also located on ultrasound images. The distances between the ankle centre and each landmark were measured and compared.

Results

The dorsal pedis artery was absent in 2 patients and impalpable but visible with ultrasonography in other 2 patients. The dorsal pedis artery was located anatomically closest to the ankle centre in patients (0.4 ± 3.4 mm lateral). Statistical analysis showed that the dorsal pedis artery, the extensor hallucis longus tendon, and the malleolar centre were located significantly closer to the ankle centre comparing with the extensor digitorum longus tendon and the tibialis anterior tendon in both patients and controls (p < 0.001).

Conclusions

As long as the dorsal pedis artery exists, it can be used as an addition to the conventional landmarks in total knee arthroplasty. Using this new landmark will help reduce errors in coronal plane alignment of tibial component.

Level of evidence

II.     

Correlation of morphologic and pathologic features of the various tendon groups around the ankle: MR imaging investigation

Objective

To determine if a statistical association exists between abnormalities in one ankle tendon group (i.e., peroneal, medial flexor, or Achilles) and those in another.

Materials and methods

A retrospective analysis of 1.5-T and 3-T MR ankle examinations in 100 patients conducted between November 1, 2011 and April 1, 2012 was performed. The cross-sectional areas and diameters of the ankle tendons—Achilles (ACH), peroneus brevis (PB) and longus (PL), tibialis posterior (TP), flexor digitorum longus (FDL), and flexor hallux longus (FHL)—were measured, and the results were correlated to determine any association with the presence of qualitative abnormalities (tenosynovitis, tendinosis, and tendon tearing).

Results

Subjects with larger diameters of the ACH tendon also revealed larger PL, TP, FDL, and FHL tendon diameters and sectional areas. Furthermore, subjects with larger PL tendons generally revealed larger flexor tendons and the same was also true when medial compartment tendons were individually assessed and measurements compared among the three of them. There was a statistically significant association with regard to the presence of tendon abnormalities (tendinosis, tenosynovitis, and tearing) in both the peroneal and medial flexor tendons. The presence of an abnormality in the ACH tendon correlated strongly with increasing diameters and areas of all the other ankle tendons except for the PB tendon.

Conclusions

There is an association between quantitative and qualitative abnormalities of one group of tendons when compared with the others with respect to the ACH, medial flexor, and peroneal tendons of the ankle, which is perhaps explained by a retinacular and fascial complex that anatomically connects the three groups.     

Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test,stress radiography,magnetic resonance imaging,and arthroscopy

Purpose

Clinicians frequently diagnose chronic ankle instability using the manual anterior drawer test and stress radiography. However, both examinations can yield incorrect results and do not reveal the extent of ankle instability. Stress ultrasound has been reported to be a new diagnostic tool for the diagnosis of chronic ankle instability. The purpose of this study was to assess the diagnostic value of stress ultrasound for chronic ankle instability compared to the manual anterior drawer test, stress radiography, magnetic resonance imaging (MRI), and arthroscopy.

Methods

Twenty-eight consecutive patients who underwent ankle arthroscopy and subsequent modified Broström repair for treatment of chronic ankle instability were included. The arthroscopic findings were used as the reference standard. A standardized physical examination (manual anterior drawer test), stress radiography, MRI, and stress ultrasound were performed to assess the anterior talofibular ligament (ATFL) prior to operation. Ultrasound images were taken in the resting position and the maximal anterior drawer position.

Results

Grade 3 lateral instability was verified arthroscopically in all 28 cases with a clinical diagnosis (100 %). Twenty-two cases showed grade III instability on the manual anterior drawer test (78.6 %). Twenty-four cases displayed anterior translation exceeding 5 mm on stress radiography (86 %), and talar tilt angle exceeded 15° in three cases (11 %). Nineteen cases displayed a partial chronic tear (change in thickness or signal intensity), and nine cases displayed complete tear on MRI (100 %). Lax and wavy ATFL was evident on stress ultrasound in all cases (100 %). The mean value of the ATFL length was 2.8 ± 0.3 cm for the stressed condition and 2.1 ± 0.2 cm for the resting condition (p < 0.001).

Conclusion

Stress ultrasound may be useful for the diagnosis of chronic ankle instability in addition to the manual anterior drawer test and stress radiography.

Level of evidence

III.

     

Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment

Acute lateral ankle ligament sprains are common in young athletes (15 to 35 years of age). Diagnostic and treatment protocols vary. Therapies range from cast immobilisation or acute surgical repair to functional rehabilitation. The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments. Injuries typically occur during plantar flexion and inversion; the ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected. Commonly, an athlete with a lateral ankle ligament sprain reports having 'rolled over' the outside of their ankle. The entire ankle and foot must be examined to ensure there are no other injuries. Clinical stability tests for ligamentous disruption include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. Radiographs may rule out treatable fractures in severe injuries or when pain or tenderness are not associated with lateral ligaments. Stress radiographs do not affect treatment. Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management. A non-operative 'functional treatment' programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle. Treatment for grade III injuries is more controversial. A comprehensive literature evaluation and meta-analysis showed that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability. Functional treatment was complication-free, whereas surgery had serious, though infrequent, complications. Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so even competitive athletes can receive initial conservative treatment. Sequelae of lateral ligament injuries are common. After conservative or surgical treatment, 10 to 30% of patients have chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness and 'giving-way'. Well-designed physical therapy programmes usually reduce instability. For individuals with chronic instability refractory to conservative measures, surgery may be needed. Subtalar instability should be carefully evaluated when considering surgery.     

Altered leg muscle activity in volleyball players with functional ankle instability during a sideward lateral cutting movement

Objectives

To study the activation patterns of tibialis anterior, peroneus longus and gastrocnemius lateralis muscles during a lateral shuffle maneuver in volleyball players with functional instability of the ankle joint.

Design

Observational case-control study.

Setting

Research laboratory.

Participants

Sixteen players with functional instability and 18 matched controls.

Main outcome measures

RMS values of tibialis anterior, peroneus longus and gastrocnemius lateralis muscles for the 50 ms before initial ground contact, timing of onset of muscle activity and linear envelopes for the period of ground contact were calculated.

Results

Onset values showed similar patterns of activation for both groups. In healthy subjects, gastrocnemius lateralis activated earlier, followed by peroneus longus and tibialis anterior. In the unstable subjects, gastrocnemius lateralis and peroneus longus activated at the same time, followed by tibialis anterior. Unstable subjects also presented lower peroneus longus activity during the 50 ms before initial ground impact, a lower peroneus longus peak magnitude and a higher gastrocnemius lateralis peak magnitude.

Conclusions

Volleyball players with ankle functional instability showed decreased peroneus longus activity before ground impact that may predispose them to repetitive sprains and explain their “giving way” sensation, since peroneus longus is the main ankle evertor and an important stabilizer against sudden and excessive inversion.     

Syndesmosis and deltoid ligament injuries in the athlete

Purpose

Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete.

Methods

A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed.

Results

The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete.

Conclusion

Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.

Level of evidence

IV.     

An uncommon ankle sprain

Objective

Ankle sprain is the most frequently occurring acute injury in tennis, accounting for 20–25% of all injuries. In the current paper, we assess the cause of ankle sprain and suggest possibilities to be considered during diagnosis.

Methods

We assessed a professional tennis player with a partial tear of the long peroneal tendon after an ankle sprain by physical exam, X‐ray and MRI.

Results

Conservative treatment by means of soft cast and propriocepsis training led to full recovery.

Conclusion

Peroneal tendon disorders must be part of the differential diagnosis after ankle sprain in the professional athlete.An ankle sprain is the most frequent occurring acute injury in tennis, accounting for 20–25% of all injuries. A flexion supination trauma is commonly the cause of this sprain, in which the lateral ligaments are most often affected.⁴However, an ankle sprain may lead to other injuries in the leg and a peroneal tendon lesion must be part of the differential diagnosis.     

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.     

Proprioception level after endoscopically guided percutaneous Achilles tendon

Purpose

To evaluate ankle function following endoscopically guided percutaneous Achilles tendon repair. The hypothesis of this study was that patients with percutaneous repair of the Achilles tendon would still display impaired involved side ankle proprioception.

Methods

Nineteen male patients with percutaneous Achilles tendon surgery were tested for bilateral ankle active angle reproduction at 10° dorsiflexion and 15° plantar flexion, peak concentric isokinetic ankle dorsiflexor and plantar flexor torque, one-leg hop for distance, and single-leg vertical jump height. Dominant sides of age- and sex-matched 19 healthy controls were evaluated for ankle active angle reproduction at 10° dorsiflexion and 15° plantar flexion, peak concentric isokinetic ankle dorsiflexor and plantar flexor torque.

Results

Peak isokinetic torque, one-leg hop for distance, single-leg vertical jump for height and ankle joint position sense at 10° dorsiflexion did not differ between the affected and unaffected side. Ankle joint position sense for active angle replication at 15° plantar flexion revealed a significant side-to-side difference. Joint position sense at 10° dorsiflexion and at 15° plantar flexion at affected side was poor in patients compared with the controls, while joint position sense at 10° dorsiflexion and at 15° plantar flexion at unaffected side was same in patients compared with the controls.

Conclusions

It has revealed a significant difference in joint position sense at plantar flexion of the patients at least 1 year after percutaneous Achilles tendon surgery compared to their unaffected limb. Large prospective longitudinal studies are needed to evaluate therapeutic interventions designed to improve proprioception.

Level of evidence

III.     

Bone bruises associated with acute ankle ligament injury: do they need treatment?

Purpose

The aim of this systematic review is to analyse the current knowledge, incidence, relevance, and need for treatment of bone bruises associated with acute ankle ligament injury.

Methods

A search was made of PubMed, OVID/Medline, Cochrane databases using the keyword “bone bruises” in combination with “ankle”, “sprain”, “management”, “surgery”, and “conservative treatment”.

Results

No randomized controlled trials or prospective cohort studies were found. Only case series were retrieved. A critical appraisal for validity and usefulness of the studies revealed that the best level of evidence on this topic is represented by retrospective comparative studies. Nine studies evaluating the management of bone bruises associated with acute ankle ligament injuries were found.

Conclusion

The clinical prognosis of bone bruises is generally good, with a normalization of MRI appearance usually within 6–12 months after trauma. Currently, there is no evidence that these lesions need specific treatment. Thus, the management of the concomitant ligament lesions is sufficient. Further research is necessary to successfully address the management of bone bruises, and more evidence is required to decide if these lesions need to be treated at all.

Level of evidence

IV.     

Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury

Purpose

To quantify the dynamic balance deficits that characterise a group with chronic ankle instability compared to lateral ankle sprain copers and non-injured controls using kinematic and kinetic outcomes.

Methods

Forty-two participants with chronic ankle instability and twenty-eight lateral ankle sprain copers were initially recruited within 2 weeks of sustaining a first-time, acute lateral ankle sprain and required to attend our laboratory 1 year later to complete the current study protocol. An additional group of non-injured individuals were also recruited to act as a control group. All participants completed the anterior, posterior-lateral and posterior-medial reach directions of the star excursion balance test. Sagittal plane kinematics of the lower extremity and associated fractal dimension of the centre of pressure path were also acquired.

Results

Participants with chronic ankle instability displayed poorer performance in the anterior, posterior-medial and posterior-lateral reach directions compared with controls bilaterally, and in the posterior-lateral direction compared with lateral ankle sprain copers on their ‘involved’ limb only. These performance deficits in the posterior-lateral and posterior-medial directions were associated with reduced flexion and dorsiflexion displacements at the hip, knee and ankle at the point of maximum reach, and coincided with reduced complexity of the centre of pressure path.

Conclusion

In comparison with lateral ankle sprain copers and controls, participants with chronic ankle instability were characterised by dynamic balance deficits as measured using the SEBT. This was attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base.

Level of evidence

III.