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.     

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.     

MRI诊断踝关节外侧韧带损伤的Meta分析

 目的 探讨MRI技术在诊断踝关节外侧韧带损伤的有效性。方法 应用Meta分析。检索3个中文数据库(中国期刊全文数据库、万方数据库、中文科技期刊数据库)和3个英文数据库(PubMed、EMbase、The Cochrane Library)进行相关研究。检索年限均为从建库至2018-11。总结了符合条件的研究,提取数据以计算磁共振成像(MRI)在诊断踝关节外侧韧带损伤时的灵敏度和特异度。结果 16项研究符合纳入,包括660例患者。MRI诊断急性距腓前韧带损伤的合并敏感度为0.93[95%CI(0.86,0.97)],合并特异度为0.55[95%CI(0.27,0.80)]。诊断慢性距腓前韧带损伤的合并敏感度为0.86[95%CI(0.77,0.91)],合并特异度为0.80[95%CI(0.67,0.89)]。诊断急性跟腓韧带损伤的合并敏感度为0.72[95%CI(0.58,0.82)],合并特异度为0.86[95%CI(0.68,0.95)]。诊断慢性跟腓韧带损伤的合并敏感度为0.57[95%CI(0.44,0.69)],合并特异度为0.92[95%CI(0.86,0.96)]。结论 MRI检查在诊断慢性距腓前韧带损伤时的诊断效能较高。诊断急性距腓前韧带损伤时,MRI检查可以有效筛选ATFL损伤患者。在诊断急慢性跟腓韧带损伤时,其阴性结果对排除跟腓韧带损伤有一定的参考价值。     

Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury

Purpose

Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury (ALALI) in favour of immobilization treatment. There is no single most effective functional treatment (tape, semi-rigid brace or lace-up brace) based on currently available randomized trials.

Methods

This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grades II and III ALALIs. The Karlsson score and the FAOS were evaluated at 6-month follow-up.

Results

One hundred and ninety-three patients (52 % males) were randomized, 66 patients were treated with tape, 58 patients with a semi-rigid brace and 62 patients with a lace-up brace. There were no significant differences in any baseline characteristics between the three groups. Mean age of the patients was 37.3 years (35.1–39.5; SD 15.3). Ninety-five males (49 %) were included. One hundred and sixty-one (59 + 50 + 52) patients completed the study through final follow-up; 32 % lost at follow-up. In two patients treated with tape support, the treatment was changed to a semi-rigid brace because of dermatomal blisters. Except for the difference in Foot and Ankle Outcome Score sport between the lace-up and the semi-rigid brace, there are no differences in any of the outcomes after 6-month follow-up.

Conclusion

The most important finding of current study was that there is no difference in outcome 6 months after treatment with tape, semi-rigid brace and a lace-up brace.

Level of evidence

I.

     

Deltoid ligament in acute ankle injury: MR imaging analysis

Objective

To identify the pattern of deltoid ligament injury after acute ankle injury and the relationship between ankle fracture and deltoid ligament tear by magnetic resonance imaging (MRI).

Materials and methods

Thirty-six patients (32 male, and 4 female; mean age, 29.8 years) with acute deltoid ligament injury who had undergone MRI participated in this study. The deltoid ligament was classified as having 3 superficial and 2 deep components. An image analysis included the integrity and tear site of the deltoid ligament, and other associated injuries. Association between ankle fracture and deltoid ligament tear was assessed using Fisher’s exact test (P?<?0.05).

Results

Of the 36 patients, 21 (58.3 %) had tears in the superficial and deep deltoid ligaments, 6 (16.7 %) in the superficial ligaments only, and 4 (11.1 %) in the deep ligaments only. The most common tear site of the three components of the superficial deltoid and deep anterior tibiotalar ligaments was their proximal attachments (94 % and 91.7 % respectively), and that of the deep posterior tibiotalar ligament (pTTL) was its distal attachment (82.6 %). The common associated injuries were ankle fracture (63.9 %), syndesmosis tear (55.6 %), and lateral collateral ligament complex tear (44.4 %). All the components of the deltoid ligament were frequently torn in patients with ankle fractures (tibionavicular ligament, P?=?0.009).

Conclusion

The observed injury pattern of the deltoid ligament was complex and frequently associated with concomitant ankle pathology. The most common tear site of the superficial deltoid ligament was the medial malleolar attachment, whereas that of the deep pTTL was near its medial talar insertion.

     

Ulnar collateral ligament injury in the overhead athlete

The ulnar collateral ligament (UCL), particularly the anterior portion of the anterior oblique ligament, is the primary static contributor to elbow valgus stability. UCL injuries are most common in athletes participating in overhead sports. Acute and chronic injuries to the UCL result in valgus instability, which may predispose the athlete to the development of disabling secondary elbow conditions. Provocative physical examination maneuvers include the valgus abduction test, the modified milking maneuver, and the moving valgus stress test. Plain radiographs and magnetic resonance imaging are the most common imaging modalities, although ultrasonography and computed tomography arthrograms can alternatively be used. UCL injuries can be treated initially with rest, anti-inflammatory medications, bracing, and/or physical therapy. Acute avulsion injuries can be repaired, especially in those under 20 years of age, but most UCL tears are now treated with reconstruction. Modifications of the Jobe figure-of-8 technique, and now the Altchek docking technique, are the most common reconstruction techniques. Many new and hybrid techniques have been described with limited clinical experience in the literature. Current techniques offer the athlete a greater than 90% chance of return to play at their preinjury level.     

Anterior cruciate ligament injury in the skeletally immature athlete

The incidence and prevalence of anterior cruciate ligament (ACL) injury in the school-age athlete is unknown, but ACL injury is certainly not a rarity, especially in girls involved with soccer and basketball. Clinical examinations provide a high degree of specificity and accuracy for the diagnosis. Clinical evaluation includes the determination of physiologic maturity, which is then entered as a factor in the treatment algorithm. Nonsurgical treatment may be definitive or used as a temporizing measure until skeletal maturity. It must include counselling about sports modification to prevent further intra-articular damage. Concerns exist about surgical intervention, which may produce deformity sequelae from physeal invasion. Patients with concommitant unstable meniscal tears require ACL reconstruction. Three types of surgical reconstruction are possible, based on the amount of physeal transgression: physeal sparing, partial physeal, and complete physeal. Treatment decisions must take into account the patient's anatomic and physiological assets and liabilities, and decisions must be made on an individual basis. Promising results have been reported with ACL reconstruction in truly skeletally immature patients, but the number of cases are small and the follow-up is relatively brief.     

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.     

Prevention of anterior cruciate ligament injury in the female athlete

The relationships of gender, age and training to the incidence of anterior cruciate ligament (ACL) injury are pivotal to developing a comprehensive neuromuscular and proprioceptive training programme to decrease ACL injuries in female athletes. A prophylactic neuromuscular and proprioceptive training programme may have direct benefit in decreasing the number of ACL injuries in female athletes. This research foundation endorses further epidemiological and biomechanical studies to determine the exact mechanism of ACL injury and the most effective intervention for decreasing ACL injuries in this high-risk population.     

MR imaging of the lateral collateral ligament of the ankle

The ankle is stabilized by three sets of ligaments: the medial collateral (deltoid) ligament, the syndesmotic ligamentous complex, and the lateral collateral ligament. Of these three, the lateral collateral ligament is the one most often injured in ankle sprains. Assessment of the extent of injury has classically relied on clinical evaluation; plain film radiographs (including stress views); and, in some acute situations, ankle arthrography and/or peroneal tenography. In this report we illustrate the use of MR in the evaluation of the lateral collateral ligament. The normal anatomy, pitfalls in image interpretation, and findings in cases of ligamentous injury are demonstrated.     

Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome

BACKGROUND: Avulsion fracture of the lateral ankle ligaments is often undetected on early radiographs. The epidemiology and treatment of such avulsion fractures have received much less attention than the epidemiology and treatment of rupture of these ligaments. HYPOTHESIS: The clinical characteristics of avulsion fracture are different from those of ligament rupture. Unlike nonoperative treatment of lateral ligament rupture, nonoperative treatment of avulsion fracture does not yield satisfactory results. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 169 consecutive patients with severe inversion injury were classified into a ligament rupture group or avulsion fracture group on the basis of physical examination findings and anterior talofibular ligament and calcaneofibular ligament radiographic views. Age, sex, activity level, and the mechanism of injury were analyzed. Patients in both groups were treated by casting. Follow-up examination of 152 patients included clinical assessment and functional evaluation based on the Karlsson system. RESULTS: Avulsion fracture was diagnosed in 44 (26%) of the 169 patients and was most common among children and patients over 40 years of age. Sedentary level activity and low-energy injury were more common in the avulsion fracture group than in the ligament rupture group (77% vs 37%, respectively, P = .001; 68% vs 43%, respectively, P =.004). Nonoperative treatment of avulsion fracture (mean Karlsson score, 89.1 points) yielded satisfactory results that were comparable with those of nonoperative treatment of ligament rupture (mean Karlsson score, 88.4 points) (P = .123). Osseous union was achieved in 65% of the patients with avulsion fracture. CONCLUSION: Avulsion fracture of the lateral ankle ligaments in cases of severe inversion injury is more common than previously believed. Because of the high incidence and difficulty of detection in children, a high level of suspicion is necessary in order to obtain an accurate diagnosis of avulsion fracture in cases of severe inversion injury and to achieve adequate stability.     

A radiological analysis of lateral ligament injuries of the ankle

Patients who presented within 5 days of an inversion injury to the ankle joint, were clinically selected for early radiological investigation and diagnosis of rupture of the lateral ligament of the ankle. Stress tenography was performed in 142 cases, and normal ranges for talar tilt and anterior draws were established in 216 normal ankles. In addition 38 cadaveric ankles were examined by peroneal tenography. No normal connection between the tendon sheath and the ankle joint was demonstrated. Sixty-five patients had positive peroneal tenograms; nine of these were positive only after manipulation. No complications occurred. Surgery was performed on 20 patients and demonstrated that common peroneal tenography was 95% accurate in diagnosing rupture of the calcaneo-fibular ligament. Of the 19 patients with proven calcaneo-fibular ligament rupture, six had a positive anterior draw sign, and nine had talar tilt. In this series both the talar tilt and anterior draw signs were found to be inaccurate. Common peroneal tenography is recommended as the method of choice for demonstrating acute rupture of the calcaneo-fibular component of the lateral ligament.     

踝关节侧副韧带损伤的超声表现

目的 分析踝关节侧副韧带损伤的超声图像特征并评价其诊断价值。方法 采用7～13MHz线阵探头探查136例临床怀疑踝关节侧副韧带损伤患者，观察胫舟、胫距前、胫跟、距腓前、跟腓、胫距后、距腓后韧带，共计952条韧带，其中，51例的超声结果与手术比较。结果 46例侧副韧带完全及部分撕裂伤的超声诊断与手术结果符合。侧副韧带挫伤以肿胀为主，部分撕裂伤超声表现为韧带局部连续性中断（跟腓韧带）和不规则低-无回声区内见丝状结构相连，完全撕裂伤超声表现为韧带连续性中断，断端挛缩（跟腓韧带）和不规则低-无回声区贯穿整条韧带，无明显断端挛缩征。结论 高频超声对踝关节侧副韧带损伤的诊断无创、较准确、廉价，具有较高的临床应用价值。     

Articular cartilage injury of the posterior lateral tibial plateau associated with acute anterior cruciate ligament injury

Thirty-nine knees in 39 patients with recent anterior cruciate ligament (ACL) rupture (age 14–55 years; with a mean age of 22.8 years) were selected from our cases of ACL reconstruction from July 2005 to June 2006, to take part in a study on articular cartilage injury of the posterior lateral tibial plateau associated with acute ACL injury and on the correlation between bone bruises depicted on MRI and cartilage injury of the posterior lateral tibial plateau detected at arthroscopic ACL reconstruction. Using preoperative MRI, we evaluated whether there were bone bruises or not in the lateral compartment of the knee and divided them accordingly into two groups: the bone bruise positive group and the negative group. The differences in the proportions of the lateral meniscus (LM) tears and the cartilage injuries in the two groups were evaluated using Fisher’s exact probability test. Thirty-five cases out of 39 arthroscopic ACL reconstructions (89.7%) were regarded as bone bruise positive in the lateral compartment and four cases (10.3%) were regarded as negative. At arthroscopic ACL reconstruction, 33 cases (84.6%) had tears in the LM posterior horn, 34 cases (87.2%) had articular cartilage injuries in the lateral femoral condyle and 29 cases (74.3%) had articular cartilage injuries in the posterior lateral tibial plateau. From 35 bone bruise positive cases, 32 cases (91.4%) had tears in the LM posterior horn, 33 cases (94.3%) had articular cartilage injuries in the lateral femoral condyle and 28 cases (80%) had articular cartilage injuries in the posterior lateral tibial plateau. Of four bone bruise negative cases, one case (25%) had a tear in the LM posterior horn, articular cartilage injury of the lateral femoral condyle and of the posterior lateral tibial plateau. There was a statistically significant correlation between the proportion of bone bruise and cartilage injury of the lateral femoral condyle (P = 0.004), that of the posterior lateral tibial plateau (P = 0.04) and that of tears in the LM posterior horn (P = 0.008). This current study has demonstrated that we need to pay attention to cartilage damage of the posterior lateral tibial plateau as well as to posterior horn tears in LM, when acute ACL injury is shown. We also have to ensure that we follow the long-term progress of cartilage injuries, with the aim of preventing these injuries becoming osteoarthritis after ACL reconstruction.     

Dorsal calcaneocuboid ligament versus lateral ankle ligament repair: a case-control study

Objective

Anatomic reconstruction is the treatment of choice for lateral ankle ligament instability. A similar technique has recently been described for stabilisation of a chronic unstable calcaneocuboid joint as an alternative to the previously proposed tenodesis and arthrodesis procedures.

Methods

Five consecutive young females experiencing recurrent giving way of six calcaneocuboid joints were treated operatively during a 4 year period using anatomic ligament repair reinforced by a periosteal flap. Results were compared to five patients who underwent anatomic lateral ankle ligament repair in a case‐control design. Outcome was measured using the Foot and Ankle Outcome Score, physical examination, and stress radiographic and MRI (calcaneocuboid group) investigation. Functional neuromuscular performance was evaluated by isokinetic torque measurements, posturometry, single‐leg drop jumps, and single‐leg long jumps.

Results

Outcome scores at follow up (5–61 months after surgery) revealed excellent results for both groups. No relevant difference was found between the affected legs and the non‐affected legs or between groups with respect to the outcome measures. MRI exhibited ligament‐like structures at the repaired dorsal calcaneocuboid joints in five out of six joints.

Conclusions

Results of anatomic repair of unstable lateral ankle and isolated calcaneocuboid joint instability equally lead to excellent results.