Unrecognized injuries of the lateral ligaments associated with lateral malleolar fractures of the ankle

Of four patients who were treated between May 1985 and November 1987 and who had both a lateral malleolar fracture and a tear of the lateral ligaments of the ipsilateral ankle, three could be followed. The fractured malleolus was treated with rigid internal fixation, but the injury to the lateral ligaments was not diagnosed until the ankle was stressed to test for stability after the internal fixation. We believe that if disruption of the lateral ligaments is noted at operation, repair is indicated. This involves only a slight prolongation of time under anesthesia and markedly increases the chances for a stable ankle. It is important to check intraoperatively for a possible tear of the lateral ligaments in a patient who has a fracture of the ankle, especially when the injury was caused by high-energy trauma.     

Injury to the lateral ligaments of the ankle

Ankle sprains are common and often are treated inadequately. Unstable lateral ankle ligaments cause abnormal ankle motion and can lead to degenerative changes. Arthrography is the superior radiographic study in acutely injured ankles. Stress tests are useful if positive; however, because false-negative tests are common, general anesthesia should be considered. Chronic injuries may be evaluated well with stress testing. Conservative treatment (that is, mobilization) with aggressive rehabilitation is probably the best treatment for all lateral ligament injuries, unless certain mechanical stability is of paramount importance. Finally, the results of late reconstruction equal those of early repair.     

Plantaris tendon reconstruction of the lateral ankle ligaments

Numerous procedures have evolved to operatively stabilize the ankle suffering from chronic inversion instability. The use of the plantaris tendon to anatomically reconstruct the lateral collateral ankle ligaments is among those that avoid the complication of restriction of subtalar joint range of motion. The authors present a modified technique of reconstructing the calcaneofibular and anterior talofibular ligaments using a plantaris tendon that maintains its insertion. A retrospective study of eight patients that elected the procedure for chronic ankle instability was conducted. The average follow-up was 12.7 months. Significant improvement in functional score (p less than 0.01) and talar tilt (p less than 0.05) was noted following the procedure. No restriction of subtalar joint motion was observed in any patient after the procedure. The advantages and disadvantages of the procedure are discussed. The authors conclude that the procedure appears to be a desirable alternative in achieving ankle stability while maintaining normal hindfoot function.     

Injuries of the lateral ligaments of the ankle joint

Summary Between 1980 and 1984, 268 patients with recent ankle ligament ruptures were treated with primary surgical repair at to 2nd Department of Trauma Surgery, University of Vienna. The decision for immediate operative treatment was based on clinical findings as well as on a positive stress roentgenogram. Ligament ruptures were diagnosed if the talar tilt on the injured side exceeded that on the uninjured side by 5° or more or if the ventral subluxability of the talus was more than 5 mm compared with the uninjured side. One hundred twenty-two patients were followed up for 2–6 years after operation; follow-up included physical examination as well as standardized and stress roentgenograms. Good results were obtained in 80% of cases, moderate results in 17%, and poor results in 3%. All of the poor results were due to persistent radiological instability and/or arthrotic joint degeneration. The incidence of infection was 1.5%.     

Stress examination of traumatized lateral ligaments of the ankle

In the diagnostic analysis of acute injury to the lateral ankle ligaments, ankle arthrography and plain film stress examination play an important role. Inasmuch as the treatment of choice, whether conservative or surgery, and insofar as the therapeutic results may be determined by the extent of injury, it is important to have access to quantitative information on the functional properties of the involved ligaments at the time of the initial diagnostic studies. This can be obtained by measuring the strain on the anterior talofibular (tf) and calcaneofibular (cf) ligaments as a function of pressure applied to the distal tibia. Any device that ensures that the externally applied pressure is proportionally carried through to the ligaments can be used for this purpose. The results of 25 quantitative stress examinations using a Telos stress device are compared with arthrography findings and findings at surgery. Stress examination correlates well with both arthrographic and operative findings. The method is also useful for the evaluation of chronic ankle instability, follow-up examinations, and for the detection of vestiges of previous trauma of the contralateral ankle. The procedure is straightforward and noninvasive and can be performed within 15 minutes.     

陈旧性踝关节外侧副韧带损伤的治疗

1996年8月～2007年12月,我院采用腓骨短肌腱重建术治疗陈旧性踝关节外侧副韧带损伤15例,效果良好。     

Colville手术治疗慢性踝关节外侧不稳

内翻应力导致的外踝扭伤是一种常见外伤,而大约10%～15%的损伤导致距腓前韧带和跟腓韧带断裂.然而经过治疗后,仍然有部分患者出现慢性踝关节外侧不稳,需要进行外科手术治疗[1].1999年8月至2004年2月,我们应用ColviHe术式重建踝关节外侧韧带,治疗踝关节慢性外侧不稳26例,取得了良好的疗效,报告如下.     

The results of reconstruction of the lateral ligaments of the ankle

Summary Eighty-one reconstructions of the lateral ligaments of the ankle were carried out at our clinics between 1967 and 1983. Three methods were used and 53 patients were followed up. The only two poor results followed infection after dural reconstruction. Peroneus brevis reconstruction, dural reconstruction and ligament advancement all had good results in over 80% of the patients. There was restriction of supination and an increase of osteoarthritis after the peroneus brevis reconstruction operations. Statistical analysis did not show that any one of these procedures was better than any other.

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Résumé De Janvier 1967 à Août 1983, 81 plasties ligamentaires externes ont été exécutées dans nos cliniques de Munich. A côté de la plastie de Viernstein utilisant le court péronier latéral, et de la plastie à la dure-mère de Jaeger, on a réalisé également des transferts ostéo-ligamentaires (Wirth), combinés avec des plasties périostées. 53 patients ont été analysés, 3,8 ans en moyenne après l'opération, sur le plan clinique et radiologique. Les deux seuls mauvais résultats sont consécutifs à une infection survenue après plastie à la dure-mère. Chacune de ces trois méthodes de traitement a donné plus de 80% de bons résultats. Dans les plasties à l'aide du court péronier latéral on a pu constater une limitation de la supination ainsi qu'une augmentation de l'arthrose. L'analyse statistique n'a cependant pas montré de supériorité de l'un de ces procédés par rapport à un autre.

     

自体肌腱移植解剖重建慢性踝关节外侧不稳定

目的 探讨采用自体半腱肌肌腱移植对不同类型慢性踝关节外侧不稳定患者进行韧带解剖重建的临床疗效.方法 2008年10月至2009年10月收治16例慢性踝关节外侧不稳定患者,男8例,女8例;年龄19～47岁(平均28.2岁).首先在麻醉下对慢性踝关节外侧不稳定患者进行应力X线片评估:对于前抽屉应力片距骨前移大于4 mm的患者,采用距腓前韧带重建,共9例;对于距骨倾斜应力片距骨倾斜角度大于10°的患者,采用距腓前韧带和跟腓韧带重建,共7例.韧带移植物采用自体半腱肌肌腱,用带线锚钉固定移植物于腓骨端,用可吸收界面螺钉固定韧带于距骨端或跟骨端.采用美国足踝外科协会(AOFAS)踝与后足评分系统对患者手术前、后的结果进行评估.采用标准应力X线片对患者手术前、后客观结果进行评估.结果 16例患者术后获6～18个月(平均12.1个月)随访.16例患者AOFAS踝与后足评分由术前的(70.50±3.98)分改善为末次随访时的(93.06 ±4.78)分,差异有统计学意义(t=-24.010,P=0.000);距骨前移距离由术前的(8.75±3.38)mm改善为末次随访时的(3.51±1.63)mm,差异有统计学意义(t=7.028,P=0.000).7例患者距骨倾斜角度由术前的16.18°±7.30°改善为术后的5.57°±2.99°,差异有统计学意义(t=5.661,P=0.001).16例患者中仅1例背屈受限10°,无严重并发症发生.结论 解剖重建外踝韧带治疗慢性踝关节外侧不稳定是一种有效的治疗方法,其具有解剖重建、固定牢固、对腓骨和腓骨肌腱影响小、能够有效节省游离肌腱的长度等优点.     

Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft

Injury to the lateral ligaments of the ankle is one of the most common sports-related injuries. Although these injures generally resolve with non-operative treatment reconstruction of the lateral ligaments of the ankle is occasionally necessary. We report the surgical technique and result of reconstruction of the anterior talo-fibular ligament using a semi-tendinosis free graft in 26 patients with an average follow-up of 24 months. 81% of patients reported complete resolution or substantial improvement in instability, swelling and sharp pain. Episodes of functional instability persisted in five patients post operatively. No significant differences were noted between the operated and contra-lateral non-operated ankle in range of motion or uniaxial balance assessment. Kin-Com testing of hamstring strength showed no differences between sides. Short term results suggest that this ligament reconstruction provides good results without sacrifice of peroneal function and has minimal donor site morbidity.     

Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability

The management of chronic lateral instability of the ankle remains controversial. In general, the anterior talofibular ligament (ATFL) must be reconstructed in all patients. Some will also need reconstruction of the calcaneofibular ligament (CFL) (or its function) to regain stability of both the ankle and the subtalar joints, and to avoid recurrence of instability. After reconstruction, most authors report good to excellent results in 80% to 85% of patients. We describe the augmented reconstruction technique of ATFL and CFL with a semitendinosus tendon allograft through a peroneal bone tunnel fixed with biodegradable anchors, and advocate this procedure as a safe, effective method to manage lateral ankle instability.     

Reconstruction of lateral ligaments of the ankle with allogeneic tendon grafts

Fresh frozen allogeneic tendon was used to reconstruct the lateral ligaments in 17 ankles. Two or more years later, 13 returned for follow-up examination. The mean age at operation was 23 years (range 15 to 39); the interval between injury and operation varied from six months to 20 years. There were no infections and no immunological rejections, and according to Sefton's criteria, nine patients were excellent and four good. No patient complained of instability of the ankle and stress radiography confirmed this improvement. Allograft reconstruction of the lateral ligaments of the ankle is a new method of treatment which restores stability without sacrificing normal tendons.     

Treatment of ruptures of the lateral ankle ligaments: a meta-analysis

BACKGROUND: Ruptures of the lateral ankle ligaments are very common; however, treatment remains controversial. The aim of the current study was to perform a meta-analysis of randomized, controlled clinical trials of existing treatment strategies for acute ruptures of the lateral ankle ligaments. METHODS: Randomized, controlled trials reported between 1966 and 1998 were included if they involved acute ruptures of the lateral ankle ligaments. Randomized, controlled trials are defined as comparative studies with an intervention group and a control group in which the assignment of participants to a group is determined by the formal procedure of randomization. Summary measures of effectiveness were expressed as relative risks with use of random effects modeling. RESULTS: When analyzing the trials, we searched for comparable outcome measures in both short and long-term follow-up studies (studies with six months to 3.8 years of follow-up). This resulted in the analyses of three outcome measures: time lost from work, residual pain, and giving-way. This report summarizes the results of twenty-seven trials. With respect to giving-way, a significant difference was noted between operative treatment and functional treatment (relative risk, 0.23; 95 percent confidence interval, 0.17 to 0.31) in favor of operative treatment and a significant difference was also noted between functional treatment and treatment with a cast for six weeks (relative risk, 0.69; 95 percent confidence interval, 0.50 to 0.94) in favor of functional treatment. With respect to residual pain, no significant difference was found between operative and functional treatment and a significant difference was found between functional treatment and treatment with a cast for six weeks (relative risk, 0.67; 95 percent confidence interval, 0.50 to 0.90). We found minimal or no treatment to result in more residual pain (relative risk, 0.53; 95 percent confidence interval, 0.27 to 1.02) and giving-way (relative risk, 0.34; 95 percent confidence interval, 0.17 to 0.71) than did functional treatment. CONCLUSIONS: We concluded that a no-treatment strategy for ruptures of the lateral ankle ligaments leads to more residual symptoms. Operative treatment leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks.     

Reconstruction of the lateral ligaments of the ankle using the plantaris tendon

The plantaris tendon was used to reconstruct the torn lateral ligaments in the ankles of nine patients in whom surgical repair of the ligaments was not feasible. All of these patients were followed for more than two years and were able to return to their preoperative occupational and athletic activities. The use of the plantaris tendon permits an anatomical reconstruction of the lateral ligaments and, unlike previously described procedures, avoids sacrificing the dynamic effect of the peroneus brevis muscle in preventing inversion of the foot.     

Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft

Purpose

The purpose of our study is to evaluate the clinical results of anatomical reconstruction of the lateral ligaments with semitendinosus allograft.

Methods

Thirty-six patients with chronic lateral instability underwent anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and the Karlsson score were used to evaluate the clinical results before and after surgery.

Results

A total of 35 patients (97.2?%) (36 ankles) were followed up for a mean of 37.9?months. The mean AOFAS score improved from 42.3?±?4.9 points preoperatively to 90.4?±?6.7 postoperatively. The mean Karlsson score improved from 38.5?±?3.2 preoperatively to 90.1?±?7.8 postoperatively.

Conclusions

Anatomical reconstruction of the lateral ligaments with semitendinosus allograft achieves a satisfactory surgical outcome for chronic ankle instability.     

Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle: a long-term follow-up study

We performed a retrospective study to assess the long-term outcome of non-augmented anatomical direct repair of the lateral ankle ligaments, as originally described by Duquennoy et al, for the treatment of chronic lateral instability of the ankle. This procedure aims to restore stability by the re-insertion and tightening of the original talofibular and calcaneofibular ligaments without division of the ligament. We examined the outcome in terms of the post-operative quality of life, the function of the joint and the development of osteoarthritis. Between 1985 and 2002, 23 patients (11 males, 12 females) with a mean age of 32 years (15 to 58) who had undergone this procedure completed the Short-Form 36 assessment of quality of life and the Olerud and Molander Ankle score for the subjective evaluation of symptoms. Clinical re-evaluation, including examination of the ankle and the completion of the American Orthopaedic Foot and Ankle Society questionnaire was performed on 21 patients after a mean follow-up of 13 years (3 to 22.2). At the final follow-up radiographs of both ankles were taken to assess the development of osteoarthritis. The mean total Short-Form 36 and Olerud and Molander Ankle scores in 23 patients at final follow-up were 79.6 points (37 to 100) and 81.6 points (40 to 100), respectively. The mean total post-operative American Orthopaedic Foot and Ankle Society score in 21 patients was 89.7 points (72 to 100). We found a significant post-operative reduction in talar tilt and anterior drawer sign (chi-squared test, p <0.001). The functional outcome of the procedure was excellent in ten patients (48%), good in seven (33%) and fair in four (19%). The results in terms of ankle function and stability did not deteriorate with time and there was little restriction in movement. This procedure is simple and effective with a very low rate of complications.     

Differential diagnosis of ruptures of the lateral ligaments of the ankle joint

Summary Ruptures of the lateral ligaments of the ankle joint occur very frequently in young persons and this subject is therefore one which deserves more attention. Once a fracture or avulsion of a ligamentary insertion has been excluded the nature and extent of the ligamentary lesion should be precisely assessed. The only objective criterion of rupture of a ligament is demonstrable instability of the joint. Since the anterior talo-fibular ligament is always found to be torn immediately following supination-inversion injury to the ligaments the talar drawer sign will be demonstrable both clinically and radiologically in such cases. This test causes almost no pain and can be carried out without anesthesia. The radiological visualization of ligamentary instability with the aid of a simple jig which stresses the ankle joint provides diagnostic information which is definitely superior to that obtained from an a-p roentgenogram of the stressed joint. This conclusion was reached by statistical analysis of 384 roentgenograms.

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Zusammenfassung Die Häufigkeit der lateralen Bandruptur am oberen Sprunggelenk ist besonders bei jugendlichen Patienten sehr groß und verdient vermehrtes Interesse. Nach Ausschluß einer Fraktur oder eines knöchernen Bandausrisses muß die exakte Beurteilung des Bandschadens erfolgen. Der Instabilitätsnachweis ist das einzige objektive Kriterium einer Bandruptur. Da bei einer frischen Bandverletzung nach einem Supination-Inversion-Trauma das Lig. fibulo-talare ant. immer gerissen ist, ist das Schubladenphdnomen des Talus sowohl klinisch als auch radiologisch nachweisbar. Diese Untersuchung ist kaum schmerzhaft und kann ohne Anästhesie durchgeführt werden. Die radiologische Darstellung der Bandinstabilitdt mit einem einfachen Halteapparat ergibt eine eindeutig bessere diagnostische Aussage als die gehaltene Aufnahme im a-p Strahlengang. Dies wurde mit statistischer Methode nach Auswertung von 384 Röntgenbildern nachgewiesen.

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Dedicated Professor M. E. Muller on his 60th birthday     

自体半腱肌肌腱结合界面螺钉修复慢性踝关节外侧副韧带损伤

 目的 观察自体半腱肌肌腱结合可吸收界面螺钉修复慢性踝关节外侧副韧带损伤的疗效。方法 应用同侧自体半腱肌肌腱结合可吸收界面螺钉修复慢性踝关节外侧副韧带损伤 12例,男 7例,女 5例; 年龄 23~39岁,平均(29.4±4.8)岁; 病程 3~6个月。于外踝处钻孔,穿过编织的自体半腱肌肌腱,肌腱两端以可吸收界面螺钉分别固定在距腓前韧带和跟腓韧带的距骨及跟骨止点处。术后 6个月摄 X线片测量距骨位置,以美国矫形足踝协会(American Orthopaedic Foot and Ankle Society, AOFAS)踝-后足评分系统及足踝疗效评分(Foot and Ankle Outcome Score, FAOS)进行疗效评价。结果 全部患者随访 6~24个月,平均 12.3个月。切口均一期愈合。距骨倾斜角由术前 15.43°±1.35°减小为术后 6个月 3.28°±1.17°,前抽屉试验距骨前移距离由术前(7.82±0.61) mm减小为术后 6个月(3.71±0.41) mm, AOFAS踝-后足评分由术前(66.92±5.63)分增加至术后 6个月(93.25±2.67)分,FAOS疼痛、其他症状、日常活动、运动、生活质量五项评分分别由术前(64.67±5.00)、( 59.50±5.35)、( 65.42±5.02)、( 52.42± 4.68)、( 65.58±4.32)分增加至术后 6个月(88.00±3.46)、( 83.75±4.37)、( 91.42±3.80)、( 87.92±3.26)、(93.17±2.59)分,差异均有统计学意义。结论 采用自体半腱肌肌腱结合可吸收界面螺钉可以重建慢性踝关节外侧副韧带的稳定性,术后踝关节功能恢复良好,其强度能满足运动需求。