Results of surgical treatment of 248 lateral ligamentous lesions of the ankle joint (author's transl)

From 1975 to 1980, 414 patients suffering from lateral ligamentous lesions of the ankle joint had undergone surgical treatment. 248 patients were seen in two follow-up examination; of these, 122 patients were examined by x-ray films taken in forced extreme joint position in two planes (a.p. and lateral) of both ankle joints, the uninjured ankle being examined for comparison. In 76.2% of the cases, both ankle joints were found to possess equal stability. Less than 10% of the follow-up patients examined showed slight restriction in mobility of the upper ankle joint. 97% of the patients questioned stated that the results of surgery were good. Only 3% expressed dissatisfaction. A severe complication was observed in 1 patient, who had an infection of the joint; cure was effected by means of arthrodesis of the upper ankle joint.     

Comparative examinations on diagnosis and therapy of fresh injuries of the exterior ligaments (author's transl)

We are conducting a standardized investigation of injuries of the exterior ligaments, using X-ray films taken in forced extreme joint position in two planes. The advantage of this method is the comparison of the X-ray films taken while exerting a constant force. The X-ray films must be taken in two planes to permit a clear statement about the severity of the injury. It is necessary to exclude a hypermobile ankle joint by means of a comparative X-ray of the healthy limb. Adequate therapy with an elastic bandage, plaster cast or surgery based on this diagnostic method will ensure good results.     

Subluxatio supinatoira tali

A talar tilt of approximately 15° or more is the indication for operative treatment of ruptures of the lateral ligaments of the ankle. Until 1978 stress x-rays were made with the films held by hand in short general anaesthesia. 84% of the x-rays held in plantar flexion of the ankle joint showed a greater talar tilt than if held in the S-O position. There was no direct connection between the degree of the anterior drawer sign and the degree of the talar tilt. After a personal information from H. Frick, since 1978 in 47 patients stress films were taken first without anaesthesia followed by films in general anaesthesia: The patient is positioned on his uninjured side. The injured leg lies horizontally on a support, the foot extends beyond the x-ray table. A cuff is applied, from which a weighted flap is put over the lateral side of the foot. After approximately 5 minutes an ap-x-ray is made. The talar tilt is generally about 25% less than in general anaesthesia. Using this method, in 1979 an increased number of ruptured lateral ligaments of the ankle was diagnosed. In 90% the indication for operation was made by this method alone. In only 5%, after insufficient talar tilt despite sufficient clinical evidence additional stress films under general anaesthesia were made, which then gave the indication for operation. Since with both methods complete muscle relaxation is not achieved we could find no definite relation between the operative findings and the amount of talar tilt. At the follow up examination the operated ruptures of the lateral ligaments of the ankle joint showed better results than those treated conservatively, in spite of the fact that conservative treatment was used with a talar tilt of up to 15° and operative treatment chosen with a talar tilt above 15°. At follow up no talar tilt was found among 33% of the operated patients, but only among 16% of conservatively treated cases. A talar tilt was found in over 50% of our patients on the healthy side, without a history of injury.     

Sonographic versus radiological assessment of chronic outer ligament instability of the upper ankle joint]

Chronic instability of the lateral upper ankle joint ligament is usually diagnosed by clinical and radiological examination. For the evaluation of an ultrasound method of testing lateral instability of the ankle joint we carried out a prospective study. We examined 23 adults who were actively engaged in some form of sport (21 male, 2 female, mean age 32 years) and had a preexisting lateral instability of the ankle. The instability was measured in the standard planes using Scheuba's stress apparatus with simultaneous ultrasound monitoring. The ultrasound examination was performed by positioning the 5-MHz applicator on the lateral side of the Achilles tendon, thus defining a plane from which the instability could be measured in both examination planes by observing the deviation between dorsal inferior edge of the tibia and the dorsal border of the talar roll. For the two examination planes, Spearman's rank-correlation coefficient between the radiological and ultrasound methods was 0.83 and 0.92. The sensitivity of the ultrasound method was 0.90, and the specificity was 0.85. Our study showed a good correlation between the two methods. A pathological talar tilt according to radiological criteria was also revealed by ultrasonography. Thus, all the advantages of ultrasound are now available for the evaluation of chronic lateral instability of the ankle joint.     

An analysis of the function of the posterior talofibular ligament

The function of the posterior talofibular ligament was studied using an apparatus which subjected the ankle joint to a measured torque and allowed the simultaneous recording of rotatory movements in two planes. Thirty osteoligamentous preparations of ankle joints were examined, half in the sagittal and horizontal planes and the remainder in the sagittal and frontal planes. Successive section of the lateral collateral ligaments was performed, including, in particular, selective division of the short and long fibres of the posterior talofibular ligament. The function of this ligament was investigated in combination with the other two collateral lateral ligaments, with the calcaneofibular ligament alone, and finally as the only remaining intact ligament. The posterior talofibular ligament plays only a supplementary role in ankle stability when the lateral ligament complex is intact. After rupture of the anterior talofibular and the calcaneofibular ligaments, however, the short fibres of the posterior ligament restrict internal and external rotation, talar tilt, and dorsiflexion, while its long fibres inhibit only external rotation, talar tilt, and dorsiflexion. As the posterior talofibular ligament has no independent stabilizing function in the intact ankle joint, an isolated rupture of this ligament is unlikely.     

Acute rupture of the lateral ligaments of the ankle joint, diagnosis and surgical treatment.

A useful method for the diagnosis of acute rupture of the lateral ligament of the ankle joint is presented. Twenty-three patients with ruptures of the lateral ligament of the ankle joint were treated surgically with suture of the lateral ligaments of the ankle. Accurate preoperative diagnosis with stress films and arthrography under local anesthesia of the ankle joint is imperative. No instances of infection or other complications were observed. All patients achieved a normal range of ankle function within three to six months. Radiograhs of the injured ankle in the forced inversion position following operation showed full stability of the ankle joint. In our opinion, all ankle injuries should be examined roentgenographically with forced inversion of the foot. Tilting of the talus of at least 10 degrees must be followed by arthrography of the ankle joint under local anesthesia. If there is leakage of contrast material along the peroneal tendon sheaths and around the joint cavity, the lateral ligament of the ankle must be sutured immediately in order to regain stability of the ankle joint.     

Mobility of the Ankle Joint: Recording of Rotatory Movements in the Talocrural Joint in vitro with and without the Lateral Collateral Ligaments of the Ankle

A method for graphic recording of rotatory movements in osteoligamentous ankle preparations is described. By this method it is possible to record characteristic mobility patterns in two planes at the same time. The ankle is affected by a known torque, so that the individual mobility patterns are reproducible with unchanged condition of the ligaments. Six amputated legs were investigated in the sagittal and horizontal planes and another six in the sagittal and frontal planes. Mobility patterns were recorded with intact ligaments and after successive cutting of the lateral collateral ligaments of the ankle in the anteroposterior direction. In the sagittal plane increased dorsiflexion was observed after total cutting of the lateral ligaments, while plantar flexion remained unchanged. In the horizontal plane the internal rotation of the talus increased in step with increasing injury to the ligament, particularly when the ankle was plantar flexed. When all collateral ligaments had been cut, an increase in external rotation occurred, especially in dorsiflexion. In the frontal plane the talar tilt increased gradually with increasing injury to the ligaments. Talar tilt was at a maximum in the neutral position of the ankle or in plantar flexion. After total severing of the collateral ligaments, however, talar tilt was most marked in dorsiflexion of the ankle.     

Treatment of lateral ankle ligament tears. Operative or conservative?

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

Vergleichende Untersuchung über den Stabilisierungseffekt konservativ-funktioneller Maßnahmen am instabilen oberen Sprunggelenk

In a comparative study the value of castless immobilisation methods for stabilising the lateral ankle instability was examined. For this the dimension of the lateral talar tilt as a sign for chronic lateral ankle instability in 32 sportsmen with chronic ankle instability was checked initially. Afterwards the reduction of this instability due to the application of the tape-bandage and the “ankle-brace” was tested under the same standardised conditions. In regard to the reduction of the lateral talar tilt a reduction of this instability of the ankle joint is possible significantly. But compared to the normal talar tilt showing a stable ankle joint, it is not possible to reach this in all cases of ankle instability. So for treatment of the lateral ligament rupture it is necessary to use the usual cast for stabilising the joint after ligament suture before reduction of the time of immobilisation is possible. The use in cases of chronic instability or as a precaution method is not restricted when a sufficient active stabilisation is possible.     

Kinematic changes after fusion and total replacement of the ankle: part 3: Talar movement

INTRODUCTION: The purpose of this study was to determine talar movement (e.g., talar rotation and talar shift during (dorsiflexion/plantarflexion) with respect to the tibia in the normal ankle, in the fused ankle, and in the replaced ankle by currently used prosthetic designs. METHODS: A 6-df device with an axial load of 200 N and a four-camera high-speed video system were used for the measurement of the range of motion in six fresh-frozen cadaveri leg specimens. While moving the foot through the whole range of motion for plantarflexion/dorsiflexion, segmental motion of the marked bones of the foot and shank were measured dynamically. Rotation and medial-lateral shift of the talus were then calculated with regard to flexion position of the foot. RESULTS: In the normal ankle, plantarflexion movement was coupled with talar inversion of 3.5 degrees, and dorsiflexion movement with talar eversion of 1.0 degree, in totally accounting for 4.5 degrees of talar rotation. While both the HINTEGRA and the S.T.A.R. prostheses did not show changes to the normal condition during the dorsiflexion/plantarflexion cycle (p < .05), talar rotation had a 60% decrease (p < .05) for the AGILITY prosthesis. In the normal ankle joint, a lateral talar shift of 1.4 mm was found to occur during dorsiflexion, and a lateral talar shift of 5.2 mm during plantarflexion. In both, the HINTEGRA and S.T.A.R. ankles, talar shift was converted into medial direction during dorsiflexion of the foot (difference to normal: p < .05), whereas talar shift in the lateral direction was found to occur during plantarflexion of the foot which was comparable to the normal ankle. The AGILITY ankle evidenced an 80% decrease of talar shift (p < .05) during the whole dorsiflexion/plantarflexion cycle. DISCUSSION: The two-component ankle (AGILITY) obviously tends to restrict tremendously talar motion within the ankle mortise, whereas the three-component ankles (HINTEGRA, S.T.A.R.) seem to allow talar range of motion comparable to that in the normal ankle. It is suggested that such a restriction of talar motion results in an increase of stress forces within and around the prosthesis, leading to polyethylene wear and potential loosening at the bone-implant interfaces. Therefore, a successful prosthetic design for the ankle should consist of three components that are shaped as anatomically as possible to provide a normal range of motion and to allow the full transmission of movement transfer between foot and shank and unconstrained movement of the talus within the ankle mortise.     

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

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

Technique Tip: Correcting Malalignment of the Talus Using a Pin-Based Distracter During Arthroscopic Ankle Arthrodesis

It is technical demanding work to perform arthroscopic ankle arthrodesis to treat end-stage ankle osteoarthritis with excessive talar tilt. This article aimed to provide an effective technique tip for the treatment of Takakura stage 3b ankle osteoarthritis with a talar tilt angle more than 15 degrees under arthroscopy. A conventional anterior arthroscopic approach is used. After arthroscopic examination and debridement, one pin which is parallel to the distal tibial surface is inserted into the tibial side of the ankle, the other pin which is parallel to the talar dome surface is inserted into the talar side of the ankle, both at the coronal plane. Then a distracter is used in the medial side to open the interspace of the tibiotalar joint and correct the talar tilt through the 2 pins, under which circumstance the tibiotalar joint surface can be well prepared. Next an anti-distracter is used in the lateral side to close the tibiotalar interspace and correct the talar tilt through the 2 pins, in which condition 3 fully threaded cannulated lag screws can be inserted through guide pins in a cross pattern to fix the ankle joint. We used the pin-based distracter to open and close tibiotalar interspace, correct the talar tilt and maintain a good mechanical axis for fusion, and the outcomes were good.     

Experimental instability of the ankle. A radiographic investigation

For determination of the optimal position in examining the ankle joint for anterior drawer sign and talar tilting, 12 legs freshly amputated above the knee were radiographically examined after successive transection of the lateral ankle ligaments in three different sequences. Apparatuses secured the position of the ankle joint in 25 degrees of inward rotation and 10 degrees and 30 degrees, respectively, of plantarflexion. Examination for anterior drawer sign gave significantly greater displacement with the foot in 10 degrees than with the foot in 30 degrees of plantarflexion and was most pronounced after the cutting of the anterior talofibular ligament. Examination for talar tilt gave a non-significantly greater displacement at 10 degrees of plantarflexion, except when cutting both the posterior talofibular and the anterior talofibular ligament. Isolated cutting of the calcaneofibular ligament gave only little displacement irrespective of the method used. Radiographic examination should be performed with 10 degrees of plantarflexion to obtain maximal displacement and 25 degrees of inward rotation of the leg to obtain a free ankle mortise in the anteroposterior projection and concentric arcs of the joint surfaces in the side projection.     

Ankle alignment on lateral radiographs. Part 1: sensitivity of measures to perturbations of ankle positioning

BACKGROUND: In ankles with end-stage osteoarthritis or with total ankle replacement (TAR), radiographic landmarks based on joint surface morphology usually are obscured and inadequate for radiographic measurement. Furthermore, because of difficulty in reproducibly positioning the ankle for a standing radiograph, any radiographic measure to accurately describe ankle alignment must tolerate perturbations of ankle positioning on clinical radiographs. To identify a radiographic measure of anteroposterior tibial-talar alignment that meets those requirements, three methods were compared to determine their sensitivity to perturbations in ankle positioning. METHODS: Ten cadaver ankles had lateral radiographs taken in varying ankle positions in nine prespecified positions in the transverse plane and in seven positions in the sagittal plane. The anteroposterior tibial-talar alignment was quantified by three methods. Sensitivities to changes of ankle position in each plane were then compared. RESULTS: With the tibial-axis-to-talus ratio (T-T ratio: the ratio into which the midlongitudinal axis of the tibial shaft divides the longitudinal talar length), sensitivity to ankle positional changes in either plane was lowest, with errors associated with 10 degrees of ankle malpositioning being 2.2%. The posterior-tibial-line-to-talus ratio (P-T ratio: a similar ratio, but using the posterior longitudinal line of the tibial shaft) showed higher sensitivity in the transverse plane than the T-T ratio, though the associated errors in either plane were nearly comparable. The tibial-axis-to-lateral-process distance (T-L distance: the perpendicular distance from the tibial axis to the tip of the lateral talar process) showed highest sensitivity in both planes. CONCLUSIONS: The T-T ratio tolerated perturbations of ankle positioning best among the tested measures. This measure is potentially applicable to clinical radiographic measurement when determining the anteroposterior tibial-talar alignment in ankles with articular degeneration or TAR. The P-T ratio also appears to have reasonable tolerance.     

Incidence of lateral talar dome lesions in SER IV ankle fractures.

Osteochondral lesions of the talar dome are commonly the result of ankle trauma. While the technique of surgical repair of ankle fractures has been well reported, there are no studies that correlate the presence or absence of talar dome lesions. A possible explanation for this may be lack of intraoperative inspection of the talar articular surface. This retrospective study evaluates the incidence of lateral talar dome lesions in 50 supination-external rotation stage IV ankle fractures. Specifically, operative reports were reviewed for the presence of lateral talar dome lesions documented through intraoperative inspection. Overall, 19 of 50 fractures, or 38%, were found to have a lateral talar dome lesion. While the bimalleolar and deltoid ligament tear type fractures exhibited more talar dome lesions, there was no significant difference between these two fracture types (p = .1111). There was no statistically significant difference among the three types (unimalleolar, bimalleolar, and trimalleolar) of supination-external rotation ankle fractures (p = .0804). The authors conclude that intraoperative inspection of the lateral talar dome should be a routine part of ankle fracture repair.     

The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity

STUDY DESIGN: Retrospective study. Objective: Assess range of motion, posterior talar glide, and residual joint laxity following ankle sprain in a population of athletes who have returned to unrestricted activity. BACKGROUND: Lateral ankle sprains occur frequently in athletic populations and the reinjury rate may be as high as 80%. In an effort to better understand risk factors for reinjury, the sequelae to injury in a sample of college athletes were assessed. METHODS AND MEASURES: Twelve athletes with a history of lateral ankle sprain within the last 6 months and who had returned to sport participation were tested. Only athletes who reported never injuring the contralateral ankle were included. The injured and uninjured ankles of subjects were compared for measures of joint laxity, ankle dorsiflexion range of motion, and posterior talar glide. Friedman's test of rank order was used to analyze the laxity measures and a MANOVA was used to assess the dorsiflexion and posterior talar glide measures. RESULTS: Laxity was significantly greater at the talocrural and subtalar joints of the injured ankles. There were no significant differences in any of the ankle dorsiflexion measurements between injured and uninjured ankles, but posterior talar glide was significantly reduced in injured ankles as compared to uninjured ankles. CONCLUSION: In our sample of subjects, residual ligamentous laxity was commonly found following lateral ankle sprain. Dorsiflexion range of motion was restored in the population studied despite evidence of restricted posterior glide of the talocrural joint. Although restoration of physiological range of motion was achieved, residual joint dysfunction persisted. Further research is warranted to elucidate the role of altered arthrokinematics after lateral ankle sprain.     

Die Arthrodese des oberen Sprunggelenks über den sog. transfibularen Zugang

OBJECTIVE: Bony fusion between tibia and talus in neutral position of foot. Return to a pain-free function of the lower limb. INDICATIONS: Extensive loss of articular cartilage accompanied by a painful and considerably limited motion with or without malalignment. Partial avascular necrosis of talar dome or distal tibial epiphysis. Neuroarthropathy (Charcot joint) with progressive malalignment of ankle. Revision surgery after failed total ankle arthroplasty. CONTRAINDICATIONS: Acute purulent joint infection. Total avascular necrosis of talus. SURGICAL TECHNIQUE: Posterolateral approach to the distal fibula taking care to preserve the periosteal vessels. Fibular osteotomy from proximal lateral to distal medial. Division of the anterior tibiofibular, anterior fibulotibial, and fibulocalcaneal ligaments. Division of posterior tibiofibular ligament. Transverse planar resection of tibial and talar articular surfaces. Freshening of the medial malleolus. Resection of the tip of medial malleolus through a medial incision. Positioning of talus perpendicular to the tibia, paying attention to the valgus of the hindfoot and external rotation. Temporary fixation with Kirschner wires. Radiographic control in two planes followed by fixation with two or three lag screws. Removal of the medial fibular cortex, freshening of the lateral gutter, and fixation of the distal fibular fragments to tibia and talus with cortical screws. RESULTS: 20 arthrodeses in 19 patients were followed up for an average of 39 months (12-69 months). All arthrodeses were fused. In one patient a fibular pseudarthrosis was encountered. All arthrodeses healed in a correct position but one that consolidated with a pes equinus of 3 degrees . The average AOFAS (American Orthopedic Foot and Ankle Society) hindfoot score reached 78.5 points (40-86 points). A marked reduction of symptoms and satisfactory function were reported postoperatively by all patients. All would be willing to undergo surgery again.     

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.     

Die Diagnostik der Bandverletzungen im Bereich des oberen Sprunggelenkes

On the basis of history and clinical findings it is attempted to stage a trauma of the ankle joint according to the genetic classification of Lauge-Hansen. This procedure is understood as a prophylactic measure against overlooking combined ligamentous lesions. Tears of the lateral collateral ligaments of the ankle are proven by stress roentgenograms taken in varus tilt position; they are performed by a specially developed method. Additionally stress roentgenograms are taken, when the talus is moved forwards (“anterior drawer sign”). Lesions of the deltoid ligament are shown by talar tilt in valgus position. Isolated tears of the anterior tibiofibular ligament can be visualized only by arthrography. If stress roentgenograms cannot confirm the clinical diagnosis, an arthrography is necessary.     

Arthroscopic Repair of Anterior Talofibular Ligament Using the Pull-Out Technique for Chronic Ankle Instability: Case Report

Arthroscopic repair of the lateral ankle ligament using the anchor system has been increasingly reported. We treated a 39-year-old woman who suffered from pain and instability in her left ankle joint. She was diagnosed with chronic ankle instability and an osteochondral lesion of the talar dome. For this patient, arthroscopic repair of the anterior talofibular ligament (ATFL) was performed. Standard anteromedial and anterolateral portals were placed, and excision of the osteochondral fragment and microfracture were performed. Then, an accessory anterolateral (AAL) portal was placed. No. 2 nylon sutures were inserted into the ATFL remnant through the AAL portal. Two bone tunnels were created at the footprint of the fibula attachment toward the posterior edge of the lateral malleolus using a passing pin, and nylon sutures anchored in the ATFL were retrieved toward the posterior fibula. The foot was held in neutral position with eversion, and nylon sutures were tied at the posterior fibula. At 1 year after surgery, the Japanese Society for Surgery of the Foot scale was improved from the preoperative value of 48 points to a postoperative value of 100 points. Stress radiography showed no difference of talar tilt angle between the involved and noninvolved ankles. Joint position sense was also improved at 3 and 6 months after surgery. This arthroscopic repair of the ATFL using the pull-out technique enabled achievement of an improved clinical score and stability of the ankle and proprioception, and there was no concern about complications of the anchor system.