Deltoid Ligament: Functional Analysis of the Medial Collateral Ligamentous Apparatus of the Ankle Joint

On 34 osteoligamentous ankle preparations the function of the various components of the deltoid ligament has been elucidated by tracing mobility patterns after successive transection of the components in varying sequence. The anterior and posterior talofibular ligaments were included in the study to investigate the interaction between these structures and the deltoid ligament. The tibiocalcaneal and the intermediate tibiotalar ligaments control abduction of the talus. The anterior tibiota-lar and talofibular ligaments control plantar flexion, while dorsiflexion is inhibited by the posterior tibiotalar and talofibular ligaments, and partly by the anterior talofibular ligament as well. In combination, the anterior and intermediate tibiotalar ligaments control external rotation, while the intermediate and posterior tibiotalar ligaments control both external and, together with the anterior talofibular ligament, internal rotation of the talus. Isolated, neither the anterior nor the posterior tibiotalar ligament appears to play any major role in ankle stability.     

Radial shortening following a fracture of the proximal radius

Background and purpose The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients.

Patients and methods Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5–12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation.

Results 60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2–4mm) was seen in 22 patients (mean age 48 (19–79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury.

Interpretation The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.     

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.     

Clinical and Social Status Following Injury to the Lateral Ligaments of the Ankle Follow-up of 144 Patients Treated Conservatively

Out of 174 patients treated conservatively for injuries to the lateral ligaments of the ankle 144 were seen at follow-up after 3.1-6.1 years (mean 4.2 years), and clinical as well as social sequelae were recorded. The diagnostic criterion was a difference in talar tilt of 6 or more degrees between the injured and uninjured foot on inversion stress radiographs.

Occupational and athletic injuries, almost equally represented, made up a total of 64 per cent. Residual symptoms were present in 21 per cent, mainly in the form of functional instability, but only four patients (3 per cent) reported daily complaints. One patient had developed reflex dystrophy, and this was the only patient who had been referred for further orthopaedic treatment. There was a close correlation between pain on movement in the ankle joint and residual symptoms which were, incidentally, unrelated to the degree of primary talar tilt. All the patients seen at follow-up had normal range of movement in the talocrural and subtalar joints. Two patients with residual symptoms had stopped working, while in the others the working ability was unaffected.

The period off work had been twice as long for patients having heavy and fairly heavy work as for those doing light work. All football players with residual symptoms had had to give up playing, but only a few had daily complaints. This indicates that some symptom-free patients have in fact latent symptoms, elicited only by fairly severe strain.     

Distal Tibiofibular Ligaments: Analysis of Function

The function of the anterior tibiofibular ligament, of the syndesmosis between the distal parts of the tibia and fibula, and of the posterior tibiofibular ligament was elucidated by tracing mobility patterns before and after successive ligament transection in varying sequence. Eighteen osteoligamentous preparations were studied. Mobility was only minimally influenced by isolated cutting of the anterior tibiofibular ligament, and even complete cutting of the distal tibiofibular ligaments involved only minor abnormality in motion. However, external rotation was greatly increased by further cutting of the anterior part of the deltoid ligament or of the posterior talofibular ligament. This indicates that isolated injury of the anterior tibiofibular ligament must be rare, and total rupture of the distal tibiofibular structures is presumably as a rule combined with lesions of the anterior part of the deltoid ligament and/or of the posterior talofibular ligament.     

Recurrent Instability of the Ankle Joint: Surgical Repair by the Watson-Jones Method

Twenty-one ankle joints with recurrent lateral instability, treated with surgical repair by the Watson-Jones method, were included in a follow-up study 1-5 years after operation. Good results were achieved in 80 per cent. However, the results were not better than those after free dissection and direct suture of the ligamentous ruptures. It is therefore recommended that the more extensive Watson-Jones procedure be reserved for selected cases.     

Evans' Repair of Lateral Instability of the Ankle Joint

A follow-up study is presented of 26 ankle joints with recurrent lateral instability, treated with surgical repair by the Evans method. The median follow-up period was 3.1 (range 1.1-6.9) years. Normal stability was achieved in 73 per cent of the ankles, and another 12 per cent were improved. Similar results are obtained with other methods of surgical repair. Preoperatively 82 per cent of the joints had a positive anterior drawer symptom. This was only found in 12 per cent postoperatively, and these ankles were all classified as having poor results, indicating the importance of reconstruction of the anterior talofibular ligament.     

Radiographic Instability of the Ankle Joint After Evans' Repair

Forty-two unstable ankle joints were treated surgically by Evans' operation. the clinical postoperative results were correlated with the objective radiological stress examinations. the mean age of the patients was 29 years (15-60 years). the clinical and radiological follow-up examinations were performed 6 months after the operation. in the stress X-ray examinations a modified stress frame was used. Clinical instability was noted in four patients. in the radiological examination one patient had a pathological finding in the talar tilt test and 18 patients in the anterior drawer sign test. the radiological instability correlated poorly with the subjective end results. Six patients were estimated to have a poor result of the operation. Five of these patients had a positive anterior drawer sign in the stress X-ray examination and one had degenerative changes in the ankle. Although Evans' repair is a simple and reliable method of reconstructing ruptures of the lateral ligaments of the ankle joint, it is associated with a relatively high frequency of positive anterior subluxation on radiological stress examination. This finding can be explained by the anatomical and geometrical factors on the lateral side of the ankle joint.     

Radiographic Instability of the Ankle Joint After Evans' Repair

Forty-two unstable ankle joints were treated surgically by Evans' operation. the clinical postoperative results were correlated with the objective radiological stress examinations. the mean age of the patients was 29 years (15-60 years). the clinical and radiological follow-up examinations were performed 6 months after the operation. in the stress X-ray examinations a modified stress frame was used. Clinical instability was noted in four patients. in the radiological examination one patient had a pathological finding in the talar tilt test and 18 patients in the anterior drawer sign test. the radiological instability correlated poorly with the subjective end results. Six patients were estimated to have a poor result of the operation. Five of these patients had a positive anterior drawer sign in the stress X-ray examination and one had degenerative changes in the ankle. Although Evans' repair is a simple and reliable method of reconstructing ruptures of the lateral ligaments of the ankle joint, it is associated with a relatively high frequency of positive anterior subluxation on radiological stress examination. This finding can be explained by the anatomical and geometrical factors on the lateral side of the ankle joint.     

Chronic Lateral Instability of the Ankle: Method of Reconstruction Using the Achilles Tendon

Reconstruction of the lateral ankle ligaments ad modum Storen, using the medial one third of the Achilles tendon as a nourished transplant is a relatively unknown procedure. Thirty patients operated on using this technique have been evaluated. the mean observation time was 4 years (range 1/2–16 years). All patients but one had a stable ankle joint and were satisfied. One was reoperated after sustaining a new injury 6 months after the original operation. the method described is a good alternative to other methods of ligamentous reconstruction. the procedure also stabilizes the subtalar joint and corrects recurrent subluxation of the peroneal tendons.     

Chronic Lateral Instability of the Ankle: Method of Reconstruction Using the Achilles Tendon

Reconstruction of the lateral ankle ligaments ad modum Storen, using the medial one third of the Achilles tendon as a nourished transplant is a relatively unknown procedure. Thirty patients operated on using this technique have been evaluated. the mean observation time was 4 years (range 1/2-16 years). All patients but one had a stable ankle joint and were satisfied. One was reoperated after sustaining a new injury 6 months after the original operation. the method described is a good alternative to other methods of ligamentous reconstruction. the procedure also stabilizes the subtalar joint and corrects recurrent subluxation of the peroneal tendons.     

人工LARS韧带在慢性踝关节外侧不稳定中的应用

目的 探讨人工LARS韧带在慢性踝关节外侧不稳定中的应用疗效。方法 回顾性分析北部战区总医院骨科2018年1月至2019年12月收治的30例慢性踝关节外侧不稳病例的临床资料,均为男性,年龄为（23.1±5.3）岁（18~27岁）,左踝19例,右踝11例。由同一位医生采用仰卧位全关节镜下行外踝Y形人工LARS韧带重建术。观察术后2周切口愈合情况,术前及术后12个月内翻应力位距骨倾斜角度。记录术前及末次随访时美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝与后足功能评分系统、踝关节功能Kofoed评分、疼痛视觉模拟量表（visual analogue scale,VAS）评分。术后指导病例行相关康复锻炼。结果 病人随访时间为（12.6±1.7）个月（12~24个月）,全部病例踝关节切口愈合情况佳,无感染等并发症发生,术后恢复满意。AOFAS评分和Kofoed评分分别由术前（42.20±5.98）分、（66.17±3.31）分提升至术后（80.63±5.39）分、（81.60±4.35）分,VAS评分由术前（7.63±0.85）分降至术后（1.03±0.67）分,内翻应力位距骨倾斜角度由术前14.73°±1.46°缩小至术后12个月的2.83°±1.01°,差异均有统计学意义（P＜0.05）。术后各项康复锻炼均达到预期目标。结论 应用人工LARS韧带治疗慢性踝关节外侧不稳疗效满意,具有踝关节稳定性好,快速恢复运动等优点,有效避免下肢深静脉血栓形成及肌肉萎缩,值得在临床上推广。     

Lateral Ligament Reconstruction of the Ankle with a Modified Watson-Jones Operation

A modified Watson-Jones technique, using only half of the peroneus brevis tendon, was applied as an operative procedure for lateral ankle instability. Twenty-nine patients with 30 operated ankles were examined with an average follow-up period of 7 years and 6 months. Functional stability was achieved in all but one of the operated ankles. In 15 cases there were periodic pains and swelling on activity, while the remaining 14 ankles were without symptoms. Supination of the foot was slightly decreased in 4 cases.     

Arthroscopic Grading of Injuries of the Inferior Tibiofibular Syndesmosis

The objective of this study was to describe the technical details of performing a newly developed arthroscopic grading of inferior tibiofibular syndesmosis injuries. Arthroscopy is emerging as the gold standard for evaluating painful, unstable ankles. The inferior tibiofibular syndesmosis contributes substantially to disorders of the ankle. However, no structured grading system exists that would help surgeons evaluate injuries of the syndesmosis. Seventy-eight patients with pain or instability symptoms in the ankle were arthroscopically evaluated for syndesmosis injury. The lesions were graded according to the prospectively developed protocol.More than 61% of the patients had syndesmosis disruptions of various grades affecting the anterior/posterior ligaments or both ligaments. Fourteen patients had anterior ligament disruptions whereas 4 patients had posterior lesions; another 7 patients had both ligaments asymmetrically injured. Eighteen of the 78 patients had symmetric grade 1 lesions, and 5 had grade 2 lesions.More than half of chronic ankle pain cases have syndesmotic lesions. Symmetrical lesions of the anterior and posterior ligaments predominate, followed by isolated anterior ligament disruptions. The proposed grading system for inferior tibiofibular syndesmosis disruptions serves as a guide to systematic documentation of injuries of the syndesmosis.     

Results of Anatomic Lateral Ankle Ligament Reconstruction with Tendon Allograft

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p < 0.01). The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively. The technique described restores mechanical stability in patients with chronic lateral ankle instability and may be considered in a select group of patients.     

Radiological and Muscular Status Following Injury to the Lateral Ligaments of the Ankle Follow-up of 144 Patients Treated Conservatively

An average of 4.2 years after conservative treatment of injury to the lateral ligaments of the ankle 144 patients attended a follow-up examination which included radiography and measurement of the strength of plantar flexion.

The mean age of the patients with osteoarthrosis was twice that for the entire material. Two patients had osteochondritis of the talus.

The strength of plantar flexion was measured in 124 patients. There was significantly less strength in the injured than in the uninjured leg, but there was no statistically significant correlation between residual symptoms and reduced strength or between radiological instability and reduced strength.

Prior to treatment all of the patients had a difference in talar tilt of 6 or more degrees between the injured and uninjured side. At follow-up there was instability in 28 patients, or 19.4 per cent, but no correlation between instability and residual symptoms. Nine patients had an anterior “drawer sign” exceeding 2 mm, but this was also without relation to residual symptoms. Radiological evidence of osteoarthrosis was found in five patients, but four of them had a stable ankle joint and only one had residual symptoms.

According to the results of the present study and a previous one (Hansen et al. 1979) and to the results reported in the literature, we find no reason to alter our present principles regarding the diagnosis and conservative treatment of injury to the lateral ligaments of the ankle.     

Radiological and Muscular Status Following Injury to the Lateral Ligaments of the Ankle Follow-up of 144 Patients Treated Conservatively

An average of 4.2 years after conservative treatment of injury to the lateral ligaments of the ankle 144 patients attended a follow-up examination which included radiography and measurement of the strength of plantar flexion.

The mean age of the patients with osteoarthrosis was twice that for the entire material. Two patients had osteochondritis of the talus.

The strength of plantar flexion was measured in 124 patients. There was significantly less strength in the injured than in the uninjured leg, but there was no statistically significant correlation between residual symptoms and reduced strength or between radiological instability and reduced strength.

Prior to treatment all of the patients had a difference in talar tilt of 6 or more degrees between the injured and uninjured side. At follow-up there was instability in 28 patients, or 19.4 per cent, but no correlation between instability and residual symptoms. Nine patients had an anterior “drawer sign” exceeding 2 mm, but this was also without relation to residual symptoms. Radiological evidence of osteoarthrosis was found in five patients, but four of them had a stable ankle joint and only one had residual symptoms.

According to the results of the present study and a previous one (Hansen et al. 1979) and to the results reported in the literature, we find no reason to alter our present principles regarding the diagnosis and conservative treatment of injury to the lateral ligaments of the ankle.     

Rotational Instability after Anterior Talofibular and Calcaneofibular Ligament Section: The Experimental Basis for the Ankle Pivot Test

The clinical diagnosis of the anterior talofibular ligament (ATFL) rupture is based on the findings from the medical history and the anterior drawer test, a maneuver that allegedly pushes the talus and rearfoot anteriorly, although with great variability in its sensitivity. We consider that an ATFL rupture is best evaluated by a rotational vector (i.e., a pivot test) owing to the uncompromised medial ligaments that will block any pure anterior translation of the talus underneath the tibia. We idealized a constrained ankle cadaver model that only allows talar movements in the axial plane. Our hypothesis was that progressive sectioning of the lateral ankle ligaments in this model would cause a progressive and significant angular laxity in internal rotation. Our results showed 3.67 degrees ± 1.2 degrees of talus rotational laxity in the intact ankle, 9.6 degrees ± 3.2 degrees after ATFL sectioning, and 13.43 degrees ± 3.2 degrees after ATFL and calcaneofibular ligament sectioning, indicating almost threefold increase in internal talocrural rotation after single ATFL sectioning and an almost fourfold increase after double (ATFL and calcaneofibular ligament) sectioning. We consider this evidence of rotational ankle laxity to be a major step in defining the correct movement to diagnose an ATFL rupture and propose a new term to avoid further inconsistencies and variability, “the pivot test.”     

The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures

The treatment of isolated lateral malleolar fractures with deltoid ligament rupture remains controversial. We prospectively analysed 35 patients with isolated lateral malleolar fractures during 2006–2013. Radiography and magnetic resonance imaging (MRI) were performed to assess the degree of reduction, ligament damage, and stability. Internal fixation was performed for all unstable valgus fractures with unacceptable fracture parameters. Fractures with residual valgus instability after fixation underwent anterior deltoid repair. The mean anterior deltoid ligament grade based on MRI was significantly different between the high-grade unstable group and the stable and low-grade unstable groups (p = 0.037 and 0.004, respectively). Postoperative medial clear space measurements were not significantly different between groups. MRI was shown to be a useful tool in the preoperative identification of isolated lateral malleolus fractures prone to valgus instability. In the case of high-grade unstable fractures of the lateral malleolus, repair of the anterior deltoid ligament is adequate for restoring medial stability.