Open Evaluation of the Peroneal Tendons Should Be Considered in Patients With Chronic Lateral Ankle Instability Undergoing Ankle Arthroscopy With Lateral Ankle Stabilization

Peroneal tendon pathology is commonly associated with chronic lateral ankle instability. Foot and ankle surgeons often rely on preoperative magnetic resonance imaging (MRI) for identification of related pathology and surgical planning in these patients. The purpose of this study was to assess the ability of preoperative MRI to accurately detect peroneal tendon pathology in patients with chronic lateral ankle instability. Consecutive surgical cases involving arthroscopic evaluation and management of lateral ankle instability sequelae were evaluated retrospectively. Preoperative MRI were compared to intraoperative findings in order to determine the sensitivity, specificity, positive and negative predictive values. Eighty-two patients met inclusion criteria, 58 females and 24 males. The average age at the time of surgery was 46 years (range 13-75). Peroneal tendon pathology was identified intraoperatively in 76 (92.7%) patients and on MRI in 40 (48.8%) patients. The most commonly identified pathologies were tenosynovitis, tendinopathy and longitudinal split/tear, with the peroneus brevis tendon being most commonly involved. MRI was 38.7% specific, 50.0% sensitive, had a positive predictive value of 92.5%, and a negative predictive value of 7.1%. While MRI is a helpful study for evaluation of co-pathologies and surgical planning in patients with lateral ankle instability, procedural selection should not be solely based on MRI results, and the peroneal tendons should be evaluated intraoperatively in patients undergoing arthroscopic procedures for lateral ankle instability.     

Associated injuries found in chronic lateral ankle instability

Sixty-one patients underwent a primary ankle lateral ligament reconstruction for chronic instability between 1989 and 1996. In addition to the ligament reconstruction, all patients had evaluation of the peroneal retinaculum, peroneal tendon inspection by routine opening of the tendon sheath, and ankle joint inspection by arthrotomy. A retrospective review of the clinical history, physical exam, MRI examination, and intraoperative findings was conducted on these 61 patients. The purpose was to determine the type and frequency of associated injuries found at surgery and during the preoperative evaluation. At surgery no patients were found to have isolated lateral ligament injury. Fifteen different associated injuries were noted. The injuries found most often by direct inspection included: peroneal tenosynovitis, 47/61 patients (77%); anterolateral impingement lesion, 41/61 (67%); attenuated peroneal retinaculum, 33/61 (54%); and ankle synovitis, 30/61 (49%). Other less common but significant associated injuries included: intra-articular loose body, 16/61 (26%); peroneus brevis tear, 15/61 (25%); talus osteochondral lesion, 14/61 (23%); medial ankle tendon tenosynovitis, 3/61 (5%). The findings of this study indicate there is a high frequency of associated injuries in patients with chronic lateral ankle instability. Peroneal tendon and retinacular pathology, as well as anterolateral impingement lesions, occur most often. A high index of suspicion for possible associated injuries may result in more consistent outcomes with nonoperative and operative treatment of patients with chronic lateral ankle instability.     

Reliability of MRI Findings of Peroneal Tendinopathy in Patients with Lateral Chronic Ankle Instability

Background

Patients with chronic lateral ankle instability also have peroneal tendinopathy often. However, preoperative MRIs of these patients are vague in many cases. Our study was performed to see the reliability of MRI findings of peroneal tendinopathy in patients with chronic lateral ankle instability.

Methods

MRI images for 82 patients who had chronic lateral ankle instability, and had received surgical treatment between March 2006 and November 2009 were compared with impressions from operating rooms. The mean age of patients was 36.4 years (range, 15 to 64 years), 82 ankles were studied, and patients with rheumatoid diseases were excluded from the study.

Results

Of the 82 cases, 26 were true positives, 38 true negatives, 13 false positives and 5 false negatives. Of 39 cases of peroneal tendinopathy diagnosed from MRI, 14 had peroneal tendon partial tears, 15 tenosynovitis, 3 dislocations, 17 low-lying muscle bellies, and 6 peroneus quartus muscles. Of 31 cases of peroneal tendinopathy observed in surgery 11 had peroneal tendon partial tears, 4 tenosynovitis, 5 dislocations, 12 low-lying muscle belliess, and 1 peroneus quartus muscle. Sensitivity and specificity of peroneal tendinopathy were 83.9% and 74.5%, respectively. Positive predictive value was 66.7%. Negative predictive value was 88.4%. Accuracy rate was 78.0%.

Conclusions

MRI is a useful diagnostic tool for detecting peroneal tendinopathy in patients with chronic lateral ankle instability. However, MRI is vague in many cases. Therefore, a thorough delicate physical examination and careful observation is needed.     

Incidence of Talar Dome Lesions with Concomitant Peroneal Tendon Pathologic Features: A Magnetic Resonance Imaging Evaluation

Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. The purpose of our research was to evaluate the incidence of osteochondral lesions of the talus (OLT) with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (i.e., chondral, osteochondral, subchondral edema, cystic changes), or both. MRI scans were then reviewed to confirm the report findings and findings not identified in the report. A total of 76 patients were identified as having an OLT. Of these 76 patients, 49 had associated peroneal tendon pathologic features. MRI evaluation revealed that 49 (65.3%) of the 76 patients with a talar dome lesion had concomitant peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated in 14.6%. The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, because tears/tendinopathy of both peroneal tendons was present in 18.6%. Tenosynovitis of the brevis and longus were seen in 21.3% of those with an OLT. Our findings suggest the need for an increased level of suspicion for injuries to the lateral ankle ligaments, peroneal tendon complex, and ankle joint when evaluating a patient with ankle instability and chronic pain.     

Is MRI Adequate to Detect Lesions in Patients with Ankle Instability?

Background  

Chondral lesions, peroneal tendon tears, and other disorders in patients with chronic ankle instability may not be detected by preoperative MRI. Also, MRI often is obtained and interpreted at the referring institution, leading to variability in reading.     

Chronic lateral ankle instability and associated conditions: a rationale for treatment

BACKGROUND: Ankle sprains have a high incidence of associated injuries and conditions that may be unrecognized at the initial time of injury. Failure to treat these conditions at the index surgery may compromise outcomes and delay recovery. The purpose of this study was to determine the type and frequency of associated injuries and conditions in military patients with chronic lateral ankle instability. METHODS: Between 1996 and 2002, 160 patients had 180 modified Brostr?m-Gould lateral ankle ligament reconstructions for chronic ankle instability. A retrospective review of the clinical history, physical examination, radiographs, and intraoperative findings was conducted. RESULTS: The overall incidence of associated extra-articular conditions and injuries found in this study was 64%; 115 conditions were identified in 180 ankles. Peroneal tendon injuries occurred with the highest frequency (28%), followed by os trigonum lesions (13%), lateral gutter ossicles (10%), hindfoot varus alignment (8%), anterior tibial spurs (3%), and tarsal coalitions (2%). Twenty revision lateral ankle ligament reconstructions were required for either persistent pain or recurrent instability. The most common associated conditions were undiagnosed hindfoot varus alignment abnormalities (28%) followed by untreated peroneal injuries (25%). CONCLUSIONS: This study confirms the frequency of conditions associated with lateral ankle instability and emphasizes several conditions that have received little attention in the literature. Identifying these associated conditions before surgery enables the surgeon to treat all conditions at one operation, returning the patient to full activity sooner. Guidelines are presented to assist clinicians in screening patients for these associated conditions.     

Predictors of Osteochondral Lesions of the Talus in Patients Undergoing Broström-Gould Ankle Ligament Reconstruction

Chronic ankle instability is associated with intra-articular and extra-articular ankle pathologies, including osteochondral lesions of the talus. Patients with these lesions are at risk for treatment failure for their ankle instability. Identifying these patients is important and helps to guide operative versus nonoperative treatment. There is no literature examining which patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on patients (N = 192) who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging, and operative procedures were documented. Patients with and without a lesion were divided into 2 cohorts. Fifty-three (27.6%) patients had 1 lesion identified on preoperative magnetic resonance imaging. Forty (69.0%) of these lesions were medial, 18 (31.0%) were lateral, and 5 patients had both. Female sex was a negative predictor of a concomitant lesion (p = .013). Patients were less likely to have concomitant peroneal tendinopathy (30.2% vs 48.9%; p = .019) in the presence of a lesion. However, sports participation was a positive predictor of a concomitant lesion (p = .001). The remainder of the variables (age, body mass index, smoking, trauma, duration, contralateral instability, global laxity) did not show a significant difference. In patients who underwent lateral ankle ligament reconstruction, females were less likely to have a lesion than males. Patients with peroneal tendinopathy were less likely to have a lesion compared with patients without. Additionally, athletic participation was a positive predictor of a concomitant lesion.     

Concomitant Lateral Ankle and Peroneal Tendon Instability Treated With Simultaneous Arthroscopic Broström and Tendoscopic Superior Peroneal Retinaculum Repair: A Case Report

Chronic lateral ankle instability is a prevalent condition, and it is commonly associated with other foot and ankle injuries. Among the associated injuries, peroneal tendon pathologies and anterolateral ankle impingement are frequently encountered. In this report, a case of concomitant chronic lateral ankle instability and dislocation of the peroneal tendons is described. While this combination of injuries is not uncommon, the method of treatment entailed arthroscopic repair of the anterior talofibular ligament and endoscopic repair of the superior peroneal retinaculum, procedures that eliminated the anterior drawer instability that had been present, and the patient remained symptom free after 24 months of follow-up.     

Correlation of stress radiographs to injuries associated with lateral ankle instability

BACKGROUND Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability.AIM To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability.METHODS A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings.RESULTS A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology(P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability(P = 0.043).CONCLUSION Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle in-stability.     

Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review

One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for “kinetic outcomes,” "kinematic outcomes,” “Broström procedure,” and “lateral ligament repair.” Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.     

Lateral ankle triad: the triple injury of ankle synovitis, lateral ankle instability, and peroneal tendon tear

Many articles have been published that discuss various lateral ankle injuries and specific lateral ankle pathology. The purpose of this article is to explore and present a specific combination of findings that the author's multiphysician practice has noticed on a frequently recurring basis. The triple injury of ankle synovitis, ankle instability, and peroneal tendon tear can be termed the Lateral Ankle Triad. While it is common to find each of these specific injuries individually, they are often found in combination.     

Peroneal tendon injuries. Report of thirty-eight operated cases

BACKGROUND AND AIMS: Peroneal tendon injuries are probably frequently overlooked causes of lateral ankle pain after distorsion trauma. We report a series of 38 patients with peroneal tendon injuries and outcome after operation. MATERIAL AND METHODS: The mean age of the patients was 30 years (range, 13 to 61). All patients were operated by the same orthopaedic surgeon (SO) and the final outcome was evaluated. RESULTS: Eighty-two per cent of the patients were competitive athletes. There were 11 partial and 3 total ruptures of the peroneus brevis tendon (PBT), 2 partial and 2 total ruptures of the peroneus longus tendon (PLT). Nine cases of subluxations or luxations were treated. There were also 5 cases of chronic peroneal tendinitis or tenosynovitis, 5 cases of peroneal tendon anomalies and 1 ganglion. The peroneal tendon lesion was associated to ankle instability in 19 cases (50%). In ninety percent of the cases the result of the operation was excellent or good. CONCLUSIONS: The lateral ligaments are usually damaged in ankle distorsion injuries, but peroneal tendon lesions are often overlooked and probably more common cause of persistent lateral ankle pain than previously thought. Ruptures and luxations of the peroneal tendons need operative treatment in most cases.     

Peroneal tendon injuries

Peroneal tendon pathology is a common cause of lateral ankle pain. Because of the difficulty of distinguishing peroneal tendon injuries from lateral ligament injuries in the setting of ankle trauma, early diagnosis is often missed. Failure to recognize and adequately treat these injuries can result in significant long-term disability. Focused history and physical examination are critical, as is a thorough understanding of the local anatomy and biomechanics involved. Acute injuries may be successfully treated conservatively; however, chronic injuries have demonstrated unsatisfactory response to conservative measures. When considering surgical management of peroneal tendon injuries, as much information as possible must be gathered through history, clinical exam, and diagnostic studies. The level of injury in correspondence with the myriad of possible etiologic factors dictates the ideal procedure to be performed. Surgery is highly individualized according to the pathology encountered, and to the skill and experience of the surgeon.     

Chronic, recurring ligament instability in the lateral ankle

According to the literature, chronic ankle instability occurs after acute rupture of the lateral ankle ligaments in 10-20% of the cases. The etiology of the instability are ligamentous damage and functional neuromuscular disorder of the peroneal muscles. The standards of diagnostics are the history with the frequency of inversion trauma per period and the interval from the primary trauma, the clinical examination and radiological stress tests. Newer diagnostic methods, up to now not well established in clinical routine, include stabilometry, cybex-measurements of the pronator muscles, the evaluation of peroneal reaction time on a tilting platform and dynamic pedography. Conservative management of chronic ankle instability consists of wearing ankle braces and rehabilitation programs concerned with peroneal muscle strengthening and coordination training. The indication for surgical reconstruction of the ankle ligaments are a well-documented mechanical instability with the neuromuscular reflexes intact and a failed physiotherapeutic training program. The surgical procedure should be selected according to a priority list: 1. anatomical repair, eventually augmented with periosteum from the fibula, 2. Watson-Jones tenodesis, and 3. Chrisman-Snook tenodesis to treat a concomittant subtalar instability.     

Chronic lateral ankle instability: review of anatomy,biomechanics, pathology,diagnosis and treatment

An ankle sprain is the most common injury encountered in athletes. Ten to twenty per cent develop chronic lateral ankle instability despite adequate non-operative treatment. An accurate diagnosis can usually be established by a detailed history, thorough physical examination and stress radiographs. Conservative treatment has a limited role in the management of chronic lateral instability. In the surgical treatment both anatomic and non-anatomic reconstructive procedures have reported excellent to good short-term results. However, longterm results favour the restoration of the normal anatomy and biomechanics by anatomic reconstruction of the lateral ankle ligaments. This review article will consider relevant surgical anatomy and biomechanics of the ankle joint and also address the pathology, diagnosis and various surgical options available for chronic lateral instability.     

关节镜联合韧带缝合治疗外踝不稳的短期疗效

目的随访采用关节镜手术联合小切口辅助下缝合距腓前韧带缝合术式治疗的患者，分析此术式治疗慢性外踝不稳的近期疗效，为进一步推广应用提供依据。 方法回顾性随访自2016年1月至2018年5月，选择保守治疗无效的踝关节机械性不稳患者，排除功能性不稳、足踝部畸形等其他病史的患者。共纳入了西南医院关节外科63例应用关节镜手术联合韧带缝合术治疗慢性外踝不稳的患者。记录围手术期并发症，采用配对t检验分析术前与术后1年以上末次随访的踝关节视觉模拟疼痛(VAS)评分、美国足踝骨科协会踝与后足(AOFAS)评分。 结果患者末次随访较术前踝关节VAS评分、AOFAS评分明显改善，差异有统计学意义(t＝17.8、20.8，两者均P<0.01)。关节镜手术探查发现：合并软组织撞击征47例，撕脱性骨折24例，前踝骨性撞击征11例，距骨软骨损伤8例，关节游离体8例，腓骨肌腱脱位1例。患者术后均无严重并发症。 结论关节镜手术联合韧带缝合术治疗慢性外踝不稳，可以获得较理想的近期疗效。该联合方案，既可以应用关节镜微创术处理踝关节内合并损伤，又可以使用锚钉技术缝合距腓前韧带，具有操作相对简单，并发症低的优势。     

MRI appearance of the lateral fibulotalocalcaneal ligament complex injury in the patients with chronic lateral ankle instability

BackgroundThe anterior talofibular ligament (ATFL) comprises the superior and inferior fascicles. The inferior fascicle is connected to the calcaneofibular ligament, and forms “lateral fibulotalocalcaneal ligament (LFTCL) complex”. This study aimed to evaluate the feasibility of diagnosing LFTCL complex injuries in patients with chronic lateral ankle instability (CLAI).MethodsForty-eight ankles (35 with CLAI and 13 without CLAI) underwent arthroscopic surgery, and preoperative magnetic resonance imaging (MRI) was conducted with 0.8 mm- thick axial and oblique slices. The diagnostic accuracy of injuries to the superior fascicle and LFTCL complex was evaluated by two observers.ResultsThe sensitivity and specificity of the LFTCL complex injury were 94.7% and 92.3% for observer 1 and 84.2% and 84.6% for observer 2, respectively.ConclusionsMRI with 0.8 mm slices could detect LFTCL complex injury in patients with CLAI. Diagnosing the LFTCL complex injury on MRI will improve outcomes of an arthroscopic isolated ATFL repair.     

Idiopathic cavovarus and lateral ankle instability: recognition and treatment implications relating to ankle arthritis

Hindfoot malalignment and chronic lateral ankle instability may lead to degenerative ankle arthritis. We retrospectively analyzed 10 patients with 13 cavovarus feet. None of the patients had underlying neurologic disorders. All patients presented with a history consistent with chronic lateral ankle instability, clinically with cavovarus feet, and radiographically with varying degrees of varus talar tilt and ankle arthritis. Ankles with severe degenerative change were fused. The ankles with mild or moderate change underwent calcaneal osteotomy with lateral ligament reconstruction and/or dorsiflexion osteotomy of the first metatarsal. A quantitative radiographic Coleman block test was utilized to aid in the preoperative planning of the calcaneal and metatarsal osteotomies. All patients had correction of preoperative deformity and resolution of pain and instability. Recognition of the association between cavovarus and chronic ankle instability and degenerative ankle arthritis may be important in developing the appropriate treatment strategy in this patient population.     

Deficiencies of MRI in the diagnosis of chronic symptomatic lateral ankle ligament injuries

BackgroundStress radiography and more recently magnetic resonance imaging have been used to study the integrity of lateral ankle ligaments in chronic symptomatic instability after injury.AimOur aim was to see if magnetic resonance imaging was as good as examination under anaesthesia and stress radiography, for diagnosing injury to the lateral ankle ligaments.MethodologyFifty eight patients, 47 men and 11 women, who were athletes or military personnel, with symptomatic instability of their ankle were included in the study. This cohort of patients had MRI scans, stress radiography and arthroscopy of their ankle. Integrity of the calcaneo-fibular ligament (CFL) was recorded arthroscopically.The sensitivity, specificity, positive and negative predictive value of MRI and stress views, in assessing integrity of the CFL, were compared against arthroscopic findings.ResultsStress radiography under anaesthesia and MRI had sensitivity of 94% and 47% respectively and specificity of 98% and 83% respectively, for diagnosing injury to the CFL. Stress radiography has a higher accuracy in diagnosing CFL injuries as compared to MRI.ConclusionThe results of this study casts doubt on the efficacy of MRI in the diagnosis of serious ankle ligament injuries.     

Magnetic resonance imaging and surgical correlation of peroneus brevis tears

This study reviewed retrospectively preoperative magnetic resonance imaging (MRI) and intraoperative findings of 32 patients who underwent surgical treatment of longstanding peroneus brevis tendon pathology. The purpose of this study was 3-fold: 1) to determine the sensitivity and specificity of MRI diagnosis of peroneus brevis tendon tears as confirmed by surgical findings, 2) to define the prevalence of osseous and soft-tissue pathologies that coexist with peroneus brevis injuries, and 3) to compare the occurrence rates of other associated pathologies found on MRI to that of the surgical findings. MRI diagnosis of a peroneus brevis tendon tear showed 83% sensitivity and 75% specificity to intraoperative findings. Four false positive and 2 false negative cases were identified. Coexisting conditions identified by MRI included a low-lying muscle belly/peroneus quartus (44%), anterior talofibular ligament rupture (50%), flattened/hypertrophy peroneus longus tendon (56%), increased signal intensity within peroneus longus tendon (53%), and a flat/convex fibular groove (78%). These results show that peroneus brevis tears rarely present as isolated injuries and support the need for a comprehensive preoperative clinical evaluation and MRI assessment of the entire lateral ankle complex.