DEFINITION

Ankle sprains are the most common athletic-associated in-jury: They represent up to 40% of all sports-related injuries. The incidence of this inversion type of ankle sprain is around 10,000 people per day.

Literature has cited that about 50% of patients with ankle sprains have some long-term sequelae of their injury. Many of these people develop ankle instability.

Ankle instability can be divided into two categories, functional and mechanical.

Functional instability refers to the subjective feeling of the ankle giving way during activity.

Mechanical instability is the term used when patients show excessive ankle motion, beyond the normal physiologic barriers.

 

 

ANATOMY

 

The lateral ankle is supported by both dynamic and static structures (FIG 1).

 

Static structures include the bony architecture of the joints and the ligaments. This bony configuration contributes about 30% of the stability, whereas the remaining 70% of stability comes from the soft tissues.

 

 

 

FIG 1 • The relative positions of the sural nerve, the lateral branch of the superficial peroneal nerve, and the inferior extensor retinaculum.

 

 

The dynamic structures that aid in the stability of the ankle include the peroneus longus and peroneus brevis tendons. These tendons run posterior to the fibula in the peroneal groove. They are kept in this groove by the superior peroneal retinaculum.

 

Once the tendons pass the distal tip of the fibula, they alter their course and run along the lateral border of the calcaneus, under the inferior peroneal retinaculum, with the peroneus brevis inserting on the base of the fifth metatarsal and the peroneus longus making another turn at the cuboid tunnel and inserting on the first metatarsal.

 

These two tendons act as the primary evertors of the ankle and also participate in plantarflexion of the ankle. As a result of their course and function, they work in a dynamic fashion to provide stability to the ankle and subtalar joints.

 

In addition to the bony configuration of the joint, the static restraints for the lateral aspect of the ankle include the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL).

 

The ATFL is the most frequently injured ligament and the weakest of the three ligaments. It is flat and broad and originates from the anterior border of the lateral malleolus and continues anteromedially to insert on the

talar body, anterior to the articular surface.

 

The CFL originates just inferior to the ATFL on the anterior border of the lateral malleolus and runs deep to the peroneal tendons and in a posterior, inferior, and medial direction to insert on the posterior aspect of the lateral calcaneus.

 

The PTFL is the strongest of this lateral ankle complex and is rarely injured. It originates from the posterior aspect of the fibula, deep to the peroneals, and inserts on the lateral tubercle of the talus, laterally to the flexor hallucis longus groove.

 

With the ankle plantarflexed, the ATFL is taut and becomes vertical, acting as a collateral ligament. In dorsiflexion, the same is true for the CFL.

 

The ATFL has been shown to be the primary restraint to inversion in the ankle.

 

PATHOGENESIS

 

Injury to the lateral ligamentous complex of the ankle is common. These inversion ankle injuries often result in attenuation or rupture to one or more of these ligaments.

 

With the loss of these static restraints, the ankle becomes mechanically unstable, moving past the normal physiologic restraints for the ankle joint (FIG 2).

 

 

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FIG 2 • Position of the elongated ATFL and CFL.

 

NATURAL HISTORY

 

Once injury to the lateral stabilizers of the ankle has occurred, the patient should undergo immobilization followed by progressive rehabilitation.

 

If this approach fails, it is usually related to peroneal weakness, proprioceptive defects, subtalar instability, and mechanical or functional instability.

 

Chronic ankle instability can lead to repetitive inversion in-juries, with the potential for fracture, osteochondral lesions of the talus, peroneal tendon injury and dislocation, and significant posttraumatic arthritis.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients with chronic lateral ankle instability will describe an inversion injury in the past. As a result, they will report that they have problems with consistent repetitive ankle sprains, a feeling of looseness in the ankle with or without pain.

 

The physician should inquire whether the patient is experiencing pain between intervals of repetitive injury. This would point toward the possibility of a secondary problem from instability (ie, osteochondritis dissecans, impingement lesion, synovitis).

 

The examination for chronic lateral ankle instability includes evaluation of the joint above (knee) and below (subtalar). Assessment should include overall alignment, range of motion, point of maximal tenderness, anterior drawer testing, evaluation of the peroneal tendons for pathology, ankle proprioception, and evaluation for associated injuries.

 

Alignment should be evaluated for both the overall lower limb and the hindfoot. Patients with hindfoot varus alignment are predisposed to ankle inversion injuries and instability. The alignment is assessed in both the seated and standing positions. The flexibility of the hindfoot should be checked.

 

Patients whose malalignment cannot be corrected with orthoses should have the alignment addressed at the time of operative ligament repair.

 

Tibiotalar as well as subtalar joint motion should be evaluated. Ankle motion has been described as ranging from 13 to 33 degrees of dorsiflexion and 23 to 56 degrees of plantarflexion.

 

 

The variability is dependent on the operator and the mode of measurement.

 

Accepted values for functional range of motion are 10 degrees of dorsiflexion and 25 degrees of plantarflexion.

 

Range-of-motion testing can always be compared to the uninjured side for comparison.

 

Subtalar motion occurs about an oblique axis running from the medial side of the talar neck to the posterolateral wall of the calcaneus. Total motion for inversion and eversion is an arc of 20 degrees, but this is extremely difficult to assess accurately. The predominance of this motion is inversion.

 

The anterior drawer test is designed to test the competency of the ATFL.

 

 

The test is performed with the patient seated and the knee flexed to 90 degrees. The tibia is stabilized with one hand while the ankle rests in relaxed plantarflexion. The contralateral hand is used to draw the talus anteriorly.

 

If the medial restraints are intact, then the movement has a rotatory component. Increased talar displacement when compared to the contralateral limb indicates a positive test. In addition, excessive motion alone can signify incompetency of the ATFL.

 

Most resources cite an absolute value of 10 mm for a positive test. A firm end point should also be noted when testing for ATFL competency.

 

Proper examination of the ankle for chronic instability includes the evaluation of the peroneal tendons. These tendons can easily be injured at the time of the varus stress that tears the ATFL as well as with the recurrent instability that follows.

 

 

Evaluation for swelling in the retrofibular space is performed.

 

 

Simple palpation of the tendons (for tenderness) and strength testing are mandatory. Peroneal weakness mandates a search for peroneal pathology.

 

The peroneal compression test can be helpful as well. The patient should be examined in a dynamic way to elicit peroneal subluxation or dislocation if it is present.

 

Proprioception testing is an essential part of evaluating chronic ankle instability. Defects in proprioception

following ankle sprains are well documented in the literature.

 

 

The modified Romberg test or stabilimetry is the best way to assess proprioception. A modified Romberg test is performed by having the patient stand first on the uninjured limb, with eyes open and then closed; this is then repeated on the injured side.

 

The difference in balance is related to the proprioception pathways of each limb.

 

The limitation of this test is that, to be accurate, there should be a full range of motion of the ankle and the subtalar joint and no pain with full weight bearing.

 

The advantage of the Romberg test is that it requires no special equipment.

 

Stabilimetry measures postural equilibrium and correlates with functional instability, but data generated on total sway in the vertical and horizontal planes require a force plate and computer analysis.

 

 

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Finally, the examiner must rule out other possibilities on the differential diagnosis and determine whether there is more than one source of pathology.

 

 

Point tenderness in the area of the fifth metatarsal base, the anterior calcaneal process, and the lateral talar process could represent fracture.

 

Full evaluation of the ankle joint for loose bodies, osteochondritis dissecans lesions, and impingement lesions should be performed.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

The use of imaging in the patient with the symptoms of ankle instability should begin with three plain radiographic views of the ankle.

 

 

These films should be evaluated for fractures of the fifth metatarsal, lateral talar process and anterior process of the calcaneus, as well as fractures to the malleoli.

 

In addition, the examiner should be looking for exostoses of the tibia and talus, osteochondral lesions of the talus, and tarsal coalitions.

 

Stress radiography can be used to evaluate anterior talar translation and talar tilt. A standardized apparatus would improve reliability and consistency in this measure. The use of the contralateral limb as a control should be included when using this measure for a surgical indication.

 

Further studies to evaluate the lateral aspect of the ankle include the use of magnetic resonance imaging (MRI). MRI can delineate peroneal tendon pathology as well as provide needed information about osteochondral lesions of the talus (FIG 3).

 

DIFFERENTIAL DIAGNOSIS

Bone

Anterior process of calcaneus fracture Lateral posterior talar process fracture Lateral malleolus fracture

Base of fifth metatarsal fracture Tibiotalar bony impingement

 

 

 

Tarsal coalition Cartilage

 

 

Osteochondral lesions of talus or tibia Subtalar cartilage flap tear

 

 

 

FIG 3 • MRI with torn ATFL.

 

 

Ligamentous

 

 

 

Functional lateral ankle instability Mechanical lateral ankle instability Subtalar instability

 

 

Syndesmosis injury Neural

 

Neurapraxia of the superficial peroneal nerve

 

 

Neurapraxia of the sural nerve, reflex sympathetic dystrophy Tendons

 

 

 

Peroneus brevis tendon tear Peroneus longus tendon tear Painful os peroneum syndrome

Peroneal subluxation or dislocation

Soft tissue

Anterolateral ankle impingement lesion Sinus tarsi syndrome

 

 

NONOPERATIVE MANAGEMENT

 

 

Nonsurgical treatment of lateral ankle instability begins with restricted activity and physical therapy. Physical therapy should focus on stretching, proprioception, and peroneal tendon strengthening.

 

In addition, braces and shoe wear modification can be used. The use of a lateral heel wedge, a flared sole, and a reinforced counter can assist patients with instability.

 

External stabilization of the ankle joint with taping or wrap dressings can provide some stabilization. Studies have shown superior initial resistance to inversion with taping, but taping has been shown to lose 50% of this initial effectiveness after 10 minutes of exercise.

 

As a result, the use of over-the-counter reusable braces is recommended for nonoperative stabilization of the ankle joint. A University of California Berkeley orthosis, an ankle-foot orthosis (AFO), or a hinged AFO may also be used to help patients avoid surgery.

 

In more sedentary patients, these modalities may provide adequate treatment, but for most athletes, they are unacceptable for long-term care.

 

SURGICAL MANAGEMENT

 

Surgery for chronic ankle instability is indicated following a trial of failed nonoperative management.

 

Patients with persistent, symptomatic mechanical instability will benefit from ligament reconstruction. This is often the case for athletes as well as patients who cannot tolerate bracing on a long-term basis.

 

Relative contraindications for surgery include pain with no instability, peripheral vascular disease, peripheral neuropathy, and inability to comply with postoperative restrictions.

 

Many procedures have been described for the management of ankle instability. They can be subdivided into anatomic and nonanatomic reconstruction techniques.

 

The authors' choice for lateral ankle ligament reconstruction is influenced and based on the patient's body habitus, activity pattern, and physical demands.

 

In patients with the need for full ankle range of motion, such as dancers, an anatomic procedure is recommended.

 

In patients who are obese, are at risk for repetitive external varus stresses, have connective tissue disorders (Ehlers-Danlos),

 

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or are undergoing revision surgery, a nonanatomic reconstruction such as the Chrisman-Snook is preferred.

 

In patients with attenuated tissue, the advent of bioengineered tissue has allowed us to augment the anatomic repair.

 

Arthroscopy of the ankle is indicated for patients who have osteochondral lesions of the talus, tibial and talar exostoses, and anterior impingement lesions. We have had excellent results in treating chronic lateral ankle instability with arthroscopic techniques.

 

Radiofrequency to provide thermal energy to the ATFL has been used with moderate success to treat patients who require arthroscopy, with the benefits best realized in the functionally unstable ankle.

 

Preoperative Planning

 

 

Preoperative planning in the case of chronic ankle instability is based on the cause of the instability. Patients should be thoroughly evaluated for the possibility of a tarsal coalition.

 

Hindfoot alignment should be addressed. Patients with a varus hindfoot are predisposed to suffer inversion injuries and the possibility of a Dwyer calcaneal osteotomy in addition to the ligament repair should be considered.

 

The presence of intra-articular pathology should also be addressed. Patients with clear pathology should have this addressed at the time of surgery.

 

Peroneal tendon injuries often accompany ankle instability and should be evaluated and treated at this setting.

 

Positioning

 

Positioning patients for lateral ankle ligament repair and reconstruction should be based on the chosen procedure.

 

For anatomic ligament repair, we prefer to place the patient in the lateral decubitus position. This allows direct access to the lateral aspect of the ankle and the ability to address peroneal pathology and perform a calcaneal osteotomy if necessary.

 

Patients who are undergoing arthroscopy should be placed in the supine position. If the surgeon then chooses open ligament repair techniques, a bump can be placed under the ipsilateral hip after the arthroscopic portion of the surgery is complete.

 

Approach

 

The incision for the Brostrom-Gould procedure was originally described as a J-shaped incision, just anterior to the fibula (FIG 4A). This allows easy exposure to the anterolateral capsule and ATFL and CFL.

 

An alternative to the J incision is a posterior curvilinear incision that allows the surgeon to repair the peroneal tendons and repair the lateral ligament complex (FIG 4B). We prefer this curvilinear incision.

 

 

 

FIG 4 • A. Anterior J incision. B. Posterior curvilinear incision.

 

TECHNIQUES

• Modified Brostrom Anatomic Lateral Ligament Reconstruction

In 1966, Brostrom reported a series of 60 patients on whom he performed a direct lateral repair of the

lateral ligaments of the ankle.4 The ligaments of the ATFL and the CFL were found to be disrupted but present, and the torn ends were shortened and repaired directly by midsubstance suturing.

In 1980, Gould modified this procedure by advancing the lateral aspect of the inferior extensor retinaculum to the fibula, reinforcing the repair of the ATFL.

In addition to reinforcement, the modification limits subtalar instability and provides a checkrein to inversion.

In this technique, the patient is placed in the lateral decubitus position. All bony prominences are padded and an axillary roll is placed to protect the upper extremity. A well-padded thigh tourniquet is placed.

 

 

The choice of an anterior incision or a posterior incision is up to the surgeon.

 

The curvilinear incision (see FIG 4B) extends from 4 to 5 cm proximal to the tip of the fibula and follows the course of the peroneal tendons.

 

 

 

Distally, carry the incision toward the base of the fifth metatarsal. Take care to avoid the superficial peroneal and the sural nerves. Take dissection down to the level of the fibular periosteum.

 

Mobilize the flaps anteriorly and posteriorly.

 

Identify the anterolateral capsule, the peroneal tendons, and the inferior extensor retinaculum.

 

The peroneal sheath can be opened proximally and distally, allowing preservation of the superior peroneal retinaculum. Peroneal tendon pathology can then be addressed.

 

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Make the anterior J-shaped incision along the anterior and distal aspects of the fibula. The incision begins at the level of the ankle joint and stops at the peroneal tendons.

 

Carry dissection down to the anterolateral joint capsule, just anterior to the fibula. Take care to avoid any branch of the superficial peroneal nerve.

 

In the distal aspect of either incision, identify the inferior extensor retinaculum and mobilize it for later Gould modification. A tag suture can be placed to help retract this tissue during the anatomic repair.

 

Identify the lateral gutter of the ankle joint and divide the capsule. Leave a cuff of tissue on the fibula to allow for advancement and imbrication of this tissue.

 

Carry the arthrotomy from the level of the tibiotalar joint to the peroneal tendons (TECH FIG 1A). Care to protect these tendons during this part of the procedure is paramount.

 

 

 

TECH FIG 1 • A. Arthrotomy. B. Suturing ATFL with pants-over-vest stitch. C. After suturing the CFL and ATFL, the ankle is ready for inferior extensor retinaculum translocation. D. Suturing of the inferior extensor retinaculum to the anterior aspect of the fibula.

 

 

This arthrotomy will divide both the ATFL and the CFL in their midsubstance. At this time, the surgeon can evaluate the tibiotalar joint.

 

Resect scar tissue; up to 5 mm of tissue can be excised.

 

Imbricate the ligaments in a pants-over-vest fashion with 0 Vicryl stitches (TECH FIG 1B-D).

 

Place the sutures but do not tie them until the ankle is held in dorsiflexion and eversion. Be sure to prevent anterior subluxation of the talus at this time.

 

After the repair, take the ankle through a range of motion to ensure that the sutures hold.

 

Once repair of the arthrotomy has been performed, advance the extensor retinaculum and secure it to the periosteum of the fibula, covering the ligament and capsular repair.

 

Perform irrigation and then subcutaneous and skin closure.

 

Apply a dressing and splint, placing the ankle in a slightly everted position.

• Modified Brostrom Anatomic Lateral Ligament Reconstruction with Bioengineered Tissue Augmentation

   

  In patients who have suffered from chronic lateral ankle instability with repeated inversion injuries, often, the tissue at the time of surgery is attenuated and of poor quality. In the past, this might have caused failure of the anatomic repair or caused the surgeon to consider using an autologous tendon

  augmentation.

   

  With the growing orthobiologic market, we have found that these bioengineered tissue augments can provide the surgeon with another option in the case of poor tissue quality, without the morbidity of autogenous tendon harvest.

   

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  The approach is the same as for the standard modified Brostrom repair.

   

  After performing the arthrotomy, select the preferred tissue graft and prepare it as recommended by the manufacturer.

   

  Secure the graft distally to the capsule with 0 Vicryl suture.

   

  After attaching the graft to the distal aspect of the capsule, perform the standard Brostrom repair.

   

  After tying the sutures through the ATFL and CFL, but before taking the ankle through a range of motion, tension the tissue implant to the fibula through bone tunnels, bone anchors, or suture to the periosteum, with the foot in an everted position.

   

   

   

  TECH FIG 2 • A,B. Tensioning collagen tissue to fibula.

   

   

  Tension the implant to ensure there is no redundancy (TECH FIG 2).

   

  Reef the inferior extensor retinaculum over the implant as well as the anatomic repair and secure it to the fibula.

   

  Close the subcutaneous tissue and skin and apply a splint in slight eversion.

• Thermal Capsular Modification for the Treatment of Chronic Lateral Ankle Instability

   

  The presence of intra-articular pathology after chronic lateral ankle instability is well documented. The need to address this pathology as well as the lateral ligament instability inspired us to develop an arthroscopic protocol to address both at the same time.

   

  The patient is placed supine on the operating table.

   

  A well-padded tourniquet is placed on the upper thigh of the operative leg.

   

  The operative extremity is then placed into a thigh-knee holder. The holder is padded to ensure there is no pressure on the peroneal nerve and the popliteal space.

   

  The operative extremity then undergoes sterile preparation and draping.

   

  A noninvasive ankle distractor strap is applied and the ankle is distracted.

   

  Introduce a spinal needle into the ankle joint through the area of the standard anteromedial portal and insufflate the joint with 1% lidocaine with epinephrine. This distends the joint and aids in preventing the need for tourniquet use.

   

   

  Incise only the skin and carry blunt dissection down to the capsule. Use a blunt trocar for a 3.5-mm arthroscope.

   

  Introduce the arthroscope into the joint and visualize the articular cartilage.

   

  Once you have confirmed the arthroscope placement, inflow is started to prevent extracapsular extravasation.

   

  The area of the anterolateral portal is transilluminated, and the surgeon can avoid the dorsal veins of the ankle as well as the branches of the superficial peroneal nerve.

   

  Use a spinal needle to confirm ankle portal placement and make the skin incision. Again, carry blunt dissection down to the capsule and penetrate the capsule with a blunt trocar.

   

  Perform a standard 21-point arthroscopic examination. Note any intra-articular pathology (synovitis, osteochondral defects, impingement lesions) and treat it accordingly.

   

  In this procedure, we have found that aggressive treatment of the anterolateral impingement lesion is necessary to allow improved visualization of the anterolateral gutter and the ATFL (TECH FIG 3A).

   

  After treating the intra-articular pathology, introduce the probe for thermal energy delivery.

   

  Once the wand is in the joint and placed in the posterior recess of the lateral gutter, remove the distraction device from the foot (TECH FIG 3B).

   

  This is necessary to allow for contraction of the tissues when the thermal energy is delivered.

   

  Use a painting technique, starting in the area of the CFL and working anteriorly.

   

  Deliver the treatment only below the “equator” of the lateral ankle portal so as not to cause an impingement lesion (TECH FIG 3C).

   

  Avoid repetitive painting of any one area to prevent injury.

   

  After adequate exposure to the thermal effects, remove the probe, close the portals, and apply a dressing.

   

  The patient is placed into a well-padded splint in slight dorsiflexion and eversion.

   

   

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  TECH FIG 3 • A. Arthroscopic visualization of ATFL (arrow). B. View after lateral gutter débridement and débridement of impingement lesion and beginning thermal capsulorrhaphy. C. View as tissue responds to thermal capsulorrhaphy.

• All-Inside Arthroscopic Anatomic Repair for Lateral Ankle Instability

 

Recently, an all-inside arthroscopic technique for anatomic repair of lateral ankle instability has been developed.9

 

It is well documented the intra-articular pathology associated with chronic lateral ankle instability, and the all-inside arthroscopic technique allows the advantage of both pathologies to be addressed with the same technique.

 

The patient is placed supine on the operating table.

 

 

 

TECH FIG 4 • A. Accessory anterolateral portal. B. The limbs of the suture are passed through the loop suture. By pulling the suture limbs, the loop is introduced into the joint and the ligament is grasped by the suture.

 

 

 

A well-padded thigh tourniquet is placed on the upper thigh of the operative leg. The affected extremity is placed on a thigh holder located under the knee.

 

The operative extremity then undergoes sterile preparation and draping.

 

Distraction of the ankle is not used during the arthroscopic procedure.

 

The described procedure requires three portals, with the accessory portal made just anterior to the fibula at 0.5 to 1 cm proximal from the tip of the distal fibula (TECH FIG 4A).

 

A standard arthroscopic examination is performed, noting for any intra-articular pathology (osteochondral lesions, bone, and soft tissue impingement) and treated accordingly.

 

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The footprint for the fibular attachment of the lateral collateral ligaments is débrided with a shaver introduced through the anterolateral portal.

 

Suture passer is introduced through the anterolateral portal and the ligament is penetrated from lateral to medial.

 

 

The Nitinol loop wire is pulled out through the accessory portal using an arthroscopic grasper. Suture is passed through the loop and pulled back through the accessory portal.

 

It is recommended to pass a double suture through the ligament to prevent ligament tearing when the suture is tensioned.

 

Two limbs of the suture are in the accessory portal, whereas the loop of the suture is in the anterolateral portal.

 

The two limbs are then pulled through the accessory portal and passed through the anterolateral portal.

 

The two suture limbs are then passed through the loop suture.

 

Pulling the two limbs will introduce the loop into the joint and the ligament is captured by the suture (TECH FIG 4B).

 

The location for the suture anchor is on the distal portion of the lateral malleolus along its anterior aspect about 1.5 cm proximal to the fibula tip for the ATFL.

 

For native ATFL location, the anchor must be placed on the fibular attachment of the anteroinferior tibiofibular ligament insertion or just distal to it.

 

 

The drill is directed from anterior to posterior on the distal fibula parallel to the plane of the lateral gutter. The bone anchor with suture is then passed through the portal.

 

Tension the sutures prior to impacting the anchor into bone.

 

The ATFL is then reattached with the ankle in dorsiflexion and valgus.

 

The same technique is used for CFL disruption or insufficiency with a few exceptions:

 

The drill guide is introduced through the accessory portal and placed 0.5 cm proximal to the tip of the lateral malleolus.

 

The drill is aimed from distal to proximal and anterior to posterior.

 

After repair, close the portals and apply a compressive dressing followed by a posterior plaster splint with the ankle in neutral position.

 

PEARLS AND PITFALLS
		Negative anterior drawer test with history consistent with instability	Beware the restraint of anterior tibial osteophytes. They can cause an abnormally negative drawer test despite a clinical picture of instability.

 

	Failed primary Brostrom ▪ Be sure to evaluate hindfoot anatomy. If the hindfoot is in varus, procedure combine lateral closing wedge and lateral slide osteotomy with a revision procedure.     Patient activity level ▪ Larger patients (>115 kg) and high-demand patients (football players) may require augmentation to the simple Brostrom-Gould procedure.     Anterolateral ankle joint ▪ An ankle impingement lesion can act as a primary pain generator. pain, no chronic instability pattern, history of previous ankle sprain     Global pain in lateral ▪ Look carefully for secondary pathology. Recurrent instability can ankle region result in osteochondritis dissecans of the talus, subluxing or dislocating peroneal tendons, subtalar instability, and other intra-articular lesions of the ankle.

 

 

POSTOPERATIVE CARE

 

Postoperatively, the patient course is divided into 3-week increments.

 

 

The first 3 weeks is non-weight bearing in a cast, the second 3 weeks is weight bearing to tolerance in a cast, and the third 3 weeks is weight bearing in a boot walker.

 

At the 9-week mark, the patient is weaned into an ankle stirrup brace and placed into a physical therapy program to begin range of motion, strengthening, and proprioceptive training.

 

Patients are then progressed as tolerated until physical therapy goals are met.

 

Patients are allowed to discontinue the brace for daily activities but are asked to brace in situations at risk for 1 year after reconstruction.

 

OUTCOMES

The clinical and functional outcome from anatomic repair for chronic lateral ankle instability is good.2

In 1988, Karlsson et al6 reported on 152 ankles with a follow-up of 6 years. Good to excellent results were found in 87% of patients. In this study, 86% of athletes reported no deterioration in function.

Predictors of poor outcome included more than 10 years of instability, generalized ligamentous laxity, and osteoarthritis of the ankle.

A prospective outcome comparison study of the Chrisman-Snook and modified Brostrom procedure by

Hennrikus et al5 demonstrated that both operations provided good or excellent stability in more than 80% of patients, but the Brostrom procedure resulted in higher Sefton scores and a statistically significant decrease in complications when compared to the Chrisman-Snook.

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Recently, a case series on 31 patients by Bell et al1 showed 91% good or excellent results 26 years after undergoing the Brostrom procedure.

Outcome assessment for thermal-assisted capsular modification for ankle instability has shown promise.3 The senior author has pioneered the use of this technology for the treatment of ankle instability.

Initial early-term follow-up studies show clear improvement in patients, with an average increase in

AOFAS hindfoot scores of greater than 25 points.

We have previously reported on 16 patients with average follow-up of 14.5 months. Good to excellent results were achieved by 80% of the patients.

Subsequent publications and presentations have mirrored these results.

 

Maiotti et al7 reported on 22 patients with 32 months of follow-up. Nineteen of these 22 patients had good to excellent results and 21 of 22 returned to sporting activity.

A few years later, Nery et al8 reported on 38 patients who underwent combined open and arthroscopic Brostrom-Gould procedures with a 9.8-year follow-up. No significantly different outcomes were found in patients who had undergone microfractures. Postoperative AOFAS scores were graded as excellent and good in 94.7% of patients.

Most recently, Vega et al9 reported on 13 patients with 22 months of follow-up after an all-inside arthroscopic repair technique for lateral ankle instability. The mean AOFAS score increased from 67 preoperatively to 97 at final follow-up.

 

COMPLICATIONS

The most common complications after repair of the lateral ligament complex are nerve related. The incidence of nerve complaints after surgery ranges from 7% to 19%.

In addition to nerve complications, wound complications and infection, stiffness, and deep venous thrombosis have been reported. These complications are of course present with all surgeries.

The possibility of recurrent instability is also a possible complication of surgery. This is most often a result of inadequate rehabilitation but can also result if the patient is not appropriately evaluated for hindfoot varus or connective tissue disease.

 

 

REFERENCES

1. Bell SJ, Mologne TS, Sitler DF, et al. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med 2006;34:975-978.

    

    

2. Berlet GC, Anderson RB, Davis WH. Chronic lateral ankle instability. Foot Ankle Clin North Am 1999;4:713-728.

    

    

3. Berlet GC, Saar WE, Ryan A, et al. Thermal-assisted capsular modification for functional ankle instability. Foot Ankle Clin 2002;7: 567-576.

    

    

4. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand

   1966;132:551-556.

    

    

5. Hennrikus WL, Mapes RC, Lyons PM, et al. Outcomes of the Chrisman-Snook and modified-Broström procedures for chronic lateral ankle instability. A prospective, randomized comparison. Am J Sports Med 1996; 24:400-404.

    

    

6. Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am 1988;70(4):581-588.

    

    

7. Maiotti M, Massoni C, Tarantino U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy 2005;21:751-757.

    

    

8. Nery C, Raduan F, Del Buono A, et al. Arthroscopic-assisted Brostrom-Gould for chronic ankle instability. Am J Sports Med 2011;39: 2381-2388.

    

    

9. Vega J, Golanó P, Pellegrino A, et al. All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int 2013;34:1701-1709.