Consensus In Chronic Ankle Instability OTSR CAI 20131

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Orthopaedics

&

Traumatology:

Surgery

&

Research

(2013)

99S,

S411—S419

Available

online

at

ScienceDirect

www.sciencedirect.com

REVIEW

ARTICLE

Consensus

in

chronic

ankle

instability:

Aetiology,

assessment,

surgical

indications

and

place

for

arthroscopy

S.

Guilloa,

T.

Bauerb,∗,

J.W.

Leec,

M.

Takao d,

S.W.

Konge,

J.W.

Stonef,

P.G.

Mangoneg,

A.

Molloyh,

A.

Pererai,

C.J.

Pearce j,

F.

Michelsk,

Y.

Tournél,

A.

Ghorbanim,

J.

Caldern

aClinique

du

Sport,

33300

Mérignac,

France

bDepartment

of

Orthopaedic

surgery,

Ambroise

Paré

Hospital,

92100

Boulogne

Billancourt,

France

cYonsei

University

College

of

Medicine,

Yonsei-ro

50,

Seodaemoon-gu,

120-752

Seoul,

South

Korea

dDepartment

of

Orthopaedic

Surgery

Teikyo

University

School

of

Medicine

2-11-1

Kaga,

Itabashi,

173-8605

Tokyo,

Japan

eFoot

and

Ankle

Surgery

Specialist

in

Orthopaedic

and

Traumatology,

Asia

Medical

Specialists,

Asia

fMedical

College

of

Wisconsin

Milwaukee,

WI

USA

gBlue

Ridge

Bone

and

Joint

ClinicAsheville,

NC

28801

Director,

Foot

and

Ankle,

Orthopaedic

Surgery

Service

Line,

Mission

Hospital,

Asheville,

NC

28801

hUniversity

Hospital

Aintree,

Lower

Lane

Liverpool

L9

7AL

UK

iUniversity

Hospital

of

Wales,

Cardiff

UK.

Spire

Cardiff

Hospital

and

London

Foot

and

Ankle

Centre

jJurong

Healthcare,

Alexandra

Hospital

Singapore

159964

kOrthopaedic

Department

AZ

Groeninge

Burg,

Vercruysselaan

5,

8500

Kortrijk,

Belgium

l15,

rue

de

la

République,

38000

Grenoble,

France

mClinique

Médipole

Garonne,

45,

rue

de

Gironis,

31036

Toulouse,

France

nChelsea

&

Westminster

Hospital,

369

Fulham

Road,

London

SW10

9NH,

UK

The

Fortius

Clinic,

17

Fitzhardinge

St,

London

W1H

6EQ,

UK

Accepted:

9

October

2013

KEYWORDS

Ankle

sprain;

Ankle

instability;

Lateral

ligament

injury;

Anterior

talo-fibula

ligament;

Ankle

arthroscopy

Summary

Ankle

sprains

are

the

most

common

injuries

sustained

during

sports

activities.

Most

ankle

sprains

recover

fully

with

non-operative

treatment

but

20—30%

develop

chronic

ankle

instability.

Predicting

which

patients

who

sustain

an

ankle

sprain

will

develop

instability

is

difficult.

This

paper

summarises

a

consensus

on

identifying

which

patients

may

require

surgery,

the

optimal

surgical

intervention

along

with

treatment

of

concomitant

pathology

given

the

evidence

available

today.

It

also

discusses

the

role

of

arthroscopic

treatment

and

the

anatomical

basis

for

individual

procedures.

Proof

of

evidence:

4.

©

2013

Published

by

Elsevier

Masson

SAS.

∗Corresponding

author.

E-mail

address:

th.bauer@orange.fr

(T.

Bauer).

1877-0568/$

–

see

front

matter

©

2013

Published

by

Elsevier

Masson

SAS.

http://dx.doi.org/10.1016/j.otsr.2013.10.009

S412

S.

Guillo

et

al.

Aetiology

of

chronic

ankle

instability

The

main

predisposing

factor

for

the

development

of

chronic

ankle

instability

(CAI)

is

the

history

of

at

least

one

previous

lateral

ankle

sprain

[1—3].

There

is

no

correlation

between

the

severity

of

the

initial

sprain

as

judged

at

the

time

of

injury

and

the

frequency

of

residual

instability

[2].

The

risk

of

developing

CAI

is

as

great

after

a

single

severe

ankle

sprain

as

after

one

or

multiple

minor

sprains.

Thus,

there

are

other

factors

contributing

to

the

development

of

CAI.

It

is

estimated

that

as

many

as

55%

of

patients

who

sus-

tain

an

ankle

sprain

do

not

seek

evaluation

or

treatment

from

a

healthcare

professional

[4].

The

absence

of

treat-

ment

after

an

ankle

sprain

predisposes

to

residual

symptoms

including

CAI

[5].

With

respect

to

giving-way

and

return

to

sport,

improved

stability

with

faster

recovery

was

noted

after

surgical

treatment

for

acute

ankle

sprain

compared

to

non-operative

treatment.

However,

the

advantages

of

this

operative

treatment

should

be

balanced

with

the

risk

of

complications

and

the

costs

[6—8].

Functional

treatment

after

acute

ankle

sprain

(with

early

proprioceptive

rehabili-

tation)

enables

better

results

and

faster

recovery

compared

to

immobilization

[9—12].

However,

there

are

still

contro-

versies

concerning

the

exact

role

of

rehabilitation

on

the

prevention

of

ankle

sprain

recurrence

[13].

Mechanical

instability

is

due

to

the

laxity

caused

by

ligaments

tears.

Functional

instability

is

due

to

propriocep-

tive

and

muscular

deficits

after

ankle

sprain

[14,15].

Both

mechanical

and

functional

instabilities

may

be

difficult

to

assess

or

distinguish

and

they

most

often

occur

as

a

combi-

nation

in

the

development

of

CAI.

The

level

of

activity

is

a

very

important

extrinsic

factor

influencing

the

impact

of

CAI

in

the

daily

life.

The

assess-

ment

of

activity

level

for

each

patient

is

useful

not

only

to

differentiate

patients

at

high

or

low

risk

of

developing

CAI

after

an

ankle

sprain,

but

also

to

find

the

optimal

treatment

and

also

allows

comparison

of

functional

results.

Different

factors

such

as

level

of

sport

activities

(professional,

ama-

teur

competitive,

leisure,

sedentary),

type

of

sport,

work

and

shoes

must

be

assessed

when

questioning

the

patient.

It

has

recently

been

suggested

that

there

may

be

a

role

for

those

early

operative

repair

of

the

ligaments

in

the

acute

stage

in

elite

athletes

with

a

severe

ankle

sprain

and

sig-

nificant

ankle

instability

as

this

is

known

to

reduce

the

risk

of

CAI

as

the

incidence

of

significant

symptoms

following

non-operative

management

is

approximately

20%

[16].

Lower

limb

varus

mal-alignment

has

been

described

as

an

important

factor

predisposing

to

ankle

sprain

and

CAI

[17].

Anatomical

variations

of

the

tibiotalar

joint

such

as

axis

of

rotation,

talar

dome

radius

or

retroposition

of

the

lateral

malleolus

can

predispose

to

ankle

sprain

and

CAI

[17—20].

Pathological

conditions

of

the

tibiotalar

joint

such

as

limitation

of

dorsiflexion

(anterior

impingement,

short

gastrocnemius),

chondral

problems

(ankle

osteochondral

defects,

loose

bodies)

or

bimalleolar

diastasis

can

provoke

or

increase

CAI

[21].

Subtalar

joint

anatomical

variations

(axis

of

rotation,

hindfoot

varus)

or

pathologies

(talocalcaneal

coalition,

subtalar

joint

laxity

due

to

injuries

of

the

cervical

lig-

ament,

the

talocalcaneal

ligament

or

the

interosseous

ligament)

act

as

risk

factors

of

CAI

[22—27].

Anatomical

and

histological

variations

of

the

collateral

lateral

ligament

(insertion

zones,

number

of

bands,

collagen

diseases)

are

also

important

intrinsic

risk

factors

for

CAI

[20,28—30].

Per-

oneal

tendons

pathologies

can

provoke

or

increase

a

CAI

[31]

and

pathologies

with

a

proprioceptive

deficit

or

imbalance

in

neuromuscular

control

are

a

frequent

cause

of

CAI

[17,32].

Evidence

from

peer-reviewed

literature

suggests

that

the

characteristics

of

patients

who

develop

chronic

ankle

insta-

bility

are

not

homogeneous.

The

aetiological

elements

of

CAI

are

a

continuum

of

pathologic

conditions

and

anatomic

variability.

A

good

knowledge

of

these

characteristics

will

improve

the

decisions

for

the

treatment.

Not

all

aetiological

aspects

are

yet

defined

and

more

studies

are

needed.

A

well-known

pathological

condition

is

the

patient

with

persisting

complaints

of

instability

asso-

ciated

with

pain,

but

without

any

objective

characteristics.

This

may

be

explained

by

formation

of

scar

tissue

and

arthro-

scopic

approach

may

be

useful

to

assess

the

ankle

joint

in

these

situations

[33].

Clinical

assessment

of

chronic

ankle

instability

History

of

an

ankle

sprain

must

precede

the

symptoms

of

CAI.

A

lateral

ankle

sprain

is

defined

as

an

episode

of

acute

inversion/supination

injury

of

the

ankle

associated

with

swelling,

lateral

ankle

pain

and

difficulty

weight-bearing.

Chronic

ankle

instability

is

defined

as

the

perception

by

the

patient

of

an

abnormal

ankle

with

a

combination

of

symptoms

including

recurrent

sprains,

pain

and

swelling

or

avoidance

of

activities.

The

following

standard

questions

should

be

asked

of

patients

with

ankle

instability:

•

how

long

ago

was

the

first

acute

event?

•

what

were

the

modalities

of

treatment?

•

does

the

ankle

continue

to

give

way?

(yes

or

no):

◦

if

yes,

with

what

frequency?

•

is

there

an

adaptation

or

avoidance

to

daily

or

sport

activ-

ities?

(yes

or

no);

•

is

there

an

ankle

pain

between

new

sprain

events?

(yes

or

no):

◦

if

yes,

the

location

of

the

pain

must

be

defined;

•

does

the

ankle

swell?

(yes

or

no):

◦

if

yes,

the

location

of

the

swelling

must

be

specified.

The

purpose

of

these

questions

is

to

establish

which

of

the

following

five

presentations

is

present

all

of

which

are

compatible

with

CAI:

•

recurrent

acute

ankle

sprain;

•

giving

way

of

the

ankle

without

new

sprain;

•

perception

of

an

insecure/unstable

ankle

by

the

patient;

•

avoidance

of/adaptation

to

daily

or

sporting

activities;

•

perception

of

an

abnormal

ankle

by

the

patient

(pain,

swelling).

The

physical

examination

must

include

comparative

assessment

of

both

ankles.

Lower

leg

and

hindfoot

align-

ment

must

be

assessed

whilst

standing

and

gait

should

be

evaluated.

Precise

location

of

tenderness

must

be

identified.

Active

and

passive

ankle

range

of

motion

(ROM)

Chronic

ankle

instability:

current-concepts

S413

is

measured

with

the

knee

extended

and

then

on

a

sit-

ting

position

with

the

legs

down

and

the

knees

flexed

to

90◦in

order

to

assess

gastrocnemius

tightness.

Hindfoot

inversion/eversion

is

compared

to

the

other

side.

In

view

of

the

difficulty

in

making

precise

measurements

of

hind-

foot

mobility,

grading

as

normal,

abnormal

(increased

or

decreased)

or

no

mobility

is

appropriate.

An

assessment

of

generalised

joint

laxity

is

important

(Beighton

scale).

Strength

and

pain

on

resisted

function

of

peroneal

and

tibialis

posterior

tendons

are

specifically

tested

and

neu-

rovascular

status

of

the

lower

legs

is

then

assessed.

Ankle

ligament

testing

is

comparative

and

performed

on

a

relaxed

patient

in

a

sitting

position

with

the

knee

flexed.

It

may

be

difficult

to

describe

the

degree

of

ankle

laxity

of

the

ante-

rior

drawer

test

between

examiners

and

therefore

a

simple

description

of

stable,

unstable,

unstable

with

sulcus

sign

may

be

preferred.

The

presence

of

varus

tilt

is

frequently

difficult

to

assess

and

laxity

or

absence

of

laxity

compared

to

the

other

side

is

likewise

preferred

[34,35].

Stability

and

proprioceptive

control

of

the

ankle

can

be

assessed

by

the

patient

standing

with

a

single

leg

stance

(eyes

open

and

then

eyes

closed).

This

test

may

be

helpful

to

differentiate

mechanical

from

functional

instability

[36,37].

Radiographic

assessment

The

standard

plain

radiographs

include:

standing

antero-

posterior,

lateral

and

mortise

views

and

a

comparative

Saltzmann

view

(or

Méary

view),

which

is

helpful

to

assess

hindfoot

alignment.

Comparative

stress

radiographic

views

with

anterior

drawer

test

and

varus

tilt

may

be

performed

although

it

should

be

recognised

that

these

have

a

high

rate

of

false

negative

results

[34,35].

Magnetic

resonance

imaging

may

be

helpful

in

the

pres-

ence

of

deep

pain

to

assess

for

osteochondral

lesions

and

tendon

injuries

and

it

will

also

confirm

the

presence

of

chronic

ligamentous

injury.

Ultrasonography

may

be

par-

ticularly

helpful

in

the

assessment

of

tendon

pathology.

Computer

tomography/MRI-arthrogram

scanning

is

not

rou-

tinely

advised

but

may

be

helpful

for

accurate

assessment

of

chondral

lesion.

Scoring

systems

for

chronic

ankle

instability

Quantifying

the

severity

of

ankle

instability

is

a

difficult

problem.

Many

patients

may

not

have

any

episodes

of

actual

giving

way

or

falling,

as

they

tend

to

avoid

aggravating

situa-

tions.

Instead,

the

main

complaint

is

often

just

a

feeling

of

vulnerability

and

this

is

hard

to

measure

objectively.

How-

ever,

an

attempt

has

to

be

made

to

gauge

the

severity

of

the

problem

in

order

to

facilitate

decisions

regarding

indi-

cations

for

surgery,

return

to

sport

and

of

course

assessing

the

quality

of

the

outcome

of

surgical

intervention.

The

history

of

outcome

scoring

for

instability

mirrors

the

experience

of

orthopaedics

as

a

whole,

moving

from

surgeon-designed

and

-administered

scores

to

more

objec-

tive

patient-centred

measures

(Table

1).

We

are

fortunate

that

in

this

area

we

have

some

objective

measures

(Table

2)

that

can

be

used

to

analyse

the

clinimetric

properties

of

the

various

outcome

scores

though

they

are

not

appropriate

for

everyday

clinical

use.

Table

1

Outcome

scores.

Generic

health

scores

Disease

specific

scores

SF12

[38]

Karlsson

1988

[44]

EuroQol

-EQ5D

[39]

Kaikkonen

1994

[45]

Ankle

joint

functional

assessment

tool

(AJFAT)

1999

[46]

Generic

foot

and

ankle

scores

Functional

Ankle

Disability

Index

(FADI)

Functional

Ankle

Disability

Sport

(FADI-Sport)

1999

[47]

American

orthopaedic

foot

and

ankle

score

(AOFAS)

[40]

Sports

ankle

rating

system

(SARS)

2003

[48]

Foot

and

ankle

outcome

score

(FAOS)

2001

[41]

Foot

and

ankle

assessment

measure

(FAAM)

2005

[49]

Ankle

instability

index

(AII)

2006

[50]

Activity

assessment

scales

Cumberland

Ankle

Instability

Tool

(CAIT)

2006

[51]

Tegner

1985

[42]

Foot

and

ankle

instability

questionnaire

(FAIQ)

2007

[52]

Halasi

2004

[43] Chronic

ankle

instability

scale

(CAIS)

2008

[53]

Identification

of

foot

and

ankle

instability

(IdFAI)

2011

[54]

To-date,

there

has

been

no

consensus

on

the

best

score

to

use.

A

variety

of

instruments

have

been

advocated,

many

of

which

are

not

validated

or

even

appropriate

for

instability

(Table

3).

A

number

of

studies

have

analysed

many

of

these

scores,

though

none

have

as

yet

proved

to

be

clearly

superior

[64—66].

The

IdFAI

score

is

the

most

recent

and

promising

score

but

it

is

yet

to

be

used

in

any

published

studies

[54].

The

authors

themselves

feel

that

it

is

a

starting

point

for

further

development

and

refinement

rather

than

a

definitive

measure.

Consensus

was

reached

that

this

area

needed

much

more

work

but

that

comparison

of

results

required

a

standard-

ised

approach.

The

FAOS

score

was

selected

as

this

has

been

validated

for

use

in

ankle

ligament

reconstruction,

it

is

patient-centred

and

easy

to

complete

[41].

This

should

be

Table

2

Physical

tests.

Non-instrumented

Instrumented

Single

leg

balance

[36,37]

Force

platforms-

static

and

dynamic

testing

[58]

Hopping

tests

—

on-the-spot,

lateral,

figure-of-8

[55]

Surface

EMG-

peroneal

reaction

times

[59]

Y

balance

test

and

star

excursion

balance

test

[56]

Balance

error

scoring

system

[57]

S414

S.

Guillo

et

al.

Table

3

Review

of

instability

literature

from

foot

and

ankle

instability

2012

to

present.

Study

Outcome

score

used

Tourné

et

al.

2012

[60]

Karlsson

Good

Jones

Livingstone

Youn

et

al.

2012

[61] Karlsson

Miller

et

al.

2013

[62] FAAM

Vega

et

al.

2013

[63] AOFAS

used

in

conjunction

with

the

EQ5D,

a

5-item

generic

health

measure

that

is

similarly

quick

and

easy

to

complete.

There

is

a

wide

variation

in

the

type

of

patient

from

the

office

worker

to

the

‘week-end

warrior’

and

the

elite

ath-

lete.

Therefore

it

is

recommended

that

the

Halasi

activity

level

score,

a

modernised

version

of

the

Tegner

Score,

is

used

to

define

the

patient

population

of

individual

series’

in

order

to

inform

comparison

of

outcome

in

light

of

demand

and

expectation

[42,43].

Arthroscopic

assessment

in

chronic

ankle

instability

A

review

of

the

literature

shows

that

13

to

35%

of

patients

report

symptoms

such

as

pain

and

recurrent

instability

after

a

successful

ligament

reconstruction

[67—71].

Intra-

articular

pathology

has

been

suggested

as

the

cause

for

these

persistent

symptoms,

and

although

many

authors

have

reported

arthroscopic

findings

in

patients

with

chronic

lat-

eral

ankle

instability,

there

has

been

no

attempt

to

correlate

the

type

and

number

of

intra-articular

lesions

with

the

patient

outcome.

Previous

studies

stated

that

osteochondral

lesions

of

the

talus,

soft

tissue

impingement

lesions,

osseous

loose

bod-

ies,

peroneal

tendon

disorders

and

other

associated

injuries

could

be

sources

of

postoperative

pain

in

chronic

ankle

instability

patients

[20,71—75].

To

date,

there

have

been

few

reports

on

surgical

results

with

regard

to

intra-articular

lesions

in

patients

with

chronic

lateral

ankle

instability.

Choi

et

al.

have

shown

that

63

out

of

65

cases

of

ankle

instability

(96.9%)

had

intra-articular

lesions,

of

which

53

cases

(81.5%)

showed

soft

tissue

impingement

as

the

most

common

asso-

ciated

lesion

[21].

Other

associated

intra-articular

lesions

included

ossicles

at

the

lateral

malleolus

(38.5%),

syndesmo-

sis

widening

(29.2%),

and

osteochondral

lesion

of

the

talus

(23.1%).

One

of

the

notable

features

of

this

study

is

that

they

have

analyzed

the

clinical

outcome

relative

to

the

presence

of

intra-articular

lesions

and

have

shown

that

the

strongest

risk

indicators

for

patients’

dissatisfaction

were

syndesmo-

sis

widening,

osteochondral

lesions

of

the

talus

and

ossicles.

The

number

and

severity

of

lesions

was

greater

in

those

with

chronic

instability

and

this

was

also

associated

with

a

poor

clinical

outcome

following

surgery.

The

high

rate

of

soft

tissue

impingement

in

chronic

ankle

instability

may

be

a

response

to

a

coexisting

intra-articular

lesion

or

repetitive

inversion

stress

to

the

ankle.

The

term

‘‘soft

tissue

impingement’’

included

hypertrophic

synovial

and

fibrotic

scar

tissue

obliterating

the

joint

space

that

corresponded

to

localized

tenderness.

Soft

tissue

impinge-

ment

is

known

to

be

strongly

associated

with

osteochondral

lesions

due

to

the

self-regeneration

mechanism

of

synovial

osteoprogenitor

cells

that

migrate

to

the

lesion

site.

How-

ever,

there

is

disagreement

about

whether

this

would

affect

the

clinical

outcome

[76—78].

Lee

et

al.

described

the

diag-

nosis

and

arthroscopic

treatment

of

soft

tissue

impingement

in

38

patients

with

chronic

ankle

pain

after

trauma

[79].

Ossicles

at

the

tip

of

the

lateral

malleolus

are

frequently

found

in

patients

with

chronic

lateral

ankle

instability.

However,

the

relationship

between

the

presence

or

the

size

of

an

ossicle

and

the

outcome

of

ligament

recon-

struction

is

poorly

understood.

Kim

et

al.

reported

that

ankles

with

large

ossicles

improved

post-reconstruction

with

regards

to

varus

stability

but

not

anteroposterior

stability

[80].

When

the

ossicle

is

large,

excision

and

the

modi-

fied

Broström

technique

may

not

be

suitable

to

achieve

mechanical

anteroposterior

stability.

Therefore,

fusing

the

ossicle

to

the

fibular

tip

or

using

other

methods

of

ligament

reconstruction

may

need

to

be

considered

in

chronic

ankle

instability

with

associated

large

ossicles

(Fig.

1).

Syndesmosis

widening

has

been

recognized

as

one

of

the

causes

of

prolonged

ankle

pain.

Injury

to

the

syn-

desmotic

ligaments

occurs

as

a

result

of

external

rotation

forces,

which

often

accompany

inversion

sprains.

Syn-

desmotic

instability

was

defined

as

the

ability

to

displace

the

fibula

laterally

more

than

2

mm

with

the

shoulder

of

the

probe

while

placed

in

the

syndesmotic

joint

[81—84].

This

criterion

was

based

on

the

study

by

Close

who

reported

that

the

maximum

widening

of

the

intra-articular

distal

tibiofibular

syndesmosis

was

approximately

1.5

mm

in

a

normal

ankle

[85].

Teramoto

and

Taylor

reported

that

a

pos-

sible

explanation

for

the

increased

incidence

of

recurrent

sprains

in

patients

with

syndesmosis

widening

is

altered

fibu-

lar

mobility

leading

to

altered

ankle

biomechanics

[86,87].

Disrupted

distal

fibular

migration

and

fibular

axial

motion

can

alter

normal

ankle

function.

The

resultant

alteration

in

ankle

function

may

predispose

the

ankle

to

inversion

sprains.

Therefore,

after

the

distal

tibiofibular

syndesmo-

sis

is

ruptured,

healing

is

protracted,

functional

disability

is

not

uncommon

and

prognosis

is

guarded.

Some

contro-

versy

exists

regarding

the

treatment

method

and

the

merits

of

screw

fixation

[82,88,89].

Han

et

al.

in

accordance

with

Ogilvie-Harris

and

Reed

suggested

that

soft

tissue

hyper-

trophy

and

its

subsequent

impingement

may

be

the

cause

of

pain

and

disability

in

chronic

tibiofibular

syndesmosis

injury

[81,82].

They

recommended

arthroscopic

marginal

resection

alone

if

it

has

been

determined

that

there

is

no

rupture

of

the

medial

deltoid

ligament

and,

thus,

no

effect

on

the

contact

surface

and

maximal

pressure

of

the

ankle

joint.

Poor

functional

outcome

from

residual

instability

of

the

distal

tibiofibular

joint

may

occur

after

lateral

ligament

reconstruction

and

anatomical

reconstruction

of

syndesmo-

sis

will

be

needed

to

restore

syndesmosis

stability.

Several

studies

have

shown

that

chronic

lateral

ankle

instability

is

often

associated

with

chondral

lesions

in

the

ankle

[73—75,90].

It

is

clear

that

high

contact

pressure

and

shear

stress

adjacent

to

cartilage

defects

may

interfere

with

hyaline

cartilage

function

in

adjacent

areas

of

normal

car-

tilage

[91,92].

Such

a

deleterious

effect

may

explain

the

worse

clinical

outcome

with

osteochondral

lesions

in

spite

Chronic

ankle

instability:

current-concepts

S415

Figure

1

Treatment

algorithm

of

an

ossicle

of

the

lateral

malleoli

in

patients

with

chronic

ankle

instability.

of

a

successful

ligament

reconstruction.

Few

investigators

have

reported

on

the

differences

in

the

clinical

outcomes

of

arthroscopic

treatment

for

osteochondral

lesions

performed

on

lateral

ligament

reconstructed

ankles

versus

arthroscopy

done

in

isolated

osteochondral

lesions

in

lateral

ligament-

intact

ankles.

There

have

been

no

clear

criteria

to

help

surgeons

decide

whether

the

ligament

remnant

will

be

sufficient

for

Brostrom—type

procedures.

Judgment

of

this

has

his-

torically

been

unscientific,

merely

relying

on

the

surgeon’s

experience.

Normal

ligaments

consist

of

90%

type

1

col-

lagen,

which

is

primarily

responsible

for

the

stiffness

and

strength

of

the

ligament

[93—95].

Any

decrease

of

type

1

collagen

suggests

the

strength

of

the

ligament

is

weaker

than

the

normal.

Yasui

and

Takao

compared

the

arthroscopic

and

histological

findings

of

the

ATFL

remnant,

and

clari-

fied

the

degree

of

irregularity

of

ATFL

fibre

in

arthroscopic

assessment.

If

the

ATFL

had

a

highly

irregular

appearance

in

arthroscopic

evaluation,

histology

showed

that

the

liga-

ment

fibres

consisted

of

scar

tissue

without

type

I

collagen

[96].

There

was

good

correlation

between

the

arthroscopic

assessment

of

irregularity

of

the

ATFL

remnant

and

the

his-

tological

appearance.

They

therefore

recommended

that

the

surgical

procedure

should

be

selected

according

to

the

arthroscopic

assessment

of

the

ATFL

remnant

(Fig.

2).

Figure

2

Selection

of

the

surgical

procedure

according

to

arthroscopic

evaluation

of

the

remnant

of

the

anterior

talofibu-

lar

ligament

(ATFL).

Therefore,

a

thorough

arthroscopic

assessment

is

indi-

cated

prior

to

lateral

ligament

reconstruction

in

addition

to

clinical

and

radiological

examination,

unless

a

patient

is

pain-free

with

negative

radiological

assessment.

This

assess-

ment

should

include

careful

inspection

for

any

soft

tissue

impingement,

syndesmosis

widening,

osteochondral

lesions

as

well

as

the

appearance

of

the

remnant

of

the

ATFL

in

order

to

determine

the

correct

surgical

strategy.

Surgical

indications

for

chronic

ankle

instability

Over

the

past

40

years,

the

orthopaedic

community

has

witnessed

an

evolution

in

knee

and

shoulder

surgery

for

unstable

joints

from

non-anatomic

reconstructions

utilizing

open

approaches

toward

anatomical

reconstructive

proce-

dures

performed

either

through

smaller

open

incisions

or

arthroscopically.

The

surgical

treatment

of

chronic

lateral

ankle

instability

is

currently

evolving

in

a

similar

manner.

Traditional

open

procedures

to

stabilize

the

ankle

using

ten-

don

grafts

placed

non-anatomically

can

result

in

a

stable

ankle.

However,

these

procedures,

such

as

the

Chrisman-

Snook,

Evans,

and

Watson-Jones,

may

over-constrain

both

the

ankle

and

subtalar

joints

resulting

in

limitation

of

joint

motion

and

long

term

development

of

degenerative

arthritis.

Contemporary

techniques

emphasize

anatomic

repair/reconstruction

to

restore

stability

while

attempting

to

minimize

these

complications.

For

the

purposes

of

this

article,

we

define

repair

as

the

primary

or

secondary

suturing

of

the

torn

lateral

ligaments.

A

reconstruction

refers

to

the

replacement

of

the

chroni-

cally

deficient

lateral

ligaments

with

local

tissues

or

with

autograft

or

allograft

tissue.

Local

ligament

soft

tissue

repair

techniques

The

classic

Broström

procedure

is

a

true

repair

of

the

lateral

ligaments

including

the

ATFL

and

the

CFL.

However,

it

is

rarely

performed

as

a

stand-alone

procedure.

Since

it

is

usu-

ally

augmented

with

a

transfer

of

the

extensor

retinaculum

S416

S.

Guillo

et

al.

either

as

a

proximal

advancement

(Gould

procedure)

or

as

a

pedicle

flap

of

retinaculum,

we

classify

this

procedure

as

a

repair/augmentation.

There

is

question

as

to

whether

the

extensor

retinaculum

truly

provides

mechanical

ankle

and

subtalar

stability

through

its

attachment

to

the

calcaneus

or

if

it

simply

provides

for

an

enhanced

proprioceptive

environment.

No

matter

the

method

of

effectiveness,

the

retinacular

augmentation

is

regarded

as

a

critical

element

of

this

procedure’s

success.

The

procedure

may

be

performed

the

traditional

manner

with

drill

holes

or

bone

anchors

with

attached

nonabsorbable

suture

may

be

uti-

lized.

It

is

the

consensus

of

the

ankle

instability

group

that

this

procedure

is

the

appropriate

first-line

consideration

for

patients

with

chronic

lateral

ankle

ligament

laxity

requiring

surgical

treatment.

Ligament

reconstruction

using

tendon

graft

or

transfer

Anatomic

reconstruction

with

tendon

graft

or

transfer

Traditionally

these

types

of

procedures

have

been

reserved

for

patients

who

have

failed

a

prior

Broström-Gould

repair.

However,

patients

who

may

stress

their

ankle

to

a

greater

degree

than

normal,

including

those

with

high

body

mass

index,

heavy

labor

occupation

or

sports

requirements,

or

patients

with

congenital

ligament

laxity

may

benefit

from

performing

ligament

reconstruction

as

the

primary

proce-

dure.

Although

isometry

of

the

lateral

ankle

ligaments

has

not

been

proven,

placement

of

the

tendon

grafts

at

the

ligaments’

anatomical

origin

and

insertion

should

be

per-

formed.

The

goal

is

to

achieve

good

ankle

stability

without

overconstraining

the

ankle

or

subtalar

joints.

Non-anatomic

positioning

of

the

graft

may

alter

the

biomechanics

of

the

joints

resulting

in

joint

loading

alterations

which

may

lead

to

joint

degeneration

over

time.

These

procedures

have

in

common

the

routing

of

the

transferred

tendon

graft

in

such

a

way

as

to

replicate

the

anatomic

positions

of

the

ATFL

and

CFL

origin

and

inser-

tion

sites.

They

vary

in

the

means

by

which

they

attain

that

positioning,

including

the

number

and

angle

of

tunnels

in

the

fibula

and

the

fixation

techniques

selected

in

each

bone

tunnel

location.

There

are

many

different

ways

the

liga-

ment

graft

can

be

secured

in

the

bone

including

anchors,

bone

tunnels

with

interference

screws,

and

endobutton

type

devices.

The

selected

fixation

device

should

be

secure

enough

to

maintain

appropriate

tension

on

the

recon-

struction

intra-operatively

as

well

as

support

healing

and

potentially

allow

for

early

joint

motion.

The

surgeon

may

elect

to

use

hamstring

autograft

or

allograft

depending

on

patient

requirements

and

the

resources

and

training

avail-

able

to

the

surgeon.

Non-anatomical

reconstruction

with

tendon

transfer

or

graft

Non-anatomic

reconstructions

of

the

lateral

ankle

ligaments

have

a

long

track

record

in

the

orthopaedic

literature

where

they

have

been

shown

historically

to

work

well

to

establish

a

stable

hindfoot

for

functional

activities.

Similar

to

the

non-anatomical

instability

procedures

performed

in

the

knee

and

shoulder,

the

long-term

results

in

the

ankle

reveal

an

increased

incidence

of

degenerative

changes

in

the

hindfoot.

Several

of

these

procedures

utilize

a

segment

or

the

entire

peroneal

tendon

as

either

a

graft

or

transfer.

The

peroneal

tendons

are

important

dynamic

stabilizers

of

the

hindfoot

and

harvesting

these

tendons

for

grafts

or

trans-

fers

may

result

in

long-term

weakness

and

loss

of

dynamic

stabilization

of

the

ankle

and

subtalar

joints.

Our

consensus

is

that

with

modern

fixation

techniques

and

the

known

long-

term

degenerative

sequelae

associated

with

non-anatomical

reconstruction,

these

procedures

should

be

avoided.

Arthroscopic

lateral

ligament

procedures

Numerous

articles

describe

a

high

incidence

of

intra-

articular

pathology

when

ankle

arthroscopy

is

performed

at

the

time

of

ligament

reconstruction

[21,72—74,82—84].

This

finding

has

prompted

many

surgeons

to

recommend

per-

forming

arthroscopy

in

association

with

a

lateral

ligament

reconstruction

[33,83].

In

the

last

five

years

there

have

been

several

arthro-

scopically

assisted

techniques

to

perform

lateral

ankle

ligament

reconstruction

described

in

the

orthopaedic

liter-

ature

[63,97—104].

These

techniques

show

early

promising

results

in

level

IV

studies

with

short-term

follow-up.

These

procedures

have

in

common

the

use

of

arthroscopic

tech-

niques

to

thoroughly

clean

out

the

lateral

gutter

to

expose

the

anatomic

origin

of

the

lateral

ligaments

on

the

distal

fibula

followed

by

placement

of

one

or

more

suture

anchors

into

the

fibula.

There

are

various

approaches

to

passing

the

sutures

through

the

ATFL,

CFL,

and

retinaculum

to

affect

a

repair/augmentation

procedure,

which

effectively

repli-

cates

the

Broström-Gould

procedure.

The

procedure

may

be

further

refined

as

specific

instrumentation

is

devised

to

facilitate

the

repair/augmentation.

Techniques

are

also

being

developed

to

perform

anatomic

reconstructions

using

tendon

graft

using

an

all

arthroscopic

approach.

These

procedures

are

very

technically

demanding

and

they

are

early

in

their

development.

We

believe

that

further

investigation

and

reporting

of

results

are

required

before

these

techniques

can

be

adopted

as

routine.

We

recommend

that

before

performing

arthroscopic

repair

or

reconstruction

in

the

ankle,

the

surgeon

should

be

highly

skilled

in

arthroscopy

of

the

ankle

and

should

have

gained

experience

on

the

procedures

in

cadaver

workshops

or

with

an

experienced

mentor.

The

presence

of

a

fibular

ossicle

can

complicate

per-

formance

of

a

lateral

ligament

reconstruction

[21].

Recent

studies

indicate

that

an

ossicle

of

less

than

1

cm

in

great-

est

dimension

can

be

safely

excised

and

a

local

soft

tissue

reconstruction

be

performed.

However,

if

the

ossicle

is

more

than

1

cm

in

any

dimension,

it

is

recommended

that

the

sur-

geon

either

fuse

the

ossicle

and

proceed

with

a

local

soft

tissue

procedure;

or

excise

the

ossicle

and

proceed

with

an

anatomic

tendon

graft/transfer

type

procedure.

Conclusion

Standardised

assessment

of

the

ankle

pre-operatively

and

at

follow-up

is

imperative

in

order

to

allow

compari-

son

of

outcome

from

treatment

with

various

techniques.

The

recording

of

clinical

information

along

with

standard-

ised

radiological

evaluation

as

has

been

described

above

Chronic

ankle

instability:

current-concepts

S417

following

this

consensus

group

meeting

will

help

and

the

recommendations

made

here

have

been

evaluated

and

are

evidence-based.

There

is

a

move

towards

patient-orientated

outcome

scores

which

is

why

the

ankle-specific

validated

systems

have

been

advocated

as

they

are

relatively

simple

to

use

with

less

chance

of

information

loss

and

increased

chance

patient

compliance.

The

anatomical

repairs

are

still

the

best

methods

of

treatment

in

symptomatic

chronic

insta-

bility

and

with

the

high

incidence

of

intra-articular

pathol-

ogy

it

is

recommended

that

an

arthroscopy

is

performed

at

the

time

of

surgery

unless

intra-articular

pathology

has

been

excluded

by

MRI

scan

and

there

is

no

history

of

pain.

There

is

a

move

towards

the

development

of

arthroscopic

anatomical

lateral

ligament

repair

which

may

well

take

over

from

the

open

approaches

that

are

currently

performed

in

a

similar

way

to

how

knee

and

shoulder

ligament

surgery

has

developed

over

the

past

10—15

years.

Anatomical

recon-

struction

with

tendon

grafts/augmentation

is

preferable

in

the

revision

cases

or

those

with

gross

laxity

or

insuffi-

cient

innate

tissue.

Non-anatomical

procedures

should

be

avoided

in

these

situations.

Early

reconstruction

of

acute

ligament

injuries

may

also

be

considered

in

the

athlete

as

this

improves

stability,

reducing

the

incidence

subsequent

complications

from

recurrent

sprains

without

compromising

or

delaying

return

to

sports.

Disclosure

of

interest

The

authors

declare

that

they

have

no

conflicts

of

interest

concerning

this

article.

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