Immediate Unrestricted Weight Bearing with Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization

Category: Ankle Introduction/Purpose: Anatomic lateral ankle ligament reconstruction has been shown to reliably restore the functional stability of the joint. Current orthopedic literature supports accelerated rehabilitation and protected weight bearing advancement as a safe and effective means to timely patient recovery. To our knowledge, there have not been clinical outcome reports of a protocol utilizing immediate unrestricted weight bearing in a stirrup brace following single anchor lateral ligament stabilization. The purpose of this study is to report on a series of patients treated with a more progressive protocol resulting in durable ankle stability and favorable clinical outcomes. Methods: A total of 28 patients with chronic lateral ankle ligament instability who failed conservative management underwent arthroscopy and modified Brostrom-Gould lateral ligament reconstruction between 2014 and 2015 were identified. The anterior talofibular and calcaneofibular ligaments were released from the fibula and advanced using one double-loaded metallic 3.5 mm suture anchor. Immediate unrestricted full weightbearing in a stirrup brace was allowed from the first postoperative day and accelerated physical therapy was initiated at 2 weeks postoperatively. Patients were assessed preoperatively, and at a minimum 1- year follow-up, using the AOFAS Hindfoot scale and VAS pain score. Additional postoperative outcome measures included the FAOS and a custom clinical questionnaire. Range of motion, ligamentous stability and single-blinded examination with Star Excursion Balance Test (SEBT) functional testing were performed postoperatively. Complication and recurrent instability rates were also recorded. Results: Twelve patients participated in the study (8F, 4 M). Mean age at final follow-up was 49 years (21-70). Average follow-up was 21 months (16 to 26). Average satisfaction score was 94%, and all patients reported they would have the procedure again. AOFAS Hindfoot score and VAS improved significantly from preoperative to postoperative, respectively (55.6 to 89.8, 5.4 to 1.6). Average postoperative FAOS score was 80.3 (51.8-100) . No measurable difference was observed on examination of range of motion, ligamentous stability, or SEBT testing in the anterior, posterolateral or posteromedial planes of the contralateral side, respectively (61.5 to 62.2 cm, 62.4 to 64.1 cm, 56.4 to 57.6 cm). No patients reported recurrent instability. Conclusion: This study demonstrates that anterior talofibular ligament and calcaneofibular ligament advancement utilizing a single 3.5 mm anchor construct followed by immediate unrestricted weight bearing is a safe and effective protocol for the treatment of chronic lateral ankle instability. Ligamentous stability was achieved and maintained in all patients across a wide variety of patient ages and desired activity levels. Patient satisfaction was excellent. This surgical technique and postoperative protocol may help reduce surgical time and implant cost, and may facilitate a more timely return to preinjury functional level.

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Donor Site Morbidity After Lateral Ankle Ligament Reconstruction Using the Anterior Half of the Peroneus Longus Tendon Autograft

The American Journal of Sports Medicine ◽

10.1177/0363546516675167 ◽

2016 ◽

Vol 45 (4) ◽

pp. 922-928 ◽

Cited By ~ 11

Author(s):

Chul Hyun Park ◽

Woo-Chun Lee

Keyword(s):

Ligament Reconstruction ◽

Plantar Flexion ◽

Lateral Ligament ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament ◽

The Mean ◽

Lateral Ankle Ligament Reconstruction ◽

Ankle Plantar Flexion

Background: The anterior half of the peroneus longus tendon (AHPLT) has been reported to be an effective autograft for ligament reconstruction with respect to strength and safety. However, there is little information regarding donor site morbidity after harvesting the AHPLT. Furthermore, to the best of our knowledge, there has not been a study on the isokinetic evaluation of ankle plantar flexion and eversion after AHPLT harvesting. Purpose: To evaluate the clinical and radiographic results after lateral ankle ligament reconstruction using the AHPLT. We further investigated whether harvesting the AHPLT for lateral ankle ligament reconstruction decreases the strength of ankle plantar flexion and eversion. Study Design: Case series; Level of evidence, 4. Methods: Thirty consecutive patients (31 cases) were treated by anatomic lateral ligament reconstruction using the AHPLT. For the clinical assessment, visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson-Peterson scores were evaluated preoperatively and at the last follow-up. For the radiographic assessment, talar tilt angle and anterior talar displacement were measured preoperatively and at the last follow-up. The peak isokinetic torques for ankle plantar flexion at angular velocities of 30 and 120 deg/s and eversion at angular velocities of 30 and 60 deg/s were measured at a minimum of 1 year after surgery. Results: The mean VAS score improved significantly from 6.4 ± 1.7 preoperatively to 1.6 ± 1.5 at the last follow-up ( P < .001). The mean respective AOFAS and Karlsson-Peterson scores improved significantly from 57.2 ± 12.8 and 66.9 ± 13.6 preoperatively to 89.0 ± 10.0 and 93.3 ± 5.7 at the last follow-up ( P < .001). The mean talar tilt angle improved significantly from 15.3° ± 6.2° preoperatively to 3.4° ± 3.0° at the last follow-up ( P < .001), and the mean anterior talar displacement improved significantly from 10.2 ± 3.3 mm preoperatively to 6.3 ± 1.9 mm at the last follow-up ( P < .001). No significant differences were observed between the uninvolved and involved legs in the mean peak torque for plantar flexion at angular speeds of 30 deg/s ( P = .517) and 120 deg/s ( P = .347) or for eversion at angular speeds of 30 deg/s ( P = .913) and 60 deg/s ( P = .983). Conclusion: Anatomic lateral ligament reconstruction using the AHPLT showed good clinical and radiographic results without a significant decrease in the peroneus longus strength. Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability.

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ATFL Elongation after Brostrom Procedure: A Biomechanical Investigation

Foot & Ankle International ◽

10.3113/fai.2008.1126 ◽

2008 ◽

Vol 29 (11) ◽

pp. 1126-1130 ◽

Cited By ~ 25

Author(s):

Kevin L. Kirk ◽

John T. Campbell ◽

Gregory P. Guyton ◽

Brent G. Parks ◽

Lew C. Schon

Keyword(s):

Range Of Motion ◽

Ligament Reconstruction ◽

Early Mobilization ◽

Lateral Ligament ◽

Anterior Talofibular Ligament ◽

Variable Reluctance ◽

Ankle Ligament ◽

Before And After ◽

Lateral Ankle Ligament ◽

Fresh Frozen

Background: Elongation of ligaments during early mobilization after reconstruction may be associated with decreased stability. We evaluated elongation of the anterior talofibular ligament (ATFL) before and after lateral ligament reconstruction within a physiologic range of motion with protected and unprotected, isolated dorsiflexion/plantarflexion range of motion. Materials and Methods: Six fresh frozen cadaver legs were used with the ATFL meticulously dissected. A differential variable reluctance transducer (DVRT) was spaced to span the course of the ATFL using consistent placement points based on previous reports. Elongation was measured in a load frame with protected motion of 30 degrees plantarflexion and 10 degrees dorsiflexion for the intact and sectioned ATFL and for the repaired specimen with and without protected motion. The proximal DVRT anchor point was detached for sectioning and repair of the ATFL and replaced at the same position. Testing was 1000 cycles at 1 Hz for the repaired protected specimen and 10 cycles at 1 Hz for all other stages. Results: Initial elongation in the unprotected, repaired group was significantly higher than initial elongation in the intact ( p < 0.01), sectioned ( p = 0.02), and repaired, protected ( p < 0.01) groups. Final elongation in the unprotected repaired group was also higher than final elongation in all other groups ( p < 0.01 for all comparisons). Conclusion: The use of protected range of motion of the ankle after lateral ankle ligament reconstruction was not associated with elongation of the ATFL. The ATFL elongated significantly by comparison without protected dorsiflexion/plantarflexion. Clinical Relevance: The study provides biomechanical support for the safety of early protected dorsiflexion/plantarflexion range of motion after Broström reconstruction.

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Immediate Unrestricted Weightbearing With Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization

Foot & Ankle Specialist ◽

10.1177/1938640020972829 ◽

2020 ◽

pp. 193864002097282

Author(s):

Gregory A. Lundeen ◽

Christopher Diefenbach ◽

Laura Hemker Moles ◽

Larissa Lee White ◽

Patrick Barousse

Keyword(s):

Ligament Reconstruction ◽

Short Form ◽

Case Series ◽

Lateral Ligament ◽

Foot And Ankle ◽

Balance Test ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament

Objective To report on a series of patients treated with immediate unrestricted weightbearing with limited protection following single anchor lateral ligament stabilization. Methods Patients with chronic lateral ankle ligament instability who underwent modified Broström-Gould lateral ligament reconstruction with a single double-loaded anchor were identified. Immediate unrestricted full weightbearing in a stirrup brace was allowed the first postoperative day and accelerated physical therapy was initiated from 2 weeks. Subsequent assessment was performed at a minimum of 1-year follow-up. Results Thirteen patients with a mean age at final follow-up of 49 years (range 21-70 years). Average follow-up was 21 months (16 to 26). American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and visual analogue scale (VAS) score improved significantly (P < .05) from preoperative to postoperative, respectively (57 to 91, 5.7 to 1.5). Average postoperative Foot and Ankle Outcome Score (FAOS) was 82 (range 52-100). Short Form–12 (SF-12) scores averaged 55 and 49 on mental component and physical components, respectively, consistent with US age-matched averages. No measurable differences in range of motion, ligamentous stability, or Star Excursion Balance Test in the anterior, posterolateral, or posteromedial planes compared to the contralateral side (P > .05) were observed. No recurrence was reported. Conclusion Immediate unrestricted weightbearing in a stirrup brace following single anchor lateral ligament reconstruction is a successful protocol for the treatment of chronic lateral ankle instability. Levels of Evidence Therapeutic, Level IV: Case series

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Subtle Cavus Deformities

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00081 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0008

Author(s):

Ashlee MacDonald ◽

Meghan Kelly ◽

Jeff Houck ◽

Judith Baumhauer ◽

Irvin Oh ◽

...

Keyword(s):

Ligament Reconstruction ◽

Recurrent Instability ◽

Lateral Ankle ◽

Allograft Reconstruction ◽

Ankle Ligament ◽

Operative Complications ◽

Cavus Foot ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction

Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. Prior reports have found increased risk of failed lateral ankle reconstruction in those with a subtle cavus deformity, and therefore, correcting the deformity is often advocated. However, other studies have been unable to identify subtle cavus deformity as a clear risk factor for recurrent injury. The purpose of this study was to 1) compare PROMIS physical function (PF), pain interference (PI), and depression scores in patients with subtle cavus deformities to those without deformity who underwent lateral ankle ligament reconstruction, 2) compare PROMIS scores in allograft and modified Brostrom-Gould (BG) reconstructions in those with subtle cavus, and 3) to evaluate for any post-operative complications in those with subtle cavus. Methods: PROMIS CAT scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and December 2017. Using CPT codes, 145 patients who underwent lateral ankle ligament reconstruction were identified. Exclusion criteria consisted of less than three-month follow-up, incomplete PROMIS scores, or multiple surgeries unrelated to the reconstruction during the follow-up period. A total of 78 patients were included in the study. Pre- and post-operative PROMIS PF, PI, and depression were collected. Patients were then divided into two groups: subtle cavus foot (n=23) and non-cavus foot (n=55). A foot was considered cavus based on physical exam and previously published radiographic parameters. The cavus group was further subdivided into allograft reconstruction and BG reconstruction. Post-operative complications were also recorded. Student t-tests were used to evaluate for differences in PF, PI, and depression t-scores in cavus vs. non-cavus groups as well as allograft vs. BG. Results: The average follow-up was 28.59+/-13.27 weeks in the cavus and 29.77+/-16.15 weeks in the non-cavus group (p=0.76). There were no differences in pre-operative PF, PI, or depression t-scores between the two groups (p>0.05). The cavus group had significantly better post-operative PF compared to the non-cavus group (49.24+/-8.14 vs. 43.17+/-6.64, p=0.001). PI was also better in the cavus group (51.12+/-8.33) compared to the non-cavus group (55.09+/-9.45), however not statistically significant (p=0.08). There were no differences in post-operative depression (p=0.58). When subdividing the cavus group, allograft reconstruction (49.49+/-7.48) had better post-operative PI t-scores compared to BG (57.17+/-8.16, p=0.04). In the cavus group, there were no instances of recurrent instability; one patient required a repeat ankle arthroscopy for debridement. One patient in the non-cavus group developed recurrent instability. Conclusion: Patients with subtle cavus deformity undergoing lateral ankle ligament reconstruction had significantly higher post-operative PROMIS PF t-scores compared to those without deformity and a trend towards improved pain post-operatively. When subdividing the subtle cavus group, allograft reconstruction demonstrated better PI scores post-operatively, and thus may be a more favorable technique in patients who have a subtle cavus deformity. Though longer follow-up is needed, our study suggests that patients with subtle cavus deformities may not require a more complex reconstruction with osteotomies to correct their deformity in order to achieve clinically meaningful improved outcomes.

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Early Versus Delayed Mobilization Post-Operative Protocols for Primary Lateral Ankle Ligament Reconstruction: A Systematic Review and Meta-Analysis

Kansas Journal of Medicine ◽

10.17161/kjm.vol1415028 ◽

2021 ◽

Vol 14 ◽

pp. 141-148

Author(s):

Matthew Vopat ◽

Alexander Wendling ◽

Brennan Lee ◽

Maaz Hassan ◽

Brandon Morris ◽

...

Keyword(s):

Ligament Reconstruction ◽

Ankle Instability ◽

Meta Analysis ◽

Early Mobilization ◽

Lateral Ligament ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction ◽

Primary Lateral

Introduction. Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review is to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature. Methods. Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947-1/28/2020). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 3 weeks of surgery). Functional outcome scores (AOFAS, Karlsson scores), radiographic measurements (anterior drawer, talar tilt) and complications evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models. Results. After our search, we found 12 out of 1,574 studies that met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group; 28.0 (5.5) vs. 26.3 (0.0) respectively, p < 0.001; although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high. Conclusions. While there were some conflicting results, findings suggest that EM post-operative protocols for patients undergoing lateral ankle ligament reconstruction may not compromise functional outcomes or post-operative stability. Because heterogeneity was high, future studies are still needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.

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Trends in PROMIS Scores in the Early Post-operative Period following Various Lateral Ankle Ligament Reconstructive Techniques

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000276 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0002

Author(s):

Ashlee MacDonald ◽

Jeff Houck ◽

John Ketz ◽

Judith Baumhauer ◽

Irvin Oh ◽

...

Keyword(s):

Ligament Reconstruction ◽

Scoring Systems ◽

Measurement Information ◽

Chronic Instability ◽

Lateral Ankle ◽

Ankle Ligament ◽

Patient Reported ◽

Lateral Ankle Ligament ◽

Lateral Ankle Ligament Reconstruction

Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. When conservative management fails and chronic instability ensues, operative treatment is often sought. Though surgical outcomes are generally good following lateral ankle ligament reconstruction, literature suggests current scoring systems for evaluating outcomes and monitoring progression have deficiencies. Patient Reported Outcomes Measurement Information (PROMIS) scores have recently been established as a method of monitoring patient outcomes. The purpose of this study was to evaluate the trends in post-operative PROMIS physical function (PF), pain interference (PI), and depression scores in patients undergoing lateral ankle ligament reconstruction. Methods: PROMIS scores were prospectively obtained from all patients evaluated in our foot and ankle clinic between February 2015 and October 2016. Using ICD-9/10 and CPT codes, a total of 111 patients who underwent lateral ankle ligament reconstruction were identified. After meeting exclusion criteria (less than three-month follow-up, incomplete PROMIS scores or multiple surgeries), 55 patients were included. PROMIS PF, PI, and depression were evaluated at each post-operative visit. Changes in scores were calculated as compared to baseline pre-operative scores and compared at each follow-up time point using two-way ANOVA. Differences in reconstruction type in patients undergoing allograft (A), modified Broström-Gould (BG), or modified Broström-Gould augmented with fibertape (BG+FT) were also evaluated. Results: The average follow-up was 27.05 weeks (range 12-60.1 weeks). 11 patients had > 9 months follow-up. Changes in PF were significantly different from baseline at all time-points except for 8-12 week follow-up. PF was significantly worse at 2 and 4-6 week follow-up, and significantly better at >12 weeks follow-up (p<0.01). PI significantly improved from baseline beginning at 8-12 week follow-up (p=0.02). Depression was unchanged from baseline at 2 weeks and 4-6 week follow-up, then significantly improved thereafter (p<0.01). Though not significant, when comparing reconstruction types, there was a trend towards slower improvement in PF in those with BG+FT (n=15), compared to A (n=17, p=0.07) and BG (n=21, p=0.051) at 8-12 weeks. Two patients had other types of reconstruction and were not included in this analysis. Conclusion: Patients undergoing lateral ankle ligament reconstruction demonstrate significant improvements in PF, PI, and depression PROMIS scores compared to baseline. Patients reached baseline PF at 8-12 weeks follow-up, and significantly improved beyond >12 weeks. PI scores were significantly improved from baseline beginning at 4 weeks follow-up. Depression scores also significantly improved at 8-12 weeks follow-up. BG+FT showed a trend of slower improvement in PF, though not significant. Though longer follow-up is needed, the significant improvements in PF, PI, and depression following lateral ankle ligament reconstruction in our study provides data that can be used for pre-operative counseling and monitoring progression post-operatively.

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Intraoperative Peroneus Brevis Tendon Rupture: A Technique to Salvage the Graft During Ankle Ligament Reconstruction

Foot & Ankle International ◽

10.1177/107110079601700610 ◽

1996 ◽

Vol 17 (6) ◽

pp. 349-351 ◽

Cited By ~ 3

Author(s):

Eugene E. Berg

Keyword(s):

Ligament Reconstruction ◽

Tendon Rupture ◽

Joint Stability ◽

Chronic Instability ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament ◽

Peroneus Brevis ◽

Lateral Ankle Ligament Reconstruction

The peroneus brevis tendon is frequently used in lateral ankle ligament reconstruction for chronic instability. Intraoperative tendon rupture at the exit of the interosseous transfibular tunnel occurred in two cases. A technique is described to salvage this situation. At 2-year follow-up, both cases had successful restoration of ankle joint stability.

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