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Purpose Knowledge of the complex anatomy of the lateral ankle ligaments is essential to understand its function, pathophysiology and treatment options. This study aimed to assess the lateral ligaments and their relationships through a 3D view achieved by digitally marking their footprints. Methods Eleven fresh-frozen ankle specimens were dissected. The calcaneus, talus and fibula were separated, maintaining the lateral ligament footprints. Subsequently, each bone was assessed by a light scanner machine. Finally, all the scans were converted to 3D polygonal models. The footprint areas of the talus, calcaneus and fibula were selected, analysed and the surface area was quantified in cm 2 . Results After scanning the bones, the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) footprints were continuous at the medial side of the fibula, corresponding to a continuous footprint with a mean area of 4.8 cm 2 (± 0.7). The anterior talofibular ligament (ATFL) footprint on the talus consisted of 2 parts in 9 of the 11 feet, whilst there was a continuous insertion in the other 2 feet. The CFL insertion on the calcaneus was one single footprint in all cases. Conclusion The tridimensional analysis of the lateral ligaments of the ankle demonstrates that the ATFLif, CFL and PTFL have a continuous footprint at the medial side of the fibula in all analysed specimens. These data can assist the surgeon in interpreting the ligament injuries, improving the imaging assessment and guiding the surgeon to repair and reconstruct the ligaments in an anatomical position.

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.

Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and non-anatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability. Level of evidence V.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The use of intramedullary fibular nailing for ankle fracture fixation has gained popularity, particularly in patients at elevated risk of wound complications. Despite its advantages, concerns remain regarding the safety of this technique and the quality of fracture reduction achieved through its minimally invasive approach. This anatomical study aimed to evaluate the potential risks to adjacent anatomical structures during the implantation of a percutaneous retrograde locked intramedullary fibular nail and to analyze the quality of fracture reduction using radiographic assessment. Methods: Ten human cadaveric lower extremities were subjected to a simulated fracture and then fixed with a nail. Reduction quality was evaluated fluoroscopically and graded accordingly. Specimens were dissected to assess damage to nearby anatomical structures, and the shortest distances between surgical sites and adjacent structures were measured. Results: Reduction quality was deemed adequate in all specimens. No damage to the peroneal tendons was observed. The mean distance between the sural nerve and the distal portal was 14.95 mm (SD 3.99) therefore this was considered a safe zone. The superficial peroneal nerve (SPN) was identified as the structure at the highest risk of injury, with a mean distance of 4.52 mm (SD 3.27) from the anterior portal and 14.17 mm (SD 5.25) from the lateral portal. The SPN was found in contact with the anterior portal in three specimens, however no structures were injured during instrumentation. Conclusion: Adequate fracture reduction can be achieved with the nail. The SPN was identified as the structure at the highest risk of damage; however, no tendons or nerves were injured during the procedure. Clinical relevance: The current findings supports intramedullary nailing as an efficient method for achieving proper fracture reduction while minimizing soft tissue complications. Nevertheless, strict adherence to the percutaneous technique is essential to minimize iatrogenic injury to neighboring structures. This includes using skin-only incisions, performing blunt dissection down to the bone, and maintaing close approximation of protection sleeves and bone at all times.

Purpose Anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament is a valid treatment of chronic hindfoot instability. The purpose of this study was to investigate the outcomes of this procedure performed by an all-inside endoscopic technique. Methods This study is a retrospective evaluation of a prospective database. Subjects were all patients who underwent an endoscopic lateral ligament reconstruction between 2013 and 2016. All patients had symptoms of ankle instability with positive manual stress testing and failed nonoperative treatment during at least 6 months. At final follow-up the outcome was assessed using the visual analogue score (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and Karlsson–Peterson scores. Results After an average follow-up of 31.5 ± 6.9 months, all patients reported significant improvement compared to their preoperative status. The preoperative AOFAS score improved from 76.4 ± 15 to 94.7 ± 11.7 postoperatively ( p  = 0.0001). The preoperative Karlsson–Peterson score increased from 73.0 ± 16.0 to 93.7 ± 10.6 postoperatively ( p  = 0.0001). The VAS score improved from 1.9 ± 2.5 to 0.8 ± 1.7 ( p  < 0.001). Two patients had complaints of recurrent instability. Conclusion Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure and produces good clinical results with minimal complications. In addition, the endoscopic approach allows an assessment of the ankle joint and treatment of associated intra-articular lesions. Level of evidence II.

Purpose The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions. Methods A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects. Results Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3–6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered. Conclusions Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI. Level of evidence V.

Purpose The purpose of this study was to evaluate a step-by-step approach to endoscopic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). Methods Fourteen lower extremity cadaveric specimens were used. Four standard portals were defined and used. A step-by-step approach using several anatomical landmarks was used to reconstruct the ATFL and CFL. The feasibility of visualising the anatomical landmarks and both ligaments and their footprints was assessed. Both ligaments were reconstructed using a gracilis graft fixed in bone tunnels. The lateral side of the ankle was completely exposed and dissected. The specimen was assessed for clinical stability of the reconstruction and damage to the surrounding anatomical structures. The distance between the centre of the tunnel and the anatomical insertions of the ligaments was measured. The distance between the portals and the nerves was measured. Results The step-by-step approach allowed a good visualisation of the entire course of the ATFL and CFL. An endoscopic reconstruction of both ligaments was performed, and good stability was obtained. The measurements revealed a good positioning of the reconstructed ligament insertions with a maximal error of 2 mm in most specimens. Anatomical dissection revealed no damage to the surrounding anatomical structures that were at risk. The average distance to the superficial peroneal nerve was 11.9 ± 5.3 mm (standard deviation), and the average distance to the sural nerve was 17.4 ± 3.2 mm (standard deviation). A safe zone was defined with regard to the surrounding nerves. Conclusion The described technique, which involves an anatomical endoscopic reconstruction of the ATFL and CFL, using a gracilis graft, is a viable option to treat lateral ankle instability. This technique is reproducible and safe with regard to the surrounding anatomical structures.

Purpose Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. Methods The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. Results For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0–10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0–10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0–5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2–12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. Conclusion Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

Intrasheath subluxation of the peroneal tendons within the peroneal groove is an uncommon problem. Open exploration combined with a peroneal groove-deepening procedure and retinacular reefing is the recommended treatment. This extensive lateral approach needs incision of the intact superior peroneal retinaculum and repair afterwards. We treated three patients with a painful intrasheath subluxation using an endoscopic approach. During this tendoscopy both tendons were inspected. The distal muscle fibers of the peroneus brevis tendon were resected in two patients. A partial tear was debrided in the third patient. All patients had a good result. No wound-healing problems or other complications occurred. Early return to work and sports was possible. An endoscopic approach was successful in treatment of an intrasheath subluxation of the peroneal tendons.

During decennia the treatment of radial head fractures has been controversial. For Mason type II fractures, more recent studies agree that open reduction and internal fixation is the treatment of choice. It restores biomechanical properties, allows an early mobilisation of motion and results in better functional outcome compared with other treatments. In this study, we present the mid‐to‐long‐term results of an arthroscopic technique for reduction and percutaneous fixation. Fourteen patients were available for follow‐up with a final assessment performed at an average of 5 years 6 months (range 1 year to 11 years 3 months). Patients were evaluated for pain, motion and radiological findings. The average elbow score (Broberg and Morrey in J Bone Joint Surg Am 68:669–674, 1986) was 97.6 points (range 86–100), corresponding with 3 good and 11 excellent results. Two of the patients with only good results had associated cartilage lesions of the capitellum. Our results show that arthroscopically assisted reduction and internal fixation of type II radial head fractures is a valid technique with consistently good outcome. Although the technique is technically demanding, it allows more precise articular fracture reduction control, as well as better evaluation of associated lesions.