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Assessing ankle abductor (ABD) strength is clinically relevant because the peroneal muscles are key contributors to lateral ankle stability. However, no previous study has examined whether isolated ABD strength can be measured reliably and reflects peroneal muscle function. This study evaluated the intra-session test–retest reliability of a novel device for isometric ABD strength assessment and examined construct validity using surface electromyography (EMG). Two independent samples were included: n = 24 for test–retest reliability and n = 15 for EMG construct validity. Strength testing was performed using a custom-built, examiner-independent device that standardized positioning and stabilization while applying resistance through a load cell. Participants executed maximal isometric ABD efforts. Reliability was assessed using ICC (2,1), SEM, coefficient of variation, and minimal detectable change (MDC95) values. EMG activity of the peroneus longus, peroneus brevis, and tibialis anterior was recorded during ankle ABD to examine muscle-specific activation patterns across force levels (30%, 50%, and 70% of maximal voluntary force). The device showed good-to-excellent reliability, with ICC values from 0.82 to 0.94 and acceptable SEM and MDC95. The most stable results were obtained using the highest value across five or six attempts. EMG analyses demonstrated a clear graded, force-dependent activation pattern in the peroneal muscles, whereas tibialis anterior activity showed greater variability and a less consistent response. These findings indicate that the device provides consistent ABD strength measurements and elicits muscle-specific activation patterns consistent with peroneal function, supporting clinical assessment of lateral ankle stabilizers and guiding rehabilitation.

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 aim of the study was to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. The hypothesis of the presented study is that suture-tape augmentation technique has comparable clinical and radiological outcomes with arthroscopic Broström repair technique. Methods Sixty-one consecutive patients with chronic ankle instability were operated between 2012 and 2016 randomized to 2 groups. First group was composed of 31 patients whom were operated using an arthroscopic Broström repair technique (ABR) and second group was composed of 30 Patients whom were operated using arthroscopic lateral ligaments augmentation using suture-tape internal bracing (AST). At the end of total follow-up time, all patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiological evaluation was performed using anterior drawer and varus stress radiographs with standard Telos device in 150 N. Talar tilt angles and anterior talar translation were measured both preoperatively, 1 year postoperatively and at the final follow-up. Results Preoperative total FAOS scores for ABR and AST groups were 66.2 ± 12 and 67.1 ± 11, respectively. Postoperative Total FAOS scores for ABR and AST groups were 90.6 ± 5.2 and 91.5 ± 7.7, respectively. There was no statistical difference in between 2 groups both pre- and postoperatively (n.s). According to FAAM, sports activity scores of ABR and AST groups were 84.9 ± 14 and 90.4 ± 12 at the final follow-up, which showed that AST group was significantly superior ( p  = 0.02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Mean operation time for AST and ABR groups were 35.2 min and 48.6 min, respectively, which shows statistically significantly difference ( p  < 0.05). There was no significant difference in recurrence rate of instability between to operation techniques (n.s). Conclusions Arthroscopic lateral ligament augmentation using suture tape shows comparable clinical outcomes to arthroscopic Broström repair in the treatment of chronic ankle instability at intermediate-term follow-up time. Arthroscopic lateral ligament augmentation using suture tape has a significant superiority in the terms of less operation time and no need for cast or brace immediate after surgery which allows early rehabilitation. It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life. Level of evidence II.

Purpose The purpose of this meta-analysis was to analyze the current comparative studies of arthroscopic and open techniques for lateral ankle ligament repair to treat chronic lateral ankle instability. Methods A systematic search of MEDLINE, EMBASE and Cochrane Library databases was performed during February 2018. Included studies were evaluated with regard to level of evidence and quality of evidence using the Modified Coleman Methodology Score. Total number of patients, patient age, follow-up time, gender ratio, surgical technique, surgical complications, complication rate, recurrent instability or revision rate, clinical outcome measures and percentage of patients who returned to sport at previous level were also evaluated. Statistical analysis was performed using RevMan, and a p value of < 0.05 was considered to be statistically significant. Results Four comparative studies for a total of 207 ankles were included. There was a significant difference in favor of arthroscopic repair with regard to AOFAS score, and there was no significant difference with regard to Karlsson score. There was a statistically significant difference in AOFAS score in favor of the arthroscopic repair (MD; 1.41, 95% CI 0.29–2.52, I 2  = 0%, p  < 0.05). There was no statistically significant difference in Karlsson score (MD; 0.00, 95% CI − 3.51 to 3.51, I 2  = 0%, n.s.). There was no statistically significant difference in total, nerve, or wound complications. Conclusions The current meta-analysis found that short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. There was no significant difference between arthroscopic and open repair with regards to Karlsson functional outcome score, total complication rate, or the nerve and wound complication subsets with the included studies with at least 12 months of follow-up. However, the current evidence is still limited, and further prospective trials with longer follow-up are needed. Level of evidence III.

Purpose The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair. Methods A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores. Results Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy. Conclusion Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. Level of Evidence IV.

Purpose The purpose of the study was to evaluate the effect of concurrent arthroscopic osteochondral lesion (OCL) treatment and lateral ankle ligament repair on the outcome of chronic lateral ankle instability. It was hypothesized that the arthroscopic OCL treatment might have some negative effect on the outcome of chronic lateral ankle instability (CLAI) by compromising the rehabilitation program. Methods Ankle arthroscopy and anatomic lateral ankle ligament repair with suture anchors were performed for 70 patients with CLAI between 2010 and 2012. Thirty-four patients (group A), 20 males and 14 females with a median age of 30(14–54) years, received arthroscopic abrasion, curettage, drilling, or microfracture for OCLs. The splint was removed daily for joint motion exercises beginning at post-operative 2 weeks and full weight bearing was allowed between post-operative week 8 and 12. The other 36 patients (group B) with no combined OCL were followed up as controls. Pre-operative and post-operative visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores, sprain recurrence, ankle stability, and range of motion (ROM) were evaluated and compared. Results The median follow-up was 46.5 (38–55) months and 44.5 (38–56) months for group A and group B, respectively. The median post-operative VAS score, AOFAS score, and Tegner score were improved from the pre-operative level for both groups with good-to-excellent results for more than 90% patients. No significant difference was found between the two groups for the subjective scores and satisfaction rate (n.s.). Recurrent sprain was found among nine patients(26.5%) of the group A and five patients (13.9%) of the group B (n.s.). The incidence of the ROM restriction of group A was significantly higher than in group B (23.5 vs 5.6%, P  = 0.043). Conclusions The concurrent arthroscopic treatment of OCL with lateral ankle ligament repair demonstrated no substantial negative effect on the overall mid-term outcome of the patients with CLAI except for a potential risk of ROM restriction. Level of evidence III.

ObjectiveTo determine T2* normal reference values for anterior talofibular ligament (ATFL) and to investigate the feasibility of the quantitative ATFL quality evaluation in chronic lateral ankle instability (CLAI) using T2* values.Materials and methodsThis study enrolled 15 patients with CLAI and 30 healthy volunteers. The entire ATFL T2* values from the MRI T2* mapping were measured. The prediction equation (variables: age, height, and weight) in a multiple linear regression model was used to calculate the T2* normal reference value in the healthy group. T2* ratio was defined as the ratio of the actual T2* value of the patient’s ATFL to the normal reference value for each patient. A Telos device was used to measure the talar tilt angle (TTA) from the stress radiograph.ResultsT2* values of ATFL in the healthy and CLAI groups were 10.82 ± 1.84 ms and 14.36 ± 4.30 ms, respectively, which are significantly higher in the CLAI group (P < 0.05). The prediction equation of the normal reference T2* value was [14.9 + 0.14 × age (years) − 4.7 × height (m) − 0.03 × weight (kg)] (R2 = 0.65, P < 0.0001). A significant positive correlation was found between the T2* ratio and TTA (r = 0.66, P = 0.007).ConclusionMRI T2* values in patients with CLAI were higher than those in healthy participants, and the T2* ratio correlated with TTA, suggesting that T2* values are promising for quantitative assessment of ATFL quality preoperatively.

Individuals with chronic ankle instability (CAI) suffer from the resulting sequela of repetitive lateral ankle sprains (LAS), whilst copers appear to cope with initial LAS successfully. Therefore, the aim of this study was to explore the intra-foot biomechanical differences among CAI, copers, and healthy individuals during dynamic tasks. Twenty-two participants per group were included and required to perform cutting and different landing tasks (DL: drop landing; FL: forward jump followed a landing). A five-segment foot model with 8 degrees of freedom was used to explore the intra-foot movement among these three groups. Smaller dorsiflexion angles were found in copers (DL tasks and prelanding task) and CAI (DL and FL task) compared to healthy participants. Copers presented a more eversion position compared to others during these dynamic tasks. During the descending phase of DL task, greater dorsiflexion angles in the metatarsophalangeal joint were found in copers compared to the control group. Joint moment difference was only found in the subtalar joint during the descending phase of FL task, presenting more inversion moments in copers compared to healthy participants. Copers rely on more eversion positioning to prevent over-inversion of the subtalar joint compared to CAI. Further, the foot became more unstable when conducting sport-related movements, suggesting that foot stability seems to be sensitive to the task types. These findings may help in designing and implementing interventions to restore functions of the ankle joint in CAI individuals.

Purpose To determine the best surgical treatment for chronic ankle instability (CAI) a systematic review was performed to compare the functional outcomes between various surgical stabilization methods. Methods A systematic search was performed from 1950 up to April 2016 using PubMed, EMBASE, Medline and the Cochrane Library. Inclusion criteria were a minimum age of 18 years, persistent lateral ankle instability, treatment by some form of surgical stabilization, described functional outcome measures. Exclusion criteria were case reports, (systematic) reviews, articles not published in English, description of only acute instability or only conservative treatment, medial ankle instability and concomitant injuries, deformities or previous surgical treatment for ankle instability. After inclusion, studies were critically appraised using the Modified Coleman Methodology Score. Results The search resulted in a total of 19 articles, including 882 patients, which were included in this review. The Modified Coleman Methodology Score ranged from 30 to 73 points on a scale from 0 to 90 points. The AOFAS and Karlsson Score were the most commonly used patient-reported outcome measures to assess functional outcome after surgery. Anatomic repair showed the highest post-operative scores [AOFAS 93.8 (SD ± 2.7; n  = 119); Karlsson 95.1 (SD ± 3.6, n  = 121)], compared to anatomic reconstruction [AOFAS 90.2 (SD ± 10.9, n  = 128); Karlsson 90.1 (SD ± 7.8, n  = 35)] and tenodesis [AOFAS 86.5 (SD ± 12.0, n  = 10); Karlsson 85.3 (SD ± 2.5, n  = 39)]. Anatomic reconstruction showed the highest score increase after surgery (AOFAS 37.0 (SD ± 6.8, n  = 128); Karlsson 51.6 (SD ± 5.5, n  = 35) compared to anatomic repair [AOFAS 31.8 (SD ± 5.3, n  = 119); Karlsson 40.9 (SD ± 2.9, n  = 121)] and tenodesis [AOFAS 19.5 (SD ± 13.7, n  = 10); Karlsson 29.4 (SD ± 6.3, n  = 39)] ( p  < 0.005). Conclusion Anatomic reconstruction and anatomic repair provide better functional outcome after surgical treatment of patients with CAI compared to tenodesis reconstruction. These results further discourage the use of tenodesis reconstruction and other non-anatomic surgical techniques. Future studies may be required to indicate potential value of tenodesis reconstruction when used as a salvage procedure. Not optimal, but the latter still provides an increase in functional outcome post-operatively. Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. This has to be kept in mind when choosing between reconstruction and repair in the treatment of CAI. Level of evidence IV.

Purpose Current methods of anterior talofibular ligament (ATFL) reconstruction fail to restore the stability of the native ATFL. Therefore, augmented anatomic ATFL reconstruction gained popularity in patients with attenuated tissue and additional stress on the lateral ankle ligament complex. The aim of the present study was to evaluate the biomechanical stability of the InternalBrace ® (Arthrex Inc., Naples, FL, USA), a tape augmentation designed to augment the traditional Broström procedure. Methods Twelve (12) fresh-frozen human anatomic lower leg specimens were randomized into two groups: a native ATFL (ATFL) and a tape augmentation group (IB). Dual-energy X-ray absorptiometry (DEXA) scans were carried out to determine bone mineral density (BMD) of the specimens. The ligaments were stressed by internally rotating the tibia against the inverted fixated hindfoot. Torque at failure (Nm) and angle at failure (°) were recorded. Results The ATFL group failed at an angle of 33 ± 10°. In the IB group, construct failure occurred at an angle of 46 ± 16°. Failure torque reached 8.3 ± 4.5 Nm in the ATFL group, whereas the IB group achieved 11.2 ± 7.1 Nm. There was no correlation between angle at ATFL or IB construct failure or torque at failure, respectively, and BMD for both groups. Conclusion This study reveals that tape augmentation for ATFL reconstruction shows similar biomechanical stability compared to an intact native ATFL in terms of torque at failure and angle at failure. BMD did not influence the construct stability. Tape augmentation proved an enhanced initial stability in ATFL reconstruction which may allow for an accelerated rehabilitation process. Level of evidence II.